summary: QI Residential - FY24-25 - 5 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
Jasper, Florida 32052
Review Date(s): November 12-15, 2024
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
LeAnn Gruentzel, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Lori Bright, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Renette Crosby, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (Interviews)
Jessica Gipson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Michele Maynard, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Desiree Taylor, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Standard 3)
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): November 12-15, 2024 Lead Reviewer Code: 192
1
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
1.08 In-Service Training 2.05 Gang Identification: Notification of Law Enforcement
1.17 Special Contract Conditions 2.08 Youth Needs Assessment Summary (YNAS)
2.11 Performance Summaries and Transmittals
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 59 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Limited
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Non-Applicable
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 Limited
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 59 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Failed
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Failed
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Limited
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
* 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 59 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Satisfactory
3.19 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 59 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 59 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 59 (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 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 service of
Living in Balance (LIB). The program’s optional supportive groups include The Council: Men of
Honor. Additional services include equine therapy, ServSafe® Foodhandler certifications,
culinary arts, and masonry. Program administration is comprised of a program director, director
of group living, compliance coordinator, Designated Mental Health Clinician Authority (DMHCA)
as the Director of Student Services, and two shift supervisors. Case management and mental
health services are provided by the DMHCA, three transition service managers, and four
therapeutic managers. Medical services are offered twenty-four hours a day, seven days a week
and 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 cottages, two basketball courts, a vocational building, a
maintenance 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 seven vacancies including a program director, kitchen manager, a recreational
therapist, and four coach counselors.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 59 (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 for volunteers, mentors, and interns who work with
youth less than ten hours a month. The program did not have any volunteers, mentors, or
interns during the annual compliance review period. The program sent their Annual Affidavit of
Compliance to the Background Screening Unit (BSU) on December 21, 2023. The program did
not have any teachers who were paid by the school board during the annual compliance review
period. Twenty-six new staff were hired within the annual compliance review period. Each staff
received an eligible background screening prior to contact with youth and youth records, and
their criminal history report were reviewed. The three applicable staff who had a break in service
received a new background screening. Twenty-three applicable staff were required to complete
a passing pre-assessment tool. Three staff were exempt from completing a pre-assessment
tool. Three staff who were hired from another provider were background screened. Each staff
was added to the provider’s Clearinghouse employee roster and each staff signed a contraband
attestation form. The provider’s SVS census needed to be updated.
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 had six staff who were applicable for a five-year rescreening. Each staff’s
rescreening was completed within the required timeframe. The screening for each staff was
submitted to the Department’s Background Screening Unit/Clearinghouse at least ten business
days prior to the five-year anniversary date or retained prints expiration date.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 59 (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. A tour of the program verified the Florida
Abuse Hotline and/or Central Communication Center (CCC) numbers were posted throughout
the facility and the youth have unhindered access to report alleged abuse. Twenty-six staff
records were reviewed, and each staff signed a code of ethics form. The program completed the
Trauma Responsive and Caring Environment (TRACE) self-assessment in April 2024. Three
incidents related to physical, psychological, or emotional abuse were reported since the last
annual compliance review, although none were found substantiated. Each staff involved in the
incidents had no contact with youth or records while the investigation was occurring until
cleared. Seven interviewed staff were able to explain the process of allowing youth to call the
Florida Abuse Hotline or the CCC to report suspected abuse. This process included notifying
the supervisor, allowing the youth to make the call, with one staff stating the supervisor brings
the youth to make the call, with the supervising dialing the number. None of the staff has ever
heard another staff telling a youth they could not make an abuse call or using profanity while
speaking with youth. The interviewed interim program director (PD) stated the program
promotes a safe environment and child abuse is not tolerated. Staff shall immediately report all
allegations of abuse, neglect, or sexual harassment. Any incident or suspected incident of
retaliation against youth or staff who reported an allegation of abuse must also be reported
immediately. Staff are required to report any alleged neglect or violation of responsibilities which
may have contributed to an incident or retaliation as well as report the information to the Florida
Abuse Hotline or the Department’s Central Communications Center Hotline. Once the call has
been completed, staff must notify the PD or supervisor on duty as soon as possible who shall
begin an immediate review. The program incorporates trauma-responsive practices into their
treatment teams, safety/soothing plans, and training. Seven interviewed staff were able to
explain the process of allowing youth to call the Florida Abuse Hotline or the Central
Communication Center (CCC) to report suspected abuse. This process included notifying the
supervisor, allowing the youth to make the call, with one staff stating the supervisor brings the
youth to make the call, with the supervising dialing the number. None of the staff has ever heard
another staff telling a youth they could not make an abuse call or use profanity while speaking
with youth. All seven interviewed youth stated they felt safe at the program, the staff spoke
respectfully to all youth, have never heard staff use profanity towards any youth, or staff giving
any youth social media, email, or telephone numbers to them. Youth knew where the abuse
hotline numbers were posted.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 59 (Revised September 2022)
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
There were three incidents related to physical, psychological, emotional abuse were reported
since the last annual compliance review. Each involved staff of the incidents had not contact
with youth or records while the investigation was occurring until cleared. None of the incidents
were found substantiated. The interviewed interim program director stated there have not been
any disciplinary actions against staff during the annual compliance review period, however, was
able to cite policy if this was to occur.
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.
There have been thirty-two incidents reported to the Central Communication Center (CCC)
during the annual compliance review period. This was a decrease in incidents since the
previous annual compliance review. There were no noted incidents or grievances which should
have been reported to the CCC. Five CCC incidents were reviewed. Each were reported within
the required two hour timeframe and were noted in the logbook. The program maintained a
CCC incident binder with all required documents and copies in the logbook entry corresponding
to each incident.
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program had ten Right Interactions (RI) incidents reported during the annual compliance
review period, which was two less incidents than the previous year. The program’s RI rate
during the previous quarter was 0.81, which was below the statewide Residential RI rate of
1.81. The RI plan was updated on February 5, 2024, and approved by the Department on
February 6, 2024. All incidents were reported to the Department’s regional office monthly, as
required. Five RI incidents reports were reviewed. Each report included a statement from all
staff involved, however, in four reports it was unable to determine if all statements were
completed by the end of the workday because statements did not include dates. All reports were
reviewed by administrator. None of the incidents involved mechanical restraints, resulted in an
injury in either staff or youth, nor had allegations of abuse. Seven staff were interviewed
regarding the RI process. Six staff who have used RI were able to explain the process, which
included notifying supervisor, medical, and mental health, de-escalating the situation,
completing an incident report with statements from all staff involved, and administration review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 59 (Revised September 2022)
One staff stated they needed to use Protective Action Response, however was still able to
describe the steps. The interviewed interim program director stated RI incidents are monitored
by discussing at monthly staff meetings and will implement a party in months with no incidents.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The Department’s Learning Management System (SkillPro), staff training records and plans,
and the program’s training tracker were reviewed for pre-service training. All instructors were
qualified to deliver training. The program submitted a training plan which was approved by the
program director and the Department’s regional residential director. Seven reviewed pre-service
records found all staff completed over 120 hours within the first 180 days of hire however, four
did not complete all required trainings with in the required timeframe. All staff completed all
essential mandatory trainings prior to having contact with the youth and their records. Three
staff completed other required trainings mandated by the Department. Four staff completed all
trainings with the exception, two staff were missing two trainings, safety and security and
motivational interviewing, and two staff were missing one training, motivational interviewing.
Five of the seven reviewed staff records showed staff completed provider contract required
trainings with two staff missing only one contract training each. Each staff completed required
trainings from other rules and manuals. One staff was applicable for being a newly hired
supervisor. Reviewed training staff records revealed the staff completed only eleven of the
required sixteen hours. Documentation confirmed six of the seven reviewed staff records
notated all completed trainings in the Department’s Learning Management System (SkillPro).
One staff had all required trainings documented in SkillPro however not all the staff’s
supervisory trainings were notated in SkillPro.
1.08 In-Service Training Limited Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The Department’s Learning Management System (SkillPro), staff training records and plans,
and the program’s training tracker were reviewed for in-service training. Only two of the seven
reviewed staff completed all of the mandatory training. One staff was missing one training, two
were missing two trainings, two were missing three, and one staff was missing ten trainings.
Reviewed documentation confirmed the staff who did not have all essential trainings to have
contact with youth and records was scheduled and supervising youth. A review of the current
year’s trainings revealed the staff is not in compliance with the required essential training. The
program relayed the staff has been taken off the schedule and is to complete all trainings before
having youth or record contact. Three of seven reviewed staff completed all other mental health
and substance abuse with one staff missing one training and three staff missing three trainings.
None of the staff had the required Substance Abuse Treatment Overly Services specialty
training. One of the seven reviewed staff completed the four reviewed contractual required
annual trainings. One staff was missing one training and five staff were missing two trainings.
The program has begun to address the training issues. The previous training coordinator was let
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Office of Accountability and Program Support Page 13 of 59 (Revised September 2022)
go and the compliance coordinator has been overseeing training. The program also has
documentation of a training calendar, newly developed sign-in sheets, and each staff receiving
individualized updated training plans at the beginning of this year to make sure staff stay on
track with trainings, as well as sending out quarterly email reminders.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures outlining their grievance process as well as staff
training in grievance procedures. The program’s grievance process includes three phases:
informal, formal, and appeal. During the informal phase, youth are encouraged to make all
efforts to reach a resolution of the grievance directly and staff should make an effort to discuss
the issue or complaint. A review of documentation verified the program’s practice correlated
with their process and maintained all grievances for the past twelve months. Only three
grievances were submitted during the annual compliance review period. Only one grievance
was applicable for the informal phase and documentation showed the staff and youth tried to
come to a resolution. All three grievances went through the formal phase however
documentation from the formal phase confirmed each complaint was responded to in the
required timeframe and resolved. None of the grievances needed to go through the appeal
phase. Seven interviewed youth were able to explain the grievance process, knew where the
box was to submit a grievance form, and could ask staff to help with filling out the form. Seven
interviewed staff relayed the grievance process, which included forms being available to youth
and both the supervisor and program director reviewing all grievances. The interviewed interim
program director was able to provide the program’s grievance process.
1.10 Interventions and Facilitator Training <---Update--->
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procures to provide instruction focusing on developing life and
social skill competencies in youth. The program’s policy states life skills help students function
more responsibly and successfully in everyday life situations, including social skills specifically
addressing interpersonal relationships. Life and social skills intervention services are provided
through Living in Balance (LIB) groups which addressed, 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,
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Office of Accountability and Program Support Page 14 of 59 (Revised September 2022)
and critical thinking, including problem-solving and decision-making. The health and hygiene,
physical environment, life and social skills training, and leisure and recreational activities
considered the gender of the program’s targeted gender group and address those needs. Non-
clinical staff may implement only non-clinical life and social skills interventions or instruction.
Direct care staff model pro-social behaviors for youth throughout the course of each day,
reinforce delinquency interventions, and guide and re-direct students toward prosocial behaviors
and positive choices. Additionally, staff shall engage students 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.
Reviewed sign-in sheets verified LIB groups were proved twice a week forty-five minutes in
length, as required. Youth Individual Health Care Records verified all youth receive health and
hygiene skills training. A review of the recreational calendar confirmed the program is also
providing life and social skills activities. Seven interviewed youth were able to relay which
groups they participated in and other life groups which included Living in Balance, job
applications, resumes, social and communicating skills, vocational, coping skills, and budgeting.
Each youth stated they practice learned skills by role playing and using when interacting with
peers. The interviewed Designated Mental Health Authority stated the idea of using everyday
interactions with peer and staff as opportunities for skill-building is key to reinforcing those
lessons in real-life situations. Offering privileges like community service events, work
opportunities, equine activities, and church participation provides both incentive and enrichment,
helping youth integrate into society and develop a sense of responsibility and contribution. The
interviewed interim program director stated the youth are provided services in Living in Balance
for life and social skills three days a week, as well as addressing the needs of the targeted
population by providing gender groups of the approved Boy’s Council.
1.12 Restorative Justice Awareness for Youth <---Update--->
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.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at the program. For details related specific to IOC service delivery, please refer
to the annual SPEP report.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures 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. The alert
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process is managed by each department head who are in charge of inputting and closing alerts.
The alerts are monitored on a daily basis and discussed in the morning management meeting.
This information is then shared with all staff during the daily briefing in which representation
from each department is in attendance. Seven youth were reviewed regarding the internal alert
system. All youth were placed on the alert system, which is maintained electronically. All youth
had open and closed alerts which were processed by the program. Twenty-four alerts were
opened by the program. Each alert was entered in the Department’s Juvenile Justice
Information System (JJIS) in the required timeframe. The three applicable alerts were noted in
the logbook as required. Eighteen alerts were on both the program’s internal alert system and
JJIS. Six alerts were closed by the program. Seven interviewed staffed stated they are informed
of youth alert is by supervisor, reviewing the Department’s Juvenile Justice System, email,
written on supervisor’s board, and daily staff debriefing. The interviewed health services
administrator (HAS) confirmed all licensed nursing staff are responsible for updating the medical
alert system. The interviewed interim program director stated medical issues are reviewed with
healthcare staff in the daily morning meetings and sick calls. Medical and mental health staff
input their respective alerts and case management inputs safety and security alerts into JJIS.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains an Individual Healthcare Record (IHCR) and an individual case
management record for each youth. Seven youth IHCR and seven individual case management
records were reviewed and each contained the youth’s name, Department identification (DJJID)
number, date of birth, county of residence, and committing offense. Each record included
sections for legal information, demographic and chronological information, correspondence,
case management and treatment team activities, and miscellaneous. 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 which is scheduled to meet on a quarterly basis.
A review of the community advisory board binder with sign-in sheets, agendas, and meeting
minutes confirmed the advisory board meeting was held quarterly during the annual
compliance review period. A review of the list of attendees, the board roster, and letters from
the program found the program director (PD) solicited involvement from a judiciary community
representative, law enforcement representative, other community partners, a business
community representative, a school board or district representative, a faith community
representative, and a LGBTQIA+ community representative. Reviewed letters in the community
advisory board binder confirmed the PD recruited, or tried to recruit when the position was
vacant, a victim, victim advocate, and a parent/guardian, whose child was previously involved
in the juvenile justice system. Reviewed documentation reflected a representative from each
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category was a member of the advisory board or were invited to join the advisory board. The
interviewed interim program directed stated the Community Advisory Board meets
quarterly and the membership consists of leaders and activists from the community. A board
member was attempted to be contacted. A voicemail requested a call back was left as
well as an email was sent and did not receive a reply.
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 to ensure staff are evaluated, at least annually, based
on established performance standards. Each newly hired staff receive a ninety-day day
evaluation then a yearly evaluation. Identified in these evaluations are the staff strengths and
weakness. Upon completion of the evaluation process, each staff meets with the program
director (PD) and supervisor to discuss areas of improvements and to develop a plan for
success. A review of seven position descriptions confirmed each staff’s performance standards
were clearly identified as well as reviewed for staff whose job functions includes implementation
of the program’s BMS. A review of seven staff records confirmed each staff received both a
ninety-day and/or an annual performance evaluation on established performance standards.
Performance standards matched the position description for each staff. A review of the contract
and amendments confirmed contractually required positions were maintained and performed as
outlined. Four of seven interviewed staff relayed they received formal evaluations of their
performance yearly and every ninety days and one staff stated every six months. Two staff were
unsure for they have been with the provider less than six months. The interviewed interim
program PD stated the program addresses vacancies by posting on local and national sites as
well as on-going recruiting and increased part-time staff. The interim PD conducted an analysis
regarding moral and is addressing the issues. Performance evaluations process consists of a
ninety-day evaluation and annual evaluation from hire date.
1.17 Special Contract Conditions Limited Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
A review of documents found five of the ten special conditions from the Memorandum of
Negotiations were being completed as required. Video-chat is being utilized for conferences, a
licensed practical nurse (LPN) is being utilized, vocations services are being provided as
required, parent/teacher conferences are being held during family day, and, though currently
vacant, the previous kitchen manager had the required experience. The program does have 4.5
therapeutic managers on staff however the part time therapist has been out on workers
compensation for over two years. The program is holding family days as required with a
therapeutic manager however the recreational therapist position has been vacant for over seven
months during the annual compliance review period. All staff are not being training in
motivational interviewing during the pre-service timeframe. No documentation of the three
reviewed closed youth records contained monthly checks being completed post release as
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required. No documentation was provided for in-home assessments being completed ninety
days prior to release for youth who live within 125 miles of the program during the annual
compliance review period. The interviewed interim program directed stated they provide
Certified Nursing Assistant, CPR/First Aid, Certified Mansory, Safe Serv and equine vocational
services.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a policy and procedure of reviewing and analyzing data trends to utilize in
decision-making practices. The program’s trend analysis and data-driven decision is
strengthened through the monthly Site Operations Summaries (SOS) tracking, including
monthly youth admissions, length of stay, incidents, youth assaults and fights, youth restraints,
and runaways, as well as staff turnover, length of stay, and exits. The program shares the SOS
reports in monthly staff meetings and postings where the data trends are easily accessible by
staff, educators, and stakeholders. The program’s practice is to share the information during the
Community Advisory Board meetings with stakeholders, confirmed while reviewing minutes from
the bard meetings. The findings from trend data analyses are utilized to determine recruitment
strategies, positive morale approaches, policy and procedures, youth supervision techniques,
and restorative justice programs.
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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 requiring the assigned case manager to notify a
youth’s parent/guardian by telephone within twenty-four hours of the youth’s admission and by
written notification within forty-eight hours of admission. The case manager must notify the
youth’s committing court, assigned juvenile probation officer (JPO), and post residential services
case manager, if applicable, within five working days of any admission. Seven youth records
were reviewed, and all seven records contained documentation confirming each youth’s
parent/guardian was contacted on the day of admission or within twenty-four hours of their
admission to the program. Six of the seven youth’s parent/guardian were notified in writing
within forty-eight hours of admission with one youth’s parent/guardian being notified in writing
four days late. Six of the seven youth’s JPO and post-residential counselor, when applicable,
were notified within five working days of the youth’s admission with one youth’s JPO being
notified one day late.
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 addressing 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. Seven youth records were reviewed, and each youth was given
an orientation on the youth’s date of admission. Though there was an admission during the
annual compliance review, per program staff, the juvenile detention center requires the program
to retrieve youth for admittance at 4:00 a.m. At the time the review team had arrived on site, the
orientation had been completed, therefore, an observation was unable to be made.
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 Central
Communications Center (CCC), 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 student handbook. Each record documented orientation also included the performance
planning process, dress code and hygiene practices, procedures for visitation and
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correspondence, expectations for release, community access, emergency procedures, a facility
tour and assignment to a living unit and room, and treatment team. Seven youth were
interviewed and each youth confirmed they were provided an orientation within twenty-hours of
admission which included receiving the program handbook, program rules, grievance
procedures, access to medical//services, treatment team assignment, and program structure.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
Seven youth records were reviewed for written consent of youth eighteen years or older. None
were applicable, as such, the program provided three additional records for review. Each
applicable youth 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 regarding classification which requires the program to
conduct an initial admission classification meeting with the youth to be attended by the therapist,
case manager, nurse, living unit representative, and parent/guardian, if available. Per policy, the
classification factors shall include a review of the youth’s physical characteristics, age and
maturity level, any identified special needs, history of violence, gang affiliations, criminal
behavior, sexual aggression or vulnerability to victimization to include the youth’s perception of
vulnerability, youth’s history of potential human trafficking, 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 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 student’s supervision status, new/updated alerts, behavioral concerns, and
relevant information to the treatment team to ensure safety and security of the student and
program. The policy indicated several examples requiring re-classification 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 student privileges and advancement or freedom of movement, prior to
anticipated off campus activity, or at the request of program director (PD) or designee.
Seven youth records were reviewed, and documentation confirmed a classification meeting
occurred for all youth reviewed. For six of the seven youth the program utilized classification
forms which addressed 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’s record
contained a classification form which was missing escape risk, security risk, and other risk from
the form. Four of the seven files included documentation regarding the review of the JJIS for
alerts with three of the youth’s admissions occurring during the dates when JJIS was offline.
One of the applicable four youths was identified as having a medical risk and 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,
freedom of movement or participation in work projects, or participation in off-campus activities.
The PD was interviewed and stated all factors, including maturity, mental health status, physical
health status, cognitive performance, age, and prior victimization, are considered and youth are
placed in program settings with other youth accordingly.
2.05 Gang Identification: Notification of Law Enforcement Failed Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
Seven youth records were reviewed for gang identification and notification of law enforcement.
One record was applicable, as such, the program provided two more records for review. Each
applicable youth was identified as having gang involvement after their admission into the
program. The local law enforcement was notified for one of the three youth’s gang association.
The program did not send notification in the required timeframe to each of the applicable youth’s
home county law enforcement nor education or their juvenile probation officer once the youth
was identified of possible gang association. The program sent one notification while the annual
compliance review team was on-site. Each youth’s applicable gang alert was entered into the
Department’s Juvenile Justice Information System (JJIS) and the internal alert system at the
program.
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 provide youth with the opportunity to develop a
plan to renounce and disaffiliate with any criminal street gang. Three applicable youth records
were reviewed for gang prevention and intervention activities. Each applicable youth was
identified as having gang involvement after their admission into the program. The Individualized
Performance Plan (IPP) 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) group for gang prevention and intervention strategies. GRADE is a seven-lesson
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program designed to educate youth on setting goals, respect, making good choices, conflict
resolution, internet safety, gang intervention, and drug awareness. The program maintained
monthly sign-in sheets to verify the interventions activities, which also listed which intervention
lesson was completed. Gang prevention and awareness efforts are also presented to non-
affiliated youth through the use the county teen court gang program. An interview with the acting
program director (PD) 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/affiliation, the program includes a gang intervention goal on their IPP.
According to the acting PD, 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
their commitment.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
Seven youth records were reviewed, and each contained a completed Residential Assessment
for Youth (RAY) within thirty days of the youth’s admission date into the program. Three of the
seven records documented the assessment in the Department’s Juvenile Justice Information
System (JJIS) and in the youth’s record. Four of the seven youth were admitted during the
timeframe JJIS was offline. Four of six applicable youth records contained RAY reassessments
at least once every ninety days after the completion of the initial RAY Assessment. Two records
documented the RAY Reassessments were not completed at least once every ninety days after
the initial RAY with one reassessment reflecting it was four days late and one reassessment
was eight days late. The remaining youth had not been at the program for ninety days at the
time of the annual compliance review therefore not yet due for a reassessment.
2.08 Youth Needs Assessment Summary (YNAS) Failed Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
Seven youth records were reviewed for Youth Needs Assessment Summary (YNAS). Four
YNAS were due when the Department’s Juvenile Justice Information System (JJIS) was offline.
During this time frame, paper YNAS were utilized. Once JJIS was activated, directive was given
to input the YNAS into JJIS and to keep the paper copies as documentation for completion in
the required timeframe. The program did input the five YNAS in JJIS however the paper YNAS
were not retained therefore was not able to determine if they were completed in the required
thirty-day timeframe. One YNAS was due prior to JJIS becoming inactive and was not
completed within the required thirty-day timeframe however is unable to determine if ever
completed for JJIS became inaccessible thirteen days later. Two YNAS were due after JJIS was
operational again. Both YNAS were completed late, seven and eighty-one days late.
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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.
Seven youth records were reviewed and confirmed in six the development of the individual
performance plan (IPP) occurred within thirty days of each youth’s admission. The remaining
performance plan was completed eight days late. Due to the Department’s Juvenile Justice
Information System (JJIS) being inaccessible, four of the seven youth records were unable to
have a Youth Needs Assessment Summary (YNAS) completed at the time of the development
of the IPP. Of the three applicable records, each plan was developed after the initial Residential
Assessment for Youth (RAY); however, not prior to the YNAS. All seven performance plans
were developed with the intervention and treatment team members present to include the
treatment team leader, the youth, a representative from administration, a living unit
representative, mental health/substance treatment staff, and education staff. No youth were
applicable for involvement with the Department of Children and Families (DCF) at the time of
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, sans parent/guardian signature,
which was filed in the youth’s official 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, except for two records. In those two records, one of the top criminogenic
needs was missing with no explanation as to why, the other two top needs were included. 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, and the parent/guardian,
within ten days of completion. Seven interviewed youth confirmed they participated in the
development of their IPP and were provided a copy of their plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
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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. Seven youth records were reviewed, and one was
applicable for revisions based on a Residential Assessment for Youth (RAY), newly acquired
information, youth progress and/or a lack of progress and one was applicable for revisions
based on youth, with both resulting in a revision to the Individualized Performance Plan (IPP) to
facilitate new goals and activities during their stay at the program to ensure their success. All
seven reviewed records included other plans incorporated into the IPP to include academic or
treatment goals. One youth, although not in the care and custody of the Department of Children
and Families (DCF) at the time of their admission, became involved with the agency during his
stay therefore their performance plan goals related to a case plan through DCF was also
incorporated into the IPP.
2.11 Performance Summaries and Transmittals Limited Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a policy and procedures 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 (IPP) unless the committing court requests a summary at a
shorter interval of thirty days. Seven youth records were reviewed for performance summaries
and transmittals. Five records were applicable, as two youth have not been at the program long
enough for a performance summary to be due. Five applicable reviewed records showed all
performance summaries were completed late; seven, seventeen, twenty-nine, twenty-nine, and
thirty-four 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. Documentation in four of the five 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. Four of the five youth records
contained performance summaries 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. One did not include a youth signature, instead the case manager wrote the youth’s
name in. Each record contained documentation reflecting 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 in four of the five records. In the remaining performance
summary, it could not be determined if the summary had been mailed to the required parties.
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Three closed records were reviewed for discharge summaries. Two Pre-Release Notifications
(PRN) were sent within the required timeframes. One PRN was sent eight days late. Two of the
three applicable records documented the original summary, along with the justification for
release. Each record contained a copy of the signed release/discharge summary. Three records
confirmed the court approved the PRN; however, none documented 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.
One record required victim notification of release per Florida Statute and in this instance, a
notification was not sent.
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 as
participation 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/video conference or provide verbal/written
input prior to the meeting. During the annual compliance review week, there were no
opportunities to observe a treatment team meeting as they were all scheduled for the week
following the review. To solicit parent/guardian involvement the program allows each youth
weekly phone calls and monthly visitation, as well as parents being encouraged to be a part of
treatment team, the admissions process, and family day. An interview with the interim program
director confirmed parents are encouraged to visit on family days and visitation. Seven youth
were interviewed and reported their parents attend their treatment team meetings, come to
family day and visitation, as well as participate in family counseling and attend their graduation.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
Seven reviewed youth records each contained documentation a formal treatment team meeting
was conducted at least once every thirty days, with the exception of one record missing the
month of April. Four records showed the program held one formal treatment team meeting five
days late; however, documentation indicates this was due to a hurricane evacuation disrupting
the schedule. Each formal treatment team meeting was documented in the youth’s case
management record. All seven reviewed youth records documented an informal treatment team
meeting was held on a bi-weekly basis each month alternating with formal treatment team
meetings. 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
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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, if
applicable, and progress for each performance plan goal. Each treatment team meeting also
documented any behaviors resulting in physical interventions, if applicable, treatment progress,
Residential Assessment for Youth (RAY) Reassessment results, and each youth was provided
an opportunity to demonstrate skills acquired in the program. A treatment team meeting was
unable to be observed due to them being scheduled for the following week of the annual
compliance review. Seven youth were interviewed and confirmed staff review their performance,
including progress on performance plan goals, positive and negative behavior, and treatment
progress during treatment team. During the meeting youth are able to show the skills they have
learned by getting to explain how the skills they are learning are working for them, talking about
the changes they have made while in the program, and talk about how they have used the skills
they have learned.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
Seven youth records were reviewed for transition planning. Four of seven reviewed records
were applicable for transition planning and in each 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, 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. One of the four 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, the other three youth had not yet had or been invited to a CRT meeting at the
time of the review. In the one applicable record there was documentation of the invitation to
participate in the CRT meeting sent by the probation department.
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2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three closed case management records were reviewed for an exit portfolio. Each record
documented the exit portfolio was discussed and initiated for the youth during the transition
conference. Two of the three records contained a copy of the youth’s transition plan and one
was missing the plan. None of the records contained a calendar with all dates, times, and
locations of upcoming community appointments. Two youth either had a copy of or had
documentation of the purchase and obtainment of a state issued identification card. One record
contained a copy of the youth’s birth certificate and social security card, the remaining two
records had documentation the parent was asked for the documentation however was never
received. All three records contained documentation of any educational and vocational
certificates earned while in the program, education records, and school transcripts. The one
applicable record did not contain a completed resume, for the remaining two youth were not
applicable due to being under the age of fifteen. One closed record contained a completed
sample of employment applications and two records did not contain completed sample
employment applications. Each record confirmed the youth’s exit portfolio was verified during
the exit 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 as well as
documentation an email was sent to the juvenile probation officer (JPO) documenting they were
provided a copy of the youth’s exit portfolio upon release.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
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 in
two records, the exit conference was held at least fourteen days prior to the youth’s release date
from the program. One record held an exit conference one day late. 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 records, and the Department’s Juvenile
Justice Information System (JJIS) confirmed the youth’s date of admission and date of
termination/release matched. All 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. In one
record, it was not indicated the parent/guardian and juvenile probation officer (JPO) were aware
of the vocational plan for the youth nor if there was evidence they were aware of the plan,
documents, and any post-release discharge plans. In all records the exit conference was held
separately from the transition and community re-entry team (CRT) meetings.
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2.17 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, RAMS Club, safety
meetings, treatment team meetings, town hall meetings, maintenance requests, a problem
resolution process, and grievance forms. 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 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. Seven interviewed youth each reported they participate in town hall
meetings and two youth reported they utilize speak-to forms, surveys, the grievance process,
and participate in student council. An interview with the interim program director indicated the
youth participate in town hall meetings, student council, and the youth are encouraged to use
the speak out forms.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program has a designated mental health clinician authority (DMHCA) who is a licensed
mental health counselor with a clear and active license which expires on March 31, 2025. No
other DMHCAs were used in the program during the annual compliance review period. A review
of the position description confirmed the DMHCA is a full-time employee who works at least forty
hours per week and is responsible for the coordination and implementation of clinical services in
the program. The DMCHA was interviewed regarding the services provided at the program. The
DMHCA ensures the clinical interventions are carried out effectively including individual therapy,
group therapy, and family therapy, which is essential for supporting the well-being and
development of the youth. The DMHCA has daily communication with the clinical staff as well as
weekly clinical supervisions with the licensed and non-licensed clinical staff.
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 designated mental health clinician authority (DMHCA) serves as the clinical supervisor. All
staff working under the DMHCA’s supervision are performing services they are qualified to
provide based on education, training, and experience which was determined by a review of the
job descriptions. The licensed mental health and substance abuse clinical staffing are in
accordance with the current contract and Florida Administrative Code. Copies of the licenses
were available on-site and were reviewed. A review of the staff roster revealed one clinical staff
is licensed, along with the DMHCA. The licensed mental health and licensed qualified
professional employed at the program had a clear and active license which expires March 31,
2025.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) serves as the clinical supervisor who
assures the non-licensed clinical staff working under their supervision are performing services
they are qualified to provide based upon education, training, and experience. Reviewed
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documentation reflected each non-licensed mental health clinical staff are working under the
direct supervision of a licensed mental health professional and received a minimum of one hour
a week on-site, face-to-face direct supervision. Direct supervision was recorded on a form which
contained all the required elements of the Department’s Licensed Mental Health
Professionals/Certified Substance Abuse Professionals Direct Supervision Log. The program
maintains a Chapter 397 license which was observed in all of the cottages and in the front
lobby. The licenses observed in the cottages were expired, however the one observed in the
lobby was current and expires March 22, 2025. The program currently employs two non-
licensed mental health and substance abuse clinical staff which is in accordance with the
current contract. The program did experience vacancies in clinical staff during the annual
compliance review period, which included the recreational therapist position. The program also
had a behavioral analyst for one year but no longer has this staff as the contract has ended. The
two non-licensed clinical staff each hold a master’s-level degree from an accredited university or
college in an approved human services field. The non-licensed clinical staff provide substance
abuse services in the program which is licensed under Chapter 397. A review of training
documentation revealed both non-licensed staff received training for conducting the Assessment
of Suicide Risk (ASR) which included twenty hours of training and supervised experience in
assessing suicide risk, mental health crisis intervention, and emergency mental health services.
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.
Seven youth mental health records were reviewed for admission screening documentation. All
youth who enter the program receive a Massachusetts Youth Screening Instrument Second
Version (MAYSI-2) assessment. All seven records included documentation a MAYSI-2 was
completed on the date of admission by a screener who had reviewed available information on
each youth. All screenings were completed by trained staff as evidenced by a review of training
records in the Department’s Learning Management System (SkillPro). Five of the screenings
were completed in the Department’s Juvenile Justice Information System (JJIS) on the day of
admission. Two of the youth entered the program while JJIS was down and had screenings
completed on a paper version of the MAYSI-2. All seven screenings were completed in full and
all required further assessment. Each record included a referral page which indicated what
specific referrals were needed for each youth. It is the program’s policy for each youth to receive
an Assessment of Suicide Risk (ASR) upon admission to the program. All seven records
included documentation each youth had a completed ASR on the date of admission. Four of the
seven youth were placed on precautionary observation (PO) during intake with mental health
staff. One youth entered the program on PO, which was continued while the youth completed
the intake process. Two youth were not applicable for PO upon admission. Referrals were
completed for all seven youth which included ASRs and a comprehensive evaluation.
The program maintains written policy and procedures for mental health and substance abuse
admission screenings. The policy addresses a standardized screening process which includes a
review of the youth’s commitment packet information, reports and records, and administration of
the MAYSI-2 in JJIS by a qualified professional. The policy includes a process for referrals being
completed based upon admission screenings and for those youth who are in need of further
assessment or immediate attention. The policy includes training for clinical staff in mental health
and substance abuse issues and the administration of the MAYSI-2. The policy includes a
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standardized process for referrals of youth identified in need of further mental health and/or
substance abuse evaluation or who may need immediate attention, which includes a hospital,
Baker Act, or Marchman Act. The interim program director (PD) was interviewed regarding the
mental health and substance abuse screening process. The interim PD reported the youth are
assessed at intake for mental health, substance abuse, and suicide risk.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The designated mental health clinician authority (DMCHA) was interviewed about the mental
health and substance abuse assessment provided at the program. The DMHCA reported prior
to the youth arriving at the program any assessments are reviewed to learn about the youth’s
history. When the youth arrive, four assessments are provided to the youth. The DMCHA also
reported time is used to assess the youth’s behavior during recreation, leisure time, during
meals, and at other times throughout the youth’s day. Seven youth mental health records were
reviewed for a mental health and substance abuse assessment or evaluation. All seven records
included a new combined mental health and substance abuse evaluation completed within thirty
calendar days of admission. Consents for substance abuse services were reviewed in each
youth record. Five of seven mental health and substance abuse evaluations were completed by
a non-licensed mental health clinical staff. All five were reviewed and signed by the licensed
mental health professional within ten calendar days after the evaluation was conducted. The
remaining two were completed by licensed staff. All seven mental health and substance abuse
evaluations included identifying demographics of the youth, reason for the evaluation, relevant
background information, behavioral observations, mental status examinations, results of an
administered interview, discussion of findings, the Diagnostic and Statistical Manual of Mental
Disorders Version Five (DSM-V) diagnosis, patterns of alcohol and other drug abuse, impact of
alcohol and other drug abuse on major life areas, risk factors of continued alcohol and drug
abuse, and recommendations. None of the youth required an updated evaluation.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
Seven youth mental health records were reviewed for mental health and substance abuse
treatment services provided by the program. All seven youth records had documentation the
initial treatment plans were developed on the date of admission. All seven initial treatment plans
included the psychiatric needs of the youth. It is the program’s policy for all new admitted youth
to receive an initial psychiatric interview upon admission, even if they are not on medications. All
seven initial treatment plans were completed on a form which included all required elements
from the Department’s Initial Mental Health/Substance Abuse Treatment Plan form. The
reviewed initial treatment plans were signed by mental health clinical staff, licensed clinical staff,
youth, treatment team leader, program management, living unit representative, and the
transition services manager. All seven records included documentation the initial treatment
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plans were mailed to the parents/guardians requesting signature. All seven youth records
included an Individualized Treatment Plan, which included psychotropic services, if applicable,
and were completed on a form which contained all elements of the Department’s Individualized
Mental Health/Substance Abuse Treatment Plan Review form. All seven records included
documentation treatment plan reviews were conducted every thirty days as required. Five of the
seven youth did not have a treatment plan review during September 2024 due to the program
being evacuated for Hurricane Milton when the treatment team was planned to meet. These
reviews were completed the week after the program returned from evacuation. All Individualized
Treatment Plans included the following signatures: clinical staff, licensed clinical staff, youth,
treatment team leader, program management, living unit representative, education
representative, medical representative, and the transition services manager. All reviewed
treatment plans also included documentation the parents/guardians and juvenile probation
officers attended the treatment plan reviews by telephone. All of the reviewed treatment plans
included the individualized services, goals, and objectives for each youth. Observations of
clinical groups were completed through video review. Three clinical groups were observed for
three days. Groups were of appropriate size and were held for the required amount of time.
Sign-in sheets were also reviewed, and all groups were held as scheduled, for the required
amount of time, and with the amount of youth required by contract.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
Seven youth records were reviewed for treatment planning documentation. All seven youth were
assigned a treatment team upon arrival to the program as evidenced by a treatment team form
which included the names and titles of all staff, family members, and community members who
were invited to the youth’s treatment team meetings. The documentation reviewed for treatment
teams reflected the following were in attendance: youth, program administration, residential
living unit representative, education representative, medical staff, mental health and substance
abuse staff, and parents/guardians. All seven records included documentation the youth who
were determined to be in need of substance abuse treatment received individual, group, and
family counseling provided by a licensed qualified professional or by a non-licensed clinical staff
in accordance with the Individualized treatment plans. All seven records included a properly
executed Authority for Evaluation and Treatment (AET) and all had a Youth Consent for
Substance Abuse Treatment completed. All reviewed mental health and substance abuse
treatment notes were documented on a form which included all required elements from the
Department’s Counseling/Therapy Progress Notes form. The youth received individual
counseling and psychosocial skills training as determined by a review of progress notes and the
Individualized Treatment Plans.
Seven youth records were reviewed for discharge planning. None of the youth records selected
were applicable. Three additional closed records were selected for review. All three records
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included a discharge plan which was documented on the Department’s Mental
Health/Substance Abuse Treatment Discharge Summary form. All seven Discharge Summaries
included future services needed. The records included documentation the Discharge Summary
was reviewed with the youth, parents/guardians, and juvenile probation officers (JPOs) during
the exit conference and a copy was provided to the 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.”
The program provides Aggression Replacement Training (ART), Seeking Safety, and Living in
Balance as the required clinical groups per a review of the contract. A review of documentation
and sign-in sheets revealed these groups are held two times per week for forty-five minutes
each, exceeding the required four substance abuse groups weekly. Seven youth were
interviewed regarding specialized treatment services. All seven youth reported attending
individual counseling weekly and family counseling monthly. Seven staff were interviewed
regarding group facilitation and all reported direct care staff do not facilitate mental health or
substance abuse groups. The designated mental health clinician authority (DMHCA) was
interviewed about mental health and substance abuse treatment services provided at the
program. The services provided at the program include: individual therapy, family therapy, and
group therapy. The groups provided include ART, Seeking Safety, and Living in Balance for
clinical groups. The interim program director (PD) was interviewed and reported the program
provides Substance Abuse Overlay Services (SAOS) for specialized treatment. One therapeutic
manager has fourteen youth on a caseload and the other two therapeutic managers have
thirteen youth on their caseloads. All non-licensed staff hold a Master’s-level degree. A review
of the youth records revealed the program is conducting individual therapy at least once every
two weeks or more often as needed, family therapy provided monthly or more often as needed,
and the psychiatrist provides services once every two weeks. The DMHCA is on site for at least
forty hours a week and the clinical staff provides on-site services on a daily basis which includes
group therapy.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
Psychiatric services at the program is provided by a licensed psychiatrist who holds a clear and
active license which expires on January 31, 2026. The psychiatrist is available for emergency
consultation twenty-hours per day, seven days a week. A psychiatric Advanced Practical
Registered Nurse (APRN) is also utilized by the program. The psychiatric APRN holds a clear
and active license which expires July 31, 2026. The psychiatrist briefs a representative of the
treatment team regarding the psychiatric status of each youth receiving psychiatric services as
evidenced by updates on the Individualized Treatment Plan reviews. The education, experience,
and licensure of the psychiatric APRN is stated on the Department of Health website. The
psychiatric APRN has a Collaborative Practice Protocol maintained on-site and was provided for
review with no noted issues. A review of the sign-in and sign-out logs confirmed the psychiatrist
conducted visits on-site every other week not exceeding fourteen days as required by contract
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during the annual compliance review period. The psychiatrist actively participates in, manages,
and supervises psychotropic medication services in the program. The psychiatrist was
interviewed regarding psychiatric services. The psychiatrist reported they evaluate the intake
youth for psychiatric problems and access their current medications. The psychiatrist also
follows up with the youth as needed for medication management and adjustment of the
medication as well as stays in contact with the family/guardian about the consent for the
medication and completes any paperwork for the youth. The psychiatrist also reported being
available for the staff to deal with any psychiatric emergencies and telephone consultations.
The psychiatrist reported being on-site every fourteen days and meets with the designated
mental health clinician authority (DMHCA) each time they are on-site and by phone as needed.
The formalized procedure for reviewing medical issues pertaining to the youth is to review the
medical records of all incoming youth and identify the ones who are in need of follow-up and
makes rounds with the nurses every two weeks. The psychiatrist did not have any concerns with
the mental health or substance abuse services at this program. The DMHCA was interviewed
regarding psychiatric services in the program. The DMHCA and psychiatrist meet every two
weeks when the psychiatrist is at the program. While the psychiatrist is on-site, the DMHCA
updates the psychiatrist on any issues with medications and youth.
Seven youth mental health records were reviewed for psychiatric service. Two youth entered
the program on psychotropic medications. Both youth received a diagnostic interview within
fourteen days of admission in accordance with Florida Administrative Code. All seven reviewed
youth were referred for an initial psychiatric interview per the program’s policy and received a
diagnostic interview which was completed within fourteen days of admission. Each initial
psychiatric interview included all required elements of history, mental status examination,
Diagnostic and Statistical Manual of Mental Disorders – Version Five (DSM-V) diagnoses,
treatment recommendations, and initial treatment goals. Two youth were continued on
medications. Both psychiatric interviews documented the explanation for the need of
medications as related to diagnoses, target symptoms, potential side effects, risks and/or
benefits of taking the medication, and frequency of medication monitoring management. The
initial psychiatric diagnostic interviews were documented on a form which included all elements
of the Department’s Clinical Psychotropic Progress Note (CPPN) form and was clearly identified
as such. Both applicable youth were continued on the same medications with no changes. Two
additional youth were placed on psychotropic medications after the initial diagnostic interview.
Three out of the four applicable youth received medications reviews every thirty days. One
youth was missing only one medication review for one month and program staff was made
aware. None of the youth had changes made to their psychotropic medications during any of the
medication reviews. All four records included the following documentation on page three of the
CPPN: identifying data, diagnosis, target symptoms of each medication, evaluation and
description of effect of prescribed medication on target symptoms, the prescribed medication’s
name, dosage, and quantity of the medication, side effects, and youth’s adherence to the
medication regime, and the psychiatrist signature and date. The height, weight, and blood
pressure was documented in each of the youth’s individual healthcare record. Tele-psychiatry is
not utilized at this 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.
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The program has a written plan detailing suicide prevention procedures. The plan was reviewed
and included the following elements: identification and assessment of youth at risk of suicide,
suicide precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, and review process. The plan also included a process for suicide
attempts and mortality review which included the following elements: circumstances surrounding
the event, facility procedures relevant to the incident, all relevant training received by involved
staff, pertinent medical and mental health services, possible precipitating factors, and
recommendations. The suicide prevention plan is reviewed annually with the last review being
conducted on January 3, 2024 by the designated mental health clinician authority (DMHCA),
designated health authority (DHA), and the psychiatrist, as evidenced by their signatures.
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.
Seven youth records were reviewed for suicide prevention services documentation. Five of the
seven records were applicable for review. Four of the five youth were determined to be at-risk of
suicide during their intake to the program. One of the youth entered the program on
precautionary observation. All youth were provided an Assessment of Suicide Risk (ASR) upon
admission to the program per program policy. All five youth were placed on constant
supervision. All five records included documentation the parents/guardians and juvenile
probation officers were notified of the youth’s potential suicide risk. The mental health staff
provided supportive services for the youth. Each assessment was completed by a licensed
mental health professional or by clinical staff being supervised by licensed staff. All five youth
were placed on standard supervision as a result of the ASRs. All five ASRs were completed
within twenty-four hours of screening and was completed by a trained clinical staff. Four of the
five ASRs were completed by non-licensed staff and it was reviewed within twenty-four hours by
the designated mental health clinician authority (DMHCA). One ASR was completed by the
DMCHA. All five youth were on constant supervision while with the therapist during the intake
process. Once screening was completed with the clinical staff and an ASR was administered, all
five youth were stepped down to standard supervision. None of the youth were transitioned to
standard supervision until the non-licensed clinical staff conferred with the DMHCA and program
director. The consultations were documented with the date and time of the meetings on the
ASRs. None of the youth required a follow-up ASR as they were placed on precautionary
observation at admission and stepped down once their intake and ASR was completed with the
mental health staff. None of the youth were applicable for activities while on precautionary
observation due to the youth remaining with mental health clinical staff. A video observation of a
youth on precautionary observation was completed during the annual compliance review week.
The youth slept on a bed in the dayroom and staff was observed watching the youth and
completing the precautionary observation log. The video and logbooks were reviewed and all
documentation was accurate.
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3.12 Secure Observation (Critical) Satisfactory Compliance
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated “Non-
Applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Seven youth records were reviewed for suicide precaution observation (PO) logs. Five out of the
seven records were applicable for review. All five records included all PO logs maintained for
duration each youth was placed on PO. The appropriate level of supervision and observations
of the youth’s behavior was documented in real time and not exceeding thirty-minute intervals.
None of the logs were application for warning signs. All PO logs were observed to be reviewed
and signed by each shift supervisor and mental health clinical staff. Two of the five reviewed PO
logs included documentation of safe housing requirements. Three logs did not have this
documented and program staff was made aware.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Seven pre-service and seven in-service staff training records were reviewed and all seven pre-
service and two in-service staff completed the required suicide prevention training. Three in-
service staff complete the two hour online course, however, was missing the four hour instructor
lead training and one staff was missing the entire six hour training. The program maintains two
suicide kits located in each cottage and each kit is co-located with a first-aid kit. Training
documentation along with all suicide/mental health drills were provided for review. All training
included mock suicide drills each quarter on each shift of the annual compliance review period
for all staff who have regular contact with the youth. A video review was able to be observed of
a conducted suicide drill. It was observed staff called the code and staff were observed
responding with a first-aid kit. Staff continued to respond until the code was cleared. All mock
suicide drills reviewed were in response to a suicide attempt or an incident of serious self-injury.
No youth were utilized in the mock drills. The program conducted two mock drills with the use of
cardiopulmonary resuscitation (CPR) during the annual compliance review period. If there were
any staff not present during the mock drill, the mental health staff reviewed the drill with those
staff members as documented on the drill scenarios. The program maintains a binder of drills
with the scenario and sign-in log for the staff who participated. Seven staff were interviewed
regarding suicide prevention training. Four staff reported they would notify mental health, two
staff reported they would maintain the youth on constant sight and sound, two staff reported
they would notify a supervisor, and one staff reported they would search the youth and their
room for sharp objects. The staff were also interviewed about locations of the knife for life, wire
cutters, and needle nose pliers. Four staff reported it is in the supervisor's office, three reported
they are on the dorms, two staff reported they are in medical, two staff reported it is in dining
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hall, one staff reported in master control, and one staff reported it is in education. Program
administrative staff was made aware of the inconsistencies in knowledge as to where the
suicide kits are located in the program. All seven staff reported suicide drills are conducted
monthly. The interim program director confirmed suicide drills are conducted monthly.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written crisis prevention plan. The crisis intervention plan was
reviewed and included the following elements: notification and alert system, means of referral,
communication, supervisor, documentation, and review.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
Seven youth records were reviewed for crisis assessments. None of the youth selected were
applicable. The program had one youth with a Crisis Assessment during the annual compliance
review period. The record contained documentation the Crisis Assessment was conducted
immediately based upon the needs of the youth. The Crisis Assessment included the following
elements: reason for assessment, mental status examination and interview, determination of
danger to self or others, initial clinical impressions, supervision recommendations, treatment
recommendations, and recommendations for further evaluation. The Crisis Assessment also
documented the notification to the parent/guardian. The Crisis Assessment was completed by a
licensed mental health professional and the alert was entered into the Department’s Juvenile
Justice Information System (JJIS) when the youth was placed on precautionary observation.
The Crisis Assessment did determine the youth posed a safety and security risk and remained
on alert until a follow-up Crisis Assessment was completed. The youth was maintained on
constant supervision which was documented on the Department’s Mental Health Alert
Observation Log. The youth was sent off-site and upon return was placed on constant
supervision and a Crisis Assessment was completed by licensed clinical staff. This assessment
did not involve a PREA event.
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3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a written emergency mental health and substance abuse plan which was
reviewed. The plan included the following elements: immediate staff response, notifications,
communication, supervision, authorization to transport for emergency mental health and
substance abuse services, transport for emergencies under Baker Act Chapter 394 and
Marchman Act Chapter 397, documentation, training, and review.
3.18 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program had two youth applicable for Baker Act procedures during the annual compliance
review period. Both youth were determined to be in need of emergency care by direct care staff.
Direct care staff placed both youth on precautionary observation and notified the designated
mental health clinician authority (DMHCA). Both youth were taken out of the program and Baker
Act procedures were followed. Local law enforcement transported both youth to the local mental
health facility with authorization from the DMHCA. One of the youth returned to the facility and
the other youth was transferred to a detention center upon release from the Baker Act and did
not return to the program. The one applicable youth was placed on constant supervision upon
return to the program and a Mental Status Examination was completed. The DMHCA completed
a Crisis Assessment and a non-licensed clinical staff completed an Assessment for Suicide Risk
(ASR) when the youth returned to the program. The ASR was reviewed and signed off on by a
licensed staff. The youth’s supervision level was maintained until it was appropriate for the
youth to be stepped down to a lower level of supervision.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Seven youth mental health and substance abuse records were reviewed for safety plans. All
seven youth had a safety plan completed on the date of their admission. All seven records
included safety plans jointly prepared by the youth and clinical staff. Four of the seven youth did
not have parental involvement during safety plan development, however, there was
documentation the program attempted contact with the parents/guardians. All reviewed safety
plans incorporated recommendations from previous and current clinical assessments as well as
screening instruments utilized by the program. All safety plans were reviewed every thirty days
as required. Five of the seven youth did not have an updated safety plan during the month of
September 2024 due to the program having to evacuate for Hurricane Milton. Safety plan
reviews were completed immediately upon return to the program. All reviewed safety plans
included the following elements: warning signs, baseline behaviors, crisis recognition, coping
strategies, preferred intervention strategies, and a debriefing process. All safety plans were
reviewed by staff who have contact with the youth. The safety plans are maintained in a binder
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in the designated mental health clinician authority’s (DMHCA’s) office and in each youth record.
Seven youth were interviewed regarding their safety plans and each reported they contributed
to their safety plan. The interim program director (PD) was interviewed regarding safety plans
for the youth and reported the plans are 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 license expires on January 31, 2026. 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, 2026. The back-up physician was not utilized 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 facility’s contract. The DHA
was interviewed, and their responsibilities include completing comprehensive physical
assessments, weekly sick call, policy, and procedure review and monitor chronic conditions.
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 (RN), one licensed practical nurse (LPN), and one of
the RNs 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. 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 160 hours. The
nursing staff is 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 January 3, 2024. FOPs and protocols related to psychiatric services and
psychotropic medication management are developed and reviewed by the program’s
psychiatrist. The psychiatrist reviewed and signed the psychiatric protocols on January 3, 2024.
The nursing protocols were signed by the nursing staff on January 3, 2024. There were no new
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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 January 8, 2024, signifying their understanding of the FOPs and any new health-related
Department policy. 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 seven youth Individual Healthcare Records (IHCR) found six were applicable for the
AET forms. Each applicable 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 of the seven was in the care of the Department of Children
and Families (DCF) and the court had authorized all treatment and procedures. An interview
with the registered nurse (RN) advised the intake paperwork is reviewed and if a new AET is
needed the juvenile probation officer (JPO) is contacted.
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 health care. A
review of seven youth Individual Healthcare Records (IHCR) found five were applicable for
parental notifications for over-the-counter (OTC) medications beyond those covered by the
Authority for Evaluation and Treatment (AET). Six of the applicable IHCRs included
documentation of attempted contact to the parent/guardian in the progress notes when a new
medication was ordered. All six 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 at time of admission. Three 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. One of the youth was in the care of the Department of Children and Families (DCF) and
the court authorized all treatment or procedures. In all seven IHCRs, each youth vaccinations
were verified within thirty days of the youth’s admission. An interview with the registered nurse
(RN) confirmed verbal consent is obtained for any OTC not previously approved by the AET or
new prescriptions, significant dosage change or for discontinuing a medication. Verbal consent
is obtained as soon as possible after an order is written by the physician.
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.
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The program has a policy and procedures regarding youth healthcare admission screening and
rescreening each time the physical custody of the youth changes. Seven youth Individual
Healthcare Records (IHCR) were reviewed for a Facility Entry Physical Health Screening
(FEPHS) form. All seven FEPHS form 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.
The interview with the RN confirmed the FEHPS forms are completed following the initial search
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 seven youth Individual Healthcare
Records (IHCR) confirmed all youth were provided a general care orientation upon admission to
the program. The Health Education form in all seven IHCRs included access to medical care,
sick call, what constitutes an “emergency,” medication process, right to refuse care, and what to
do in the case of a sexual assault or attempted sexual assault, the role of non-disciplinary health
care providers, and Standard Universal Precautions were discussed with the youth as
evidenced by their signature documented on the Health Education form in the youth’s IHCR.
The program provides the contractual frequency of health education monthly.
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. Seven youth
Individual Healthcare Records (IHCR) 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. Two youth were applicable for taking psychotropic medication
upon admission, and documented notification to the psychiatrist. According to an interview with
the registered nurse (RN), the RN notifies the DHA by telephone for all admissions on the same
day of admission.
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
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healthcare needs are identified. A review of seven youth Individual Healthcare Records (IHCR)
found each HRH was completed on the day of the admission. All seven 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 focused note in the admission documentation. An interview with the registered nurse
(RN) confirmed the HRH is completed by the nurse during the initial nursing assessment.
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 seven Individual Healthcare Records (IHCR)
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 seven 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 seven youth refused the genital exam which was
documented as “youth refused” on each CPA in the IHCRs, and all seven youth signed a refusal
form which reflected the refused portion on the CPA. The CPA in all seven records included
documentation of the most recent verified Tuberculosis Skin Test (TST) 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
the DHA completes the initial CPA within seven days of admission.
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 (STI) 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 seven Individual Healthcare Records (IHCR) found all youth were clinically screened
and evaluated for STIs on the date of admission. All seven of the IHCRs were applicable for
further evaluation or referred to the DHA and was documented on the Department’s Sexually
Transmitted Infections form. All testing, screening, clinical evaluations, and diagnoses were
documented on the Department’s Infectious and Communicable Diseases (ICD) forms,
excluding the HIV results, and were filed in the lab section of the IHCR. None of the youth were
out of the Department’s physical custody; therefore, a rescreening was not applicable. All seven
were offered counseling, testing, and referral for treatment for HIV. One of youth consented to
receive an HIV test and had documented consent from the youth. The HIV results were filed
confidentially in a sealed envelope marked “Confidential”. The envelope was signed by the DHA
as proof of review. Documentation included pre/post test counseling in the IHCR of the one
applicable youth. The program’s policy ensures the youth’s HIV test results are only disclosed to
the youth’s legally authorized representative, health care providers during treatment, the
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Department of Health for purposes of reporting, health facility staff committees conducting
facility monitoring, medical personnel who have been subject to significant exposure, and health
care facility personnel or agents for healthcare provider who have a need to know during patient
care. Pre and post-test counseling services are provided by the DHA. Seven youth were
interviewed, and all seven advised testing can be requested. An interview with the registered
nurse (RN) confirmed all youth are interviewed during the initial assessment to obtain history
per the DHA’s standing admission orders. All youth are screened for STI’s 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. None of
the youth presented with a similar sick call complaint three or more times within a two-week
period. Four of seven youth had a sick call request, one was addressed by the registered nurse
(RN) and three by the licensed practical nurse (LPN). The three reviewed by the LPN was
reviewed in person with the RN and documented on the form. 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 Health Services Rule, including vital signs,
treatment, education, and follow-up plans. Each of the sick call events were documented on the
Sick Call Index and on the program’s Sick Call Referral Log. All the dates listed on the Sick Call
Index corresponded to the completed Sick Call Request forms located in the youth IHCRs. Sick
call occurs seven days per week twice a day. Sick call hours are posted on the medical office
door and living units, sick call forms are located on the living units. An exam table and
equipment are used to perform sick call. Seven youth were interviewed and all six advised
seeing a nurse immediately and one advised seeing a nurse within one day of completing a sick
call request. All seven youth advised the ability to see a doctor or dentist if needed. An interview
with the nurse advised youth can submit a sick call at any time by placing it in the sick call box.
The box is monitored at a minimum of once a day. A sick call was not completed while review
team was on-site therefore could not be observed.
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 seven youth Individual Healthcare Records (IHCR) found six youth
required on-site episodic care. In all IHCR’s, the on-site care was provided by a licensed
healthcare staff documented 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, kitchen, 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
expiration or deterioration. An observation of three first-aid kits confirmed the kits were fully
stocked with designated health authority (DHA) approved contents. The nurse monitors the first-
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aid kits weekly and checks 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. The nurse
conducted a self-test of the AEDs in front of the regional monitor with no issues. The batteries of
the AED were last changed in June 2024 and expire in June of 2026. The AED pads were
changed January 2024 and expire in January 2029.
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 fourteen training
records confirmed all staff were trained in episodic, first-aid, and emergency care, and the
administration of the epinephrine auto-injector. An episodic care even was not completed while
review team was on-site therefore could not be observed. 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 for
youth. Naloxone (Narcan) Nasal Spray should not be ordered for each individual youth. Storage:
Naloxone Nasal Spray kit stock must be maintained in a designated area. Naloxone Nasal
Spray Kits 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 kit when there is 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. Seven interviewed staff confirmed the ability to call 9-1-1 in the event of
an emergency. Seven youth were interviewed, and each youth confirmed a doctor can be seen
if needed. The RN advised episodic care if completed by a non-licensed staff can completed the
required form HS-049 to notify nursing staff upon their return to assess youth who received
treatment.
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 health care provider. A review of seven Individual Healthcare
Records (IHCR) found four were applicable for off-site care. In all four applicable IHCRs, 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. One youth was
applicable for discharge documentation, and 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 IHCRs. None of the youth required follow-up testing, referrals, or appointments. The
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registered nurse (RN) confirmed the designated health authority (DHA) is notified of all medical
off-site care and is flagged for review.
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 seven youth Individual Healthcare Records (IHCR) found three 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. Two of the youths were taking prescribed medication on an on-going basis and were
updated after the periodic evaluation. One youth was undergoing treatment for physical health
condition. All three applicable youth for chronic conditions were classified with a medical grade
of two to four and 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 nurse confirmed the youth are identified upon
intake or by the designated health authority (DHA) to having a chronic condition. The youth is
then placed on the medical tracker for monitoring and tracking of due dates.
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 seven youth Facility Entry Physical Health Screening (FEPHS)
found two youth were taking medication at the time of admission. Each of the youth medications
were verified prior to the youth being admitted into the program, and the prescription notification
was documented and, in the 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
seven youth IHCRs found five youth were applicable for current medications to be continued,
discontinued, changed, or for new medications to be ordered. Each of the five-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. Five of the
youth were applicable for over the counter (OTCs) and were administered according to
approved protocols. The Department 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 of the youth’s medications. There were no undocumented
explanations for lapses or errors in medication administration for any of the reviewed IHCRs.
The registered nurse (RN) documented side-effects monitoring weekly on the MAR for all five
reviewed IHCRs. The MAR contains all required elements. The youth initialed each provided
medication entry. There were no indications of lapses or errors in medication administration.
None of the youth had any refusals of medication. Two of the youth were applicable for
psychotropic medication subsequent to admission. There were no standing orders for
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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 escorted by the youth care worker counselor and approached 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 was
maintained in each of the youth records. Seven youth were interviewed, and two advised nurse
provides medication and five advised no medication. An interview with the nurse advised
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. All medications were stored in a separate, secured area, inaccessible to the youth.
Narcotics and other controlled medications were 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 presents. 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 would maintain a shift-to-shift inventory of all
controlled substances in the event a youth is prescribed a controlled substance and document
this 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. Four 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 registered
nurse (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 rule. The interview with the nurse confirmed the process for disposal and destruction of
medications.
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
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(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) and program director (PD) on February 7,
2024. The program’s infection control procedures include prevention, containment, treatment,
and reporting requirements related to infectious diseases, as according to Occupational Safety
and Health Administration (OSHA) federal regulations and the Centers for Disease Control and
Prevention (CDC) guidelines. The plan addresses common 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’s Exposure Control and Infection Control Plan is written in accordance
with the OSHA standards. 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 evaluation. Any exposure incident will be immediately reported to the PD by
the chain of command. In the public sector, the employee will complete a First Report of Injury
or Illness Form within twenty-four hours. Private sector employees under contract with the
department will complete the OSHA 300 or their private insurance carrier’s first report of injury.
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 was written in accordance with OSHA
standards and is in breakroom, master control, and the medical department. An interview with
the interim PD confirmed the plan is in master control and it is reviewed monthly. An interview
with the nurse confirmed the training and location of the plan.
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, is indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures regarding youth supervision. The policy and
procedures require a staff-to-youth supervision ration of one-to-eight during daytime activities
and one-to-twelve during sleeping hours. During each day of the annual compliance review
week, staff were observed to be in ratio with youth. Three staff were interviewed regarding how
many youth were in their direct supervision and two were able to respond, without counting the
correct number of youth. One staff counted one extra youth than was in their supervision when
asked. Throughout the annual compliance review week, staff were observed watching youth
waiting on a bathroom break between education movement, escorting youth to the dining hall,
speaking with youth outside, escorting youth to dorms, in the education rooms, completing
chores, and assisting with a snack pickup. Staff were observed to be interacting positively with
all youth in accordance with the policy and procedures. Each dorm had the daily schedule
posted and available to all youth and all youth were observed to be engaged in activities
throughout the annual compliance review week.
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 regarding a behavior management system (BMS).
The BMS was reviewed and signed by all applicable parties who were involved in the
development, implementation, and ongoing maintenance of it and has not been changed since
the previous annual compliance review. The policy and procedures include a protocol for staff to
receive feedback regarding their implementation of the BMS as well as a process for staff to
discuss with youth any sanctions, youth can explain their behavior, and both discuss alternative,
acceptable behaviors, and reasonable reparations for certain behaviors. The program had a
collaborative agreement with the education providers and the program director (PD) provided
training to the education staff for the BMS. Seven youth records were reviewed, and each
included an orientation packet which documented a review of the BMS. Four reviewed position
descriptions each included the implementation of the program’s BMS, as required. Seven
reviewed staff pre-service training records confirmed staff completed BMS training. Each dorm
was observed to contain a posting of the BMS containing rules governing conduct and positive
and negative consequences for youth to access. The youth handbook also included the BMS for
youth to access. The BMS included all required elements and did not include increased length
of stay, denial of basic rights, promotion of group discipline, punishment of youth by other youth,
or disciplinary confinement as consequences. Staff and youth interactions were observed and
confirmed adherence to all elements of the BMS. The BMS includes a variety of rewards for
youth to earn including access to the RAM room, an area where they are able to relax and play
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video games or read separate from other youth, additional books are allowed, youth can have
access to a music player, and access to the RAM locker where youth can choose items for their
room or personal use while at the program. The BMS did not include any additional special
provisions outlined in the contract. Seven staff were interviewed, and each understood no rights
can be taken away from youth, how to inform youth of consequences, which consequences can
be imposed, rewards youth can earn, and the implementation of behavior reports with the BMS.
Seven youth were interviewed, and each showed an understanding of the BMS, consequences,
and rewards. The interim PD displayed an understanding of the BMS by listing how youth can
make progress by earning their days and weeks to advance to the next level, how rewards are
tracked through daily and weekly reports, how consequences are addressed daily, and monthly
meetings/trainings are held with staff to address implementation of the BMS.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures regarding ten-minute checks. At the time of the
annual compliance review the program had fifty-one cameras throughout the facility and all were
operational. The cameras have a storage capacity of up to thirty days. A review of ten-minute
check logs documented staff wrote each check in real time and initialed the check sheet. The
check logs were reviewed for each month of the annual compliance review period and checks
were completed at least every ten minutes with the exception of one set of checks completed
thirteen minutes late, another completed twenty-one minutes late, two instances of checks
completed one minute late, and one set of checks completed two minutes late. The program
documented early checks as well with some being completed three minutes after the initial
check and others completed every six to nine minutes. A review of nine video checks including
each dorm and applicable shift confirmed staff looked into each youth room, some shone a
flashlight through the window to observe the youth, and checks were completed at least every
ten minutes with the exception of two checks completed one minute late and one completed two
minutes late. Seven staff were interviewed, six responded checks are completed at least every
ten minutes, and one was unaware, however, the staff had not had to complete checks as they
had not worked an overnight shift.
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.
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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 regarding youth census, counts, and tracking. The
policy and procedures require master control to maintain an ongoing count of all youth
throughout each day and all staff escorting youth to be in constant sight and sound supervision
of youth. Observations of youth counts confirmed prior to movement, each youth lines up and
counts off, staff call in the number of youth they are escorting, and master control verifies the
movement. A review of logbooks for the annual compliance review period confirmed counts are
conducted at the beginning and end of each shift, before all movement, randomly throughout
the day, and when youth are admitted, discharged, or temporarily away from the program.
Seven interviewed staff each confirmed the emergency count procedures and knew headcounts
occur every hour during nighttime shifts and every thirty minutes throughout the day.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures regarding logbooks and shift reports. The program
maintains a master control logbook, living unit logbooks, and shift reports. Logbooks from the
annual compliance review period were reviewed and each was bound with numbered pages. All
entries were made in ink and any mistakes were struck through with a single line and initialed by
staff correcting the error. No entries were destroyed or removed and all applicable entries
included the date and time of any incident, names of staff and youth involved, brief description
of the event, and the names and signatures of the staff making the entry. Any incidents reported
to the Department’s Central Communications Center were documented as required. Staff
documented a review of living unit logbooks and shift reports by writing their name. Logbooks
indicated adherence to the daily schedule with minimal interference. The shift reports provided a
brief update on the events, alerts, activities, and any changes in youth status. Shift reports were
maintained on each dorm for forty-eight hours and stored in master control after for staff review.
The program documented all events, incidents, and activities within the logbooks as required.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
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The program has a policy and procedures regarding key control. The policy and procedures
included all required elements. The distribution and collection of keys were observed and
confirmed personal keys are handed in and the master control staff either handed over a chit or
obtained the staff’s work keys from a lockbox. A review of the key inventory confirmed the keys
in use matched those listed. Visitor’s personal keys are stored in the welcome area in a lockbox
and staff personal keys are stored in a lockbox in master control where their program keys are
kept, both of which were not easily accessible while locked. This process was confirmed by the
supervisor through an informal interview. All keys were confirmed to be locked in the lockbox
when not in use. Permanent keys are authorized by the program director (PD) and authorization
forms are maintained by the PD for their verification and review. Restricted keys are only
authorized for use by the positions which require them. The policy and procedures indicated if
keys are damaged, it is reported to the shift supervisor and returned to the PD who is
responsible for discarding them, updating the inventory as applicable, and issuing a new set of
keys. There were no incidents relating to key control reported to the Department’s Central
Communications Center(CCC) or Florida Abuse Hotline throughout the annual compliance
review period. The program maintains a key inventory log to track the issuance and return of all
keys. A sample of five key rings confirmed the number of keys matched what was listed on the
inventory log. Three staff were informally interviewed, and each knew the number of keys on
their key ring and the function of each key. Seven interviewed staff confirmed personal keys are
given to the master control operator, two stated the personal keys are securely stored, one
indicated a chit or token is given in place of the personal keys, five stated program keys are
assigned, one stated youth have no access to keys, and one indicated keys should not be
visible to youth and a search is conducted for any missing keys.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include 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 regarding contraband procedures. The policy and
procedures included a clearly delineated list of items considered to be contraband, informing the
youth of potential consequences if found with contraband, disciplinary action towards staff if
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found in possession of contraband, contacting of law enforcement for any illegal contraband,
and searches of the facility grounds, physical plant, of youth, and incoming and outgoing mail.
The interview with the program director (PD) confirmed the policy and procedures. The
program’s visitor sign-in log contains a contraband attestation statement and the staff records all
contained a signed contraband attestation form. The program documented the confiscation and
disposition of all contraband found. One instance of illegal contraband occurred during the
annual compliance review period and the program contacted law enforcement, as required,
however, law enforcement did not take possession of the contraband as it was not found on a
staff or a youth. The disposal of non-illegal contraband was documented in the contraband log
and logbooks. A review of search reports and seven staff interviews confirmed youth rooms and
areas accessible to youth are searched at least once a week. Different rooms and areas are
searched on a rotating basis each day throughout the week. The interim program director was
able to relay the contraband policy.
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 regarding search procedures. Youth searches were
observed throughout the annual compliance review week. Searches prior to youth movement
confirmed youth were electronically wand searched and pat searched when exiting education.
Youth were treated with dignity and respect, staff talked youth through the search, and staff of
the same gender as the youth completed the search. One youth returning from a transport was
observed being searched, with no issues noted. A video review of five staff and visitor searches
was conducted, and one exception was noted where the staff’s clear bag was looked at from the
outside but not opened and searched. Seven interviewed staff and seven youth all confirmed
searches occur at 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 a policy and procedures regarding vehicles and maintenance. The program
uses two vehicles to transport youth. Both vehicles had an annual safety inspection,
maintenance records, were locked when not in use, contained a steering wheel lock, had the
appropriate number of seatbelts, had a safety screen, and had a go bag which contained the
first-aid kit, fire extinguisher, seatbelt cutter, and window punch. Both vehicles’ doors to the
passenger area could not be opened from the inside. Five random vehicles were checked, and
all vehicles were locked when not in use. Seven interviewed youth confirmed they have never
seen any contraband inside the vehicles, and all confirmed they were only secured with a
seatbelt, handcuffs, and leg cuffs. Seven interviewed staff confirmed seatbelts and handcuffs
are used to secure youth, and four additionally stated leg cuffs. All staff indicated they take a
program cellular telephone on transports with three additionally indicating radios. Five staff
stated first-aid kits are brought on transports and one added a seatbelt cutter and window punch
are brought.
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5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures regarding the transportation of youth. The policy and
procedures included all elements required by Florida Administrative Code. The policy and
procedures and an informal interview with staff confirmed a program cellular telephone is issued
to staff transporting youth who are required to call the program upon arrival and departure. A
ratio of one staff to five youth, not including the driver, is maintained on all transports. A
transport of one youth confirmed two staff went with the youth to the off-site appointment and
one staff was the same gender as the youth. Observations confirmed both staff and the youth
were secured in the vehicle with a seatbelt and the youth was wearing hand and leg cuffs. The
program tracks staff driver’s licenses and driving record information to ensure the approved staff
are able to continue completing transportation. Youth are not permitted to drive program or staff
vehicles. Seven interviewed staff confirmed personal vehicles cannot be used to transport
youth, six stated vehicles are searched prior to and after use, one indicated they are not
searched, and all seven were aware of the emergency response procedures and proper ratios.
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 for weekly safety and security audits. The policy and
procedures addressed all required elements of the auditing process. The program director (PD)
is responsible for conducting audits, implementing corrective action, and following up to verify
the actions have been completed. A review of documentation confirmed the program conducted
audits weekly throughout the annual compliance review period. The program followed up and
documented any repairs which were completed. The program had no deficiencies regarding
weekly safety and security checks during the annual compliance review period. The interim
program director indicated the weekly audits assist the program in addressing any issues.
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 tool inventory and management which
ensure youth do not use tools or equipment as weapons or for security breaches. The
procedure addresses the issuance, inventory, and control of the equipment and tools. All tools
are inventoried prior to being issued for work and all tools are inventoried following work
activities. The program inventories sharp-edged tools daily except on days not used and there is
a monthly inventory of all tools without sharp edges or points. The tools in the living areas and
the maintenance building are clearly marked for identification. A locked shadow board is kept in
the maintenance building. Some of the tools were seen locked up were a large wrench, box
cutters, a saw, wire cutters, an Allen wrench, and hammers. Ten reviewed tools confirmed each
was secured, marked for easy identification, and the inventory matched for all but the box cutter.
The program explained the inventory had recently been updated and they would follow up with
the maintenance mechanic. Machetes, bowie knives, or other long blade knives are prohibited.
If a tool is missing staff shall notify the program director (PD) and the maintenance supervisor
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immediately. A tag is placed on the shadow board until a replacement tool is in its place. If a
sharp-edged tool goes missing during a youth activity the PD is notified and the staff member
supervising the activity writes an incident report, documents in the logbook and calls the
Department’s Central Communications Center (CCC) in the required time frame. A kitchen
knife did go missing and was found on a youth. The CCC was called immediately, and the knife
was returned to the kitchen.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries to themselves, other youth, and staff. Seven youth
case management records were reviewed and all seven had a risk assessment completed
along with training and a test in which they passed. Procedures included established ratios, tool
distribution and collection, and search criteria during work projects. Youth using tools were not
able to be observed during the annual compliance review week. Seven staff interviews were
conducted, and all confirmed youth were allowed to use only class B tools, specifically mops
and brooms. Seven youth interviews were reviewed and established the youth were allowed to
clean with mops and brooms.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a policy and procedures which establish guidelines required for outside
contractors, which includes information regarding tool control and restrictions. The sign-in
sheets were reviewed for outside contractors. There were no issues, and the forms were filled
out properly. The guidelines for the outside workers included the tools being checked at arrival
and departure. Youth were restricted from the area being worked on and there were no missing
tools noted. Five project invoices were reviewed and the dates on the invoices matched up with
the sign-in sheets. All tools were inventoried upon arrival and departure and 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 the drill documentation confirmed the program conducts the Department approved Continuity
of Operations Plan (COOP) drills monthly on all shifts. The drill forms documented the type of
drill, date and time, the participants, a scenario, and findings with recommendations if needed.
The program had evacuation routes and egress plans posted in all buildings. There are twenty-
three fire extinguishers at the program, and all were inspected annually with the date clearly
legible. Reviewing seven staff interviews, it was confirmed fire drills, suicide/mental health,
medical, escape, and tornado drills were all completed. The seven interviewed youth confirmed
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drills were completed monthly or more often. The youth all knew what to do in case of a fire at
the program.
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) located in the program’s administration office and on each dorm in which all staff can
review. The COOP was updated on April 3, 2024, and approved on April 24, 2024. The COOP
contains listed relocation sites in case of an emergency. The program did relocate due to
Hurricane Milton. The equipment and supplies are located in the kitchen which include canned
goods, water, extra clothing, first-aid supplies, and blankets. The COOP addresses phases of
the disaster plan and management including preparedness, response, and recovery. Different
types of emergencies are included in the COOP such as fire, severe weather, program
disturbances, hostage situations, bomb threats, chemical spills, flooding, and terrorist attacks.
The program keeps a binder in the administration office with the COOP containing the youth’s
information. The information includes full name, Department identification number, admission
date, date of birth, recent picture, gender, race, guardian information, juvenile probation officer
contact information, names of the committing judge, state attorney, youth’s attorney, committing
offense, notation of jurisdiction retention, victim notification if applicable, a physical description
of the youth, their overall health status, and personal physician if known.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and 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 maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures for the program director (PD) to maintain strict control
of flammable, poisonous, toxic items and materials and a complete inventory of all such items.
The policy states no hazardous materials shall be stored in the program living areas. All
hazardous materials are monitored monthly by the maintenance staff and any discrepancies
shall be reported to the PD who also serves as the designated safety and security coordinator.
All cleaners and toxic items are stored and locked in maintenance and in the laundry rooms.
Positions which can handle toxic items are listed as maintenance staff, youth care workers, shift
supervisors, master control, kitchen and medical staff, and the PD. The program’s policy states
the maintenance staff is responsible for the safe and lawful disposal of hazardous items. It
should be noted no hazardous items were disposed of during the annual compliance review
period. The program disposes of hazardous waste through a bio-hazardous contractor. The
maintenance personnel was out on extended leave during the annual compliance review week.
Liquid waste is disposed of in one of the plumbing drains and kitchen waste, minus grease, was
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disposed of in the kitchen. When staff become aware of a chemical spill, they notify master
control of the location, and the shift supervisor has control of the shut-down for all air handlers
and ventilations systems. If needed, the program contacts assistance from outside of the facility.
The interim PD was interviewed and reiterated policy and procedures. Ten chemicals were
observed, and all were secure with no discrepancies. A Safety Data Sheet (SDS) was included
in a binder in the maintenance building and in the laundry rooms.
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 and supervision for flammable, toxic,
caustic, and poisonous items. Youth are prohibited from using and possessing flammable, toxic,
or caustic materials at the program and the program maintains strict control of these items. The
youth cannot clean up hazardous items nor do they handle or dispose of any person’s bio-
hazardous material, bodily fluids, or human waste. The seven youth interviews confirmed no
chemicals are used by youth.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
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Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program allows visitation and communication for youth while in the program. The visitation
schedules are posted in both dorms. The visitation log and schedule confirmed visitation was
every weekend and family day is one time each month on a weekend. All paperwork and sign-in
forms were filled out properly except the date of May 4, 2024, where one staff’s information was
missing. Identification cards were checked, rules were provided, searches were completed, and
staff initials were all completed in the visitation log. The telephone log was reviewed, and each
youth is scheduled for a day to make a call, typically on weekends, and additional times for calls
can be scheduled for youth to communicate with approved people. All mail, both outgoing and
incoming, is searched in front of the youth. The mail log was reviewed, and mail can be sent
and/or received any day of the week. The youth handbook shows the youth how to address an
envelope. Case management verified any youth with a human trafficking background would
require clarification from the juvenile probation officer to verify the youth’s guardian and other
family members are not under current or past investigation for human trafficking-related
charges. The interviewed interim program director reported the program has an agreement with
the Language Line Services for all third-party language assistance. Five of seven interviewed
youth knew there were services for non-English speaking youth and two youth were not aware
of any services for youth who do not speak English as a first language.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program shall provide a variety of recreational and leisure activities. The program’s activity
schedule documented a range of supervised and structured indoor and outdoor recreational and
leisure activities, and a large muscle activity is provided. The logbook indicated recreation was
conducted as scheduled. The activities promote social and cognitive skill development,
creativity, teamwork, healthy competition, mental stimulation, and physical fitness. The program
takes precautionary measures to ensure youth are safe during activities. The recreational
therapist position was vacant at the time of the annual compliance review; however, one did
work for four of eleven months and provided service to youth as required. Seven reviewed
individualized performance plans verified each youth had a recreational goal. Seven interviewed
youth noted they were offered football, basketball, and workouts in the gym. Seven interviewed
staff noted at least one hour daily is available to the youth for activities. Indoor activities included
board games, watching television, checkers, and cooperative games.
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5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The 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.
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report_type: QI Residential

rule: Indicator 1.08

excerpt: In-Service Training

rating: Limited Compliance

rule: Indicator 1.17

excerpt: Special Contract Conditions

rule: Indicator 2.05

rating: Failed Compliance

rule: Indicator 2.08

excerpt: Youth Needs Assessment Summary (YNAS)

rule: Indicator 2.11

excerpt: Performance Summaries and Transmittals