summary: QI Residential - FY23-24 - 3 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Polk Halfway House
TrueCore Behavioral Solutions, LLC
(Contract Provider)
2145 Bob Phillips Road
Bartow, Florida 33830
Review Date(s): November 14-17, 2023
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Nicos Antonakos, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Rob Aguis, Career and Technical Education Deputy Director (Standard 1)
Christine Calvert-Joyner, Office of Accountability and Program Support, South Region
Supervisor (Standard 1 and Interviews)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Evan Hald, Office of Education, Southwest Region Education Coordinator (Standard 2)
Yvrose Sylvain, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Sharon Wong, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Program Name: Polk Halfway House MQI Program Code: 1049
Provider Name: TrueCore Behavioral Solutions, LLC Contract Number: 10359
Location: Polk County / Circuit 10 Number of Beds: 24
Review Date(s): November 14-17, 2023 Lead Reviewer Code: 180
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
3.06 Mental Health and Substance Abuse Treatment*
3.08 Specialized Treatment Services*
5.16 Fire, Safety, and Evacuation Drills
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 71 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 71 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Non-Applicable
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 71 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 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* Limited
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Limited
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 71 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 71 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Limited
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
5.25 Controlled Observation Non-Applicable
5.25 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 71 (Revised September 2022)
Program Overview
Polk Halfway House is a twenty-four-bed program for ten- to fourteen-year-old males; however,
the program provides services for males up to sixteen-years-old, as needed. The program is
located in Bartow, Florida. The program is operated by TrueCore Behavioral Solutions, LLC,
through a contract with the Department. The program provides Mental Health Overlay Services
(MHOS), which are provided to youth with moderate to serious mental disorders and who may
have co-occurring substance-related disorders. In addition, the program fosters each youth by
providing Thinking for a Change (T4C) and Impact of Crime (IOC) as evidenced-based practices
as well as Anger Management for Substance Abuse and Mental Health, Skillstreaming the
Adolescent, Adolescent Career Development, Thinking Feeling Behaving, and Strategies for
Anger Management. Additional treatment services include individual and family therapy.
Program administration is comprised of an interim facility administrator and one assistant facility
administrator. Case management services are provided by one case manager and one
transitional services manager. Mental health staff at the program includes one director of clinical
services who is a licensed mental health counselor and serves as the designated mental health
clinician authority (DMHCA), two non-licensed therapists, one recreation therapist, and a
contracted psychiatrist. Medical services are offered 8:00 a.m. to 4:30 p.m. daily and are
provided by one full-time registered nurse (RN) who is the health services administrator (HSA),
one licensed practical nurse (LPN), one pro-re-nata (PRN) part-time LPN, and a contracted
medical doctor (MD) who serves as the designated health authority (DHA). Educational services
are provided by the Polk County School District. The layout of the program includes one large
building which houses administration, classrooms, case management, a clinic, dormitory rooms,
and a youth dayroom. The program has thirty-seven operating security cameras providing
coverage, and all were operational. During the time of the annual compliance review, the
program had nine vacant positions including one case manager, one facility administrator, two
youth care worker IIs, four youth care worker Is, and one transition services manager.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 71 (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 maintains a written policy and procedures to ensure all newly hired staff and
volunteers receive an initial background screening. The program had fourteen newly hired staff
and one volunteer since the last annual compliance review. A review of the staff records found
each of the twenty-three staff received a background screening prior to contact with youth and
confidential records. Documentation reflected a criminal history report was reviewed and the
Staff Verification System (SVS) module was updated for each of the fourteen staff. None of the
reviewed records were applicable for obtaining an exemption prior to working with youth or for a
break in service. The program utilizes a pre-employment assessment tool for all direct-care
staff. Reviewed documentation reflected each of the applicable newly hired staff received a
passing score on the pre-employment assessment tool prior to hire. A background screening
was completed for the new volunteer prior to contact with youth and the SVS module was
updated. There were no interns eligible for an initial background screening since the last annual
compliance review. The Annual Affidavit of Compliance with Level 2 Screening Standards was
submitted to the Department’s Background Screening Unit (BSU) on December 13, 2022,
meeting the annual requirement. The Polk County School District, which provides teachers for
the program, submitted the Annual Affidavit of Compliance with Level 2 Screening Standards to
the BSU on December 13, 2022.
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 maintains a written policy and procedures to ensure all staff and volunteers
receive a background rescreening every five years from their initial hire date. The program’s
administrator tracks each staff’s hire date and intern/volunteer’s start date to determine when
the five-year rescreenings should be submitted. The program had four staff applicable for a five-
year rescreening since the last annual compliance review. Each staff’s rescreening was
completed and submitted to the Department’s Background Screening Unit at least ten business
days prior to each staff’s five-year anniversary. There were no volunteers or interns applicable
for a five-year rescreening since the last annual compliance review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 71 (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 maintains a written policy and procedures ensuring an environment free of abuse
and neglect and in which youth and staff feel safe and secure. The policy reflects youth and
staff have unhindered access to reporting alleged abuse to the Florida Abuse Hotline. The
policy outlines the reporting procedures for staff to follow when a youth would like to make an
abuse call. Additionally, the program maintains a staff handbook which outlines the program’s
code of conduct. All staff are required to sign and acknowledge receipt of the staff handbook
and code of conduct which outline the grievance policies and their understanding of the
program’s code of conduct. A review of five staff records found each record contained
documentation of acknowledgement, receipt, and review of the program’s code of conduct.
Observations conducted during the annual compliance review week found postings of the
Florida Abuse Hotline and the Department’s Central Communications Center (CCC) telephone
numbers throughout the program. The program has a telephone in the youth dayroom area
which directly connects to the Florida Abuse Hotline. Once a youth requests to conduct an
abuse call, the youth care worker informs the shift supervisor, and the youth is allowed to make
an abuse call. The reviewed documentation and an interview with the interim facility
administrator (FA), verified the program completed the Trauma Responsive and Caring
Environment (TRACE) self-assessment on February 21, 2023. The interim FA stated all staff
are trained during orientation on trauma-responsive practices and received a yearly refresher
during in-service training. A review of all incidents since the last annual compliance review
found there were five alleged incidents which involved complaints related to physical,
psychological, or emotional abuse since the last annual compliance review. Two incidents were
closed as substantiated for improper conduct by staff. The Florida Abuse Hotline and the CCC
were notified as required for each reviewed incident. There were no applicable cases for any
potential human trafficking victims, children of sexual exploitation, or labor trafficking reported at
the time of the annual compliance review. Five youth were interviewed, and each reported
feeling safe at the program. All five interviewed youth stated they had never been stopped from
calling the Florida Abuse Hotline or the CCC since they have been at the program. Each of the
five youth knew the Florida Abuse Hotline number was posted throughout the program, and
there was a direct line telephone available for youth to use. Each of the youth stated staff were
respectful when speaking with youth, and on occasion may use curse words. None of the
interviewed youth exchanged emails, telephone numbers, or social media contact information
with staff. Five staff were interviewed, and each knew the process for allowing the youth to call
the CCC and the Florida Abuse Hotline. All interviewed staff reported they never observed a
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Office of Accountability and Program Support Page 11 of 71 (Revised September 2022)
coworker telling a youth they could not make an abuse call. Four of five interviewed staff stated
they never heard a coworker use profanity towards the youth. One staff stated they heard a
coworker using profanity; however, this was corrected by management. The interviewed interim
FA stated the program’s code of conduct includes standards for professional conduct, and
corrective actions to address behavior and employment problems. If a staff has been accused of
physical abuse, threats, and/or profanity towards youth, the staff is placed on leave pending a
complete investigation for any allegations of physical abuse, threats, or profanity toward youth.
In addition, all staff are trained on how to make reports to the CCC or Florida Abuse Hotline.
Staff are trained to call the CCC or Florida Abuse Hotline if they suspect abuse or neglect of
youth. The staff understand they are mandated reporters and receive yearly in-service training
updates to ensure staff are knowledgeable for contacting the CCC or Florida Abuse Hotline. The
interim FA reported program youth are asked during treatment team if their access to call the
Florida Abuse Hotline has been impeded.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program maintains a written policy and procedures regarding abuse reporting, which is
following the Department’s criteria for reporting abuse. The program’s practice is to initiate an
internal investigation regarding the complaint and remove the staff involved from contact with
youth, when necessary. The program had five allegations related to physical, psychological, or
emotional abuse involving a staff or other youth since the last annual compliance review, and all
were reviewed. Two of the five reviewed allegations were unsubstantiated, one allegation was
still under review, and two allegations were closed as substantiated for improper conduct by
staff. An interview with the interim facility administrator (FA) reported management investigates
all allegations of abuse or neglect and make recommendations based on findings immediately.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program maintains a written policy and procedures regarding response to incidents in
accordance with Florida Administrative Code. The program had thirteen reportable incidents
since the last annual compliance review. A review of five incidents found each was reported to
the Department’s Central Communications Center (CCC) within two hours of the incident or staff
becoming aware of the incident. All the five incidents were documented in the program’s
logbook. A review of the program’s internal incident reports found there were no incidents which
should have been reported to the CCC and were not. The program has experienced a decrease
in the number of reportable incidents to the CCC compared to the last annual compliance
review period.
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Office of Accountability and Program Support Page 12 of 71 (Revised September 2022)
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program maintains a written policy and procedures regarding the utilization of physical
intervention techniques in accordance with Florida Administrative Code. The program had
seven Protective Action Response (PAR)/Right Interactions (RI) incidents since the last annual
compliance review. There was documentation to support a monthly summary of PAR/RI Reports
was submitted to the Department each month since the last annual compliance review. A review
of the five PAR/RI Reports found all involved staff completed appropriate statements prior to the
end of their shift. The PAR/RI Reports were reviewed by a PAR/RI-certified supervisor. The
PAR/RI Reports were reviewed and processed within seventy-two hours by all required parties.
A copy of the PAR/RI Report was placed in the program’s centralized file within forty-eight hours
of approval by the facility administrator (FA) or designee. The program’s PAR/RI training plan
was approved by the Department’s Office of Talent, Leadership, and Culture on January 9,
2023. None of the reviewed reports documented the use of mechanical restraints. Five reviewed
PAR/RI Reports did not result in injury to the youth or staff. Reviewed documentation indicated
there were no allegations of abuse by the youth during the PAR/RI incident. None of the
reviewed post-PAR/RI interviews indicated a need for a medical review. The program
experienced a decrease in the number of PAR/RI Reports compared to the last annual
compliance review period. The program’s PAR/RI rate during the previous quarter was 2.32,
which is above the statewide Residential PAR/RI rate of 1.82. Four of five interviewed staff were
able to explain the program's PAR/RI process and procedures. One staff was not required to be
PAR/RI certified and did not conduct PAR/RI due to their position description. Two interviewed
staff stated they had used PAR/RI and three had not used PAR/RI. An interview with the interim
facility administrator (FA) reported the program’s management team reviews all PAR/RI related
incidents and use of force to ensure all PAR/RIs are complete according to policy. The
management team completes a camera review of the incidents and meets with all staff involved
for the post-PAR/RI interview.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program maintains a written policy and procedures regarding a pre-service training plan for
all new staff. The pre-service training is provided through a combination of instructor-led and
web-based courses. Five staff training records were reviewed for pre-service training. All five
reviewed training records documented each staff completed the pre-service training within 180
days of hire. All five staff training records showed documentation to support each staff exceeded
the required 120 hours of pre-service training. Required trainings included Protective Action
Response (PAR)/Right Interactions (RI), first-aid, cardiopulmonary resuscitation (CPR),
automated external defibrillator (AED), professionalism and ethics, suicide prevention,
emergency procedures, child abuse reporting, facility operating procedures, and Prison Rape
Elimination Act (PREA), prior to having any contact with youth. In addition, staff completed
active shooter training, standards of conduct, adolescent development and behavior, restorative
justice, the Department’s Central Communication Center (CCC) reporting, civil rights,
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communication, Confidentiality/Health Insurance Portability and Accounting Act (HIPAA),
Department of Juvenile Justice Legacy, Equal Employment Opportunity, gang awareness,
human trafficking intervention, infection control, information security awareness, Department’s
Juvenile Justice Information System (JJIS), mental health and substance abuse, motivational
interviewing (MI), quality report writing, safety, security, and supervision of youth, sexual
harassment, effective and respectful treatment of youth, and trauma response practices.
Reviewed documentation confirmed staff were trained in the grievance process, behavior
management system (BMS), and the intended and safe use of tools. Shift supervisors, youth
care workers, and the recreation therapist are counted in the staff-to-youth ratio. All completed
trainings were documented in the Department’s Learning Management System (SkillPro) and
were delivered by qualified trainers.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program maintains a written policy and procedures regarding in-service training for all staff.
Five staff training records were reviewed for in-service training which included two supervisors.
All five reviewed staff training records documented each staff exceeded the twenty-four hours of
annual in-service training requirements. All five staff had current certifications in Protective
Action Response (PAR)/Right Interactions (RI), first-aid, automatic external defibrillator (AED),
and cardiopulmonary resuscitation (CPR). Each staff was trained in six hours of suicide
prevention, active shooter, human trafficking intervention, Information Security Awareness,
mental health and substance abuse, Prison Rape Elimination Act (PREA), professionalism,
interpersonal communication, and ethics, sexual harassment, and trauma responsive practices.
In addition, staff were trained in emergency drills, infection control, blood-borne pathogens, and
the Exposure Control Plan. Each staff was trained in Mental Health Overlay Services (MHOS),
which is required by contract, along with additional trainings included in the program’s training
plan. Two supervisor records were reviewed, and each supervisor completed the eight hours of
management and supervisory training which included coaching, leadership, and personal
accountability. The program has a training calendar which is updated as changes occur. All
trainings were delivered by qualified trainers and were documented in the Department’s
Learning Management System (SkillPro). The program maintains a written in-service training
plan which was submitted to the Department’s regional director on December 30, 2022.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program maintains a written policy and procedures regarding the grievance process.
According to the program’s policy, procedures are in place to confirm each youth’s right to
grieve and ensure all youth are treated fairly, respectfully, without discrimination, and their rights
are protected. The program’s grievance procedures include informal, formal, and appeal
phases. Informal complaints are handled as soon as possible, but no later than twenty-four
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Office of Accountability and Program Support Page 14 of 71 (Revised September 2022)
hours from when the youth submitted the informal complaint, which excludes weekends and
holidays. The assistant facility administrator (AFA) investigates any grievance received and
resolves it in writing with the youth within seventy-two hours of receiving the grievance. Youth
are also provided with the opportunity to file an alternative informal request by utilizing a
conference request form as a first opportunity to voice an objection and informally resolve a
complaint. Grievance and conference request forms were available to youth and were observed
during the program tour. A review of documentation verified the program maintains copies of
grievances for the past twelve months. Reviewed documentation found there were five
grievances submitted by youth since the last annual compliance review. A review of five
grievances revealed the youth’s grievances were resolved at the formal phase. Each grievance
was addressed within the seventy-two-hour time frame. Five youth were interviewed and were
able to explain the grievance process to include submission of a completed grievance form into
the secured grievance box. All five interviewed youth reported being able to request assistance
in completing a grievance form if needed. Five staff were interviewed, and each staff was able
to explain the grievance process. An interview with the interim facility administrator (FA)
reported staff are trained on the grievance process during orientation. Youth are informed of the
grievance process at orientation and are provided with a handbook detailing the grievance
process. The grievance process is a three-part process which includes an informal conference
request. If the youth's issues are not resolved, the youth can write a formal grievance and place
it in the grievance box which is checked twice a day. The grievances are responded to within
seventy-two hours.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program has a written policy and procedures regarding delinquency interventions and
facilitator training. During the annual compliance review period, the program provided
documentation the therapists conducted clinical groups to include Anger Management for
Mental Health and Substance Abuse Clients, Strategies for Anger Management, Thinking,
Feeling, Behaving, and Skillstreaming the Adolescent groups. The only non-clinical non-primary
group outlined in contract is the Adolescent Career Development group. All three therapists had
a master’s-level degree or licensed mental health counselor credentials and were trained to
facilitate all of the program’s groups. A review of the program’s activity schedule verified all
contractually required groups were provided as scheduled. A review of the program’s activity
schedule confirmed the program is providing structured, planned programming, or activities at
least sixty percent of the youth’s waking hours. An interview with the interim facility administrator
(FA) and reviewed sign in sheets verified the therapists conducted Adolescent Career
Development groups. An interview with the program’s clinical director indicated group services
are provided at least four days a week for forty-five minutes. At the time of the annual
compliance review there were two non-licensed therapists and a licensed clinical director
providing services.
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Office of Accountability and Program Support Page 15 of 71 (Revised September 2022)
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 maintains a written policy and procedures to address life skills training for youth.
The program provides life skills training through Skillstreaming the Adolescent, psycho-social
skills training, and career development groups. The life skills groups specifically address
communication, interpersonal relationships and interactions, non-violent conflict resolution,
anger management, and critical thinking. A review of the program’s activity schedule and sign-in
sheets confirmed life skills training groups are provided to the youth once a week by the
therapist. All staff conducting groups received formal training and on-the-job training by a
certified trainer to deliver the curricula. Five interviewed youth reported they participated in life
skills group while at the program. Each of the five interviewed youth stated they practice new
skills learned in group by participating in role play activities. The interviewed clinical director
confirmed Skillstreaming the Adolescent, psycho-social skills training, and career development
groups provide life skills training to the youth at the program. The interviewed interim facility
administrator (FA) verified the program is providing life skills groups to the youth.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s restorative justice programming includes Impact of Crime (IOC) groups which is
a primary service. In addition, youth participate in reparation activities at the program. The youth
participate in community service projects, such as assisting maintenance staff with cleaning of
the program, assembling food baskets for families in need, assisting with the elderly at the local
assisted living facility, writing victim letters, and assisting with outside community clean-up
projects. The program had one guest impact speaker during the annual compliance review
period. The groups and activities are designed to assist youth in accepting responsibility for
harm they have caused by their past criminal actions, challenging them to recognize and modify
their irresponsible thinking such as denying, minimizing, rationalizing, and blaming victims, and
expose youth to victims’ perspectives through victim speakers. The interviewed interim facility
administrator (FA) confirmed youth participate in community service projects along with
completing IOC groups. An interview with the clinical director confirmed IOC groups are
conducted twice a week. Five interviewed youth confirmed they participated in IOC groups and
four youth stated they participated in community service projects. An informal interview was
conducted with the local pastor, who stated faith-based staff come to the program twice a week
on Sunday mornings and Tuesday nights to speak with the youth. In addition, the pastor
requested youth from the program to assist in setting up food baskets for 100 families in need.
Observations during the annual compliance review week confirmed four youth went to the local
church to assist in preparing Thanksgiving food baskets to families in need.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 16 of 71 (Revised September 2022)
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 written policy and procedures addressing youth alerts. The program enters
an alert into the Department’s Juvenile Justice Information System (JJIS) for youth requiring an
alert which may not have been previously entered prior to the youth’s admission. The program
has an alert board in the main conference room which identifies each youth’s special alerts,
escape risk, and/or gang affiliation. The alert board also identifies youth placed on any type of
mental health and/or medical alert. Reviewed documentation indicated the program’s internal
alert report is reviewed daily during shift briefings by the program's shift supervisory staff. Alerts
are also entered in the logbooks. Five youth records were reviewed for case management,
medical, and mental health alerts. All applicable alerts were accurately entered into JJIS and
documented in the program’s logbook. The entered alerts included the name and title of the
staff entering the alert and were entered in JJIS and the logbook on the same date. The alerts
entered in JJIS and the logbook matched. Five staff were interviewed, and each reported they
are informed of youth alerts during shift meetings, review of the program’s alert board, and
through reviewing the logbook. An interview with the interim facility administrator (FA) confirmed
upon admission into the program, youth records are reviewed for alerts and an assessment is
completed with the youth. Youth are placed on an alert board and alerts are provided to the
leadership team. Staff review logbook entries and the alert board daily when coming on shift.
Administration reviews alerts daily during the morning meeting and changes are updated as
needed. The clinical director enters and closes alerts in JJIS. The interviewed registered nurse
(RN) stated healthcare staff update medical alerts.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program has a written policy and procedures to ensure the management of all records are
consistent across operations and programs, consistent with company philosophy, goals, and
objectives, and consistent with legal and contractual requirements. A review of five youth
healthcare, mental health and substance abuse, and case management records showed each
was marked “Confidential” and each record documented the youth’s name, Department
identification number (DJJID), the youth’s date of birth, county of youth’s residence, date of
admission, and committing offense. Observations during the annual compliance review week
showed all Individual Healthcare Records, mental health and substance abuse records, and
case management records were secured in a locked room, which was not accessible to youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 17 of 71 (Revised September 2022)
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 meets at least every ninety to 120 days.
Reviewed documentation supported the program’s community advisory board meets at least
every ninety to 120 days. The reviewed meeting minutes, sign-in sheets, and agendas
documented meetings occurred on November 3, 2022, March 23, 2023, June 22, 2023, and
September 19, 2023. Documentation showed community advisory board meetings are held in-
person and utilizing a video conferencing software program for those members who cannot
attend in person. The advisory board members consist of a member from law enforcement,
interested community partners, a community business member, a school board member, a
victim advocate, a parent/guardian whose child was previously involved in the juvenile justice
system, and a faith-based community member. A review of community advisory board agendas
and meeting minutes documented the program provides the board members with information
regarding program updates, community updates, and community service activities. An interview
with the interim facility administrator (FA) reported the community advisory board meets on a
quarterly basis. Membership recruitment is on-going through email, letter writing, and phone
calls. An interview with a faith-based community member, who is part of the advisory board was
conducted. The pastor stated his organization has been involved with the program for many
years and they attend the community advisory board on a regular basis.
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 written policy and procedures regarding staff performance reviews. The
program conducts ninety-day performance evaluations for newly hired staff and annual
evaluations for all staff thereafter. A review of five position descriptions verified each staff’s
performance standards were clearly defined. Five staff personnel records were reviewed for
annual performance evaluations. The performance evaluations were specific to the applicable
staff’s job description. All five reviewed performance evaluations found each staff’s evaluation
was based on the performance standards for their position. The evaluations rated the staff’s
quality of work, modeling appropriate behavior, a positive reinforcement in a four-to-one ratio,
and each evaluation included ratings on the staff’s job-specific responsibilities. Five staff were
interviewed, and three staff reported receiving an annual evaluation, one staff reported receiving
a six-month evaluation, one staff reported receiving a ninety-day evaluation, and two staff stated
they receive coaching on a regular basis. Three of the five staff reported communication
amongst the staff at the program is good, and two reported communication is fair. An interview
with the interim facility administrator (FA) indicated staff are provided with a ninety-day
performance evaluation and receive a yearly evaluation to provide them with feedback
regarding their performance.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 18 of 71 (Revised September 2022)
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s contract, eleven amendments, and Memorandum of Negotiation were reviewed
for special contract provisions and/or items not captured within reviewed indicators, and
considered contract specific requirements, which may exceed the minimum requirements
outlined in Florida Administrative Code. Contract specific requirements within this category
include opportunities to create positive changes, the use of trained volunteers/mentors, and the
provision of regular faith-based opportunities. The program has a policy regarding affording
youth the opportunity to participate in community service and off-campus activities. Reviewed
documentation and on-site interviews verified the program youth participate in community
service and community relationship building through restorative justice programming.
Additionally, the program had documentation to support off-site community service events were
occurring. Community service projects were also occurring on-site at least monthly. Five
interviewed youth attested they have the opportunity to complete community service hours at
the program and participate in incentive and educational outings. Reviewed documentation
supported outings were occurring. The program has a policy and procedures regarding the use
of volunteers. The program shall utilize volunteers to provide services and programs for youth
for the purpose of enhancing the activities of the program. The program utilized the mentor
services of a local church and had one guest impact speaker since the last annual compliance
review. The interviewed interim facility administrator (FA) reported the program only had one
motivational speaker due to youth and staff turnover. The program has a policy and procedures
ensuring all program youth have access to faith-based programs and services, at least weekly,
in keeping with their faith. Youth interviews, reviewed documentation, and an interview with a
local pastor verified staff from a local church come to the program on Sunday mornings and
Tuesday nights each week. In addition, the pastor has assisted the program in coordinating
community service for the youth to participate in, and the church plans to send up to twenty staff
to celebrate Thanksgiving with the youth at the program. The interviewed interim FA confirmed
the participation in events/activities. Five interviewed youth verified the program participates in
church, community service projects, and off-campus activities.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 19 of 71 (Revised September 2022)
1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
The program’s Amendment ten to the contract, which was executed on August 23, 2023,
requires the program to provide career and technical education (CTE) services to the youth at
the program. The CTE services include Florida Ready to Work - Soft Skills, cardiopulmonary
resuscitation (CPR)/first-aid, Occupational Safety and Health Administration (OSHA) 10
certifications, and an industry certification from the Master Credential List. The recreation
therapist provides career and technical education services. The recreation therapist has a
bachelor’s degree in psychology and criminology. The program is offering OSHA 10
certification; however, youth are having difficulty earning credentials due to comprehension
skills. The program offers Florida Ready to Work - Soft Skills; however, the youth are having
trouble comprehending the content. The program will begin shifting to Florida Ready to Work -
Digital Skills, which was recommended by Win-Learning. The digital skills will be more age
appropriate for the youth. The program is offering first-aid and CPR training as the pre-
vocational and vocational services. Youth certifications were reviewed, and the program is
currently not offering any certifications from the Master Credential List. Since Amendment 10
was executed, no credentials have been earned by youth. The program does not have a
designated time for CTE built into the education schedule. CTE is offered two nights eeach
week for an hour each night. The program reported CTE is not entirely age appropriate for the
youth in the program; however, the program will work towards offering industry certifications
from the K-8 Digital Tools list of credentials. Participation in CTE was unable to be observed
during the annual compliance review week. Five youth were interviewed, and youth reported
obtaining their CPR certification and learning about various careers in school. The interim facility
administrator (FA) was interviewed and confirmed the program is offering CPR, first-aid, and
OSHA 10. In an informal interview, the regional compliance manager stated the program is
working with the Department’s director of post-secondary and workforce education to set up
industry certification from the Master Credential List for the youth. In addition, the program is
working on obtaining computers for the youth to use, since all the certifications from the Master
Credential List are digital.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 20 of 71 (Revised September 2022)
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 written policy and procedures for reviewing and analyzing data trends to
utilize in decision-making practices. The program uses several different tools which are utilized
for the purpose of data collection and analysis. Aggregate data is accumulated through the
program’s dashboards, electronic records system, survey completion, and use of the
Departments Juvenile Justice Information System (JJIS). The program’s trend analysis and
data-driven decisions are strengthened through an internal database and dashboard system
which allows for daily data entry by every program. This daily process and outcome information
is aggregated into weekly and monthly totals, displayed in interactive dashboards specific to
each program, and provided back to corporate as well as program management for the
purposes of tracking trends and informing risk management. The dashboards are updated every
Monday with the previous week's data, including operations, mental health, health services,
support services, human resources, and the Trauma Responsive and Caring Environment
(TRACE) results. The program shares the trends in monthly staff meetings and postings where
the data trends are easily accessible by staff, educators, and stakeholders. Information is
discussed in daily meetings with administrative staff. Staff are updated monthly, in all staff
meetings, during quarterly advisory board meetings, and monthly corporate senior management
meetings. The findings from trend data analyses are utilized to determine recruitment strategies,
positive morale approaches, update the policy and procedures, youth supervision techniques,
restorative justice programs, and individual and family services.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 21 of 71 (Revised September 2022)
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 written policy and procedures addressing initial contact to parents/guardians
and court notification upon each youth’s admission. Reviewed telephone call verification logs
confirmed the program notifies the youth’s parent/guardian by telephone within twenty-four
hours of the youth’s admission. All five youth records included documentation to support the
youth’s committing court, juvenile probation officer (JPO), and applicable post-residential
counselor were notified, in writing, within five working days of the youth’s admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a written policy and procedures regarding youth orientation. A review of five
youth case management records found the program provided an orientation for each youth on
the day of admission. The programs orientation included services available, daily schedule,
expectations and responsibilities of the youth, written information on the program’s behavior
management system, information on how to access medical and mental health services, access
to the Florida Abuse Hotline or the Department’s Central Communications Center telephone
numbers, contraband, dress code and hygiene procedures, community access, emergency
procedures, services provided, and assigned living units. The program’s standardized
orientation packet included a map of the program indicating designated areas which were not
accessible to youth and a youth handbook. Each record contained a signed acknowledgement
and orientation checklist form signed by the youth and residential case manager documenting
the orientation process. The program’s handbook outlined the program’s rules governing
conduct and positive/negative consequences for behavior. The youth orientation also included
information on the performance plan process, dress code and hygiene requirements,
procedures regarding visitation, mail, and use of the telephone, anticipated length of stay,
grievance procedures, emergency drills, physical design of the program, and assignment to a
living unit. Observations of a youth orientation were not conducted during the annual
compliance review week. Five youth were interviewed, and all reported the program orientation
began within twenty-four hours of admission. Each youth was able to explain their interpretation
of the orientation process. One youth stated their shackles were removed once they reached
the program, they met with the interim facility administrator (FA), met with other staff, was
searched, received the program clothing, had a snack, met with the clinical director, and the
therapist. Additionally, a telephone call was given to them. One youth reported meeting the
clinical director, the case manager talked about levels and privileges, a tour was given, different
rooms were showed, and they met with counselors and staff. The other three youth were able to
recall orientation details about school schedules, rules, and pertinent information.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 22 of 71 (Revised September 2022)
2.03 Written Consent of Youth Eighteen Years or Older Non-Applicable
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has not had any youth eighteen years of age or older during the annual
compliance review period; therefore, this indicator is rated non-applicable.
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 written policy and procedures regarding classification factors and
procedures, including all required elements outlined by the Department’s policy. The admission
classification is utilized for assigning each newly admitted youth to a living unit and sleeping
room. The initial classification factors included, at a minimum, the youth’s physical
characteristics, gender, height, weight, and general physical stature, age, maturity level,
identified special needs including medical, mental health, development or intellectual and
physical disabilities, history of violence, gang affiliation, and criminal behavior. A review of the
Department’s Juvenile Justice Information System (JJIS) for all five youth case management
records confirmed a new Vulnerability to Victimization and Sexually Aggressive Behavior
(VSAB) screening was completed and entered prior to each youth’s room assignment. All five
youth case management records contained documentation indicating each youth was initially
classified on the date of admission based on the classification criteria on the classification
forms.
All reviewed records were found to contain monthly reassessments for each of the youth to
increase the youth’s privileges or freedom of movement, participation in work projects, or other
activities involving tools or instruments which could be used as potential weapons or means of
escape. The interviewed interim facility administrator (FA) reported the program’s admission
classification form is used when a youth enters the program. The youth's mental status, physical
health status, cognitive performance, age, and prior victimization are taken into consideration
when determining room assignments.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 23 of 71 (Revised September 2022)
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a written policy and procedures for gang identification and notification to law
enforcement. One of the five reviewed youth case management records had a gang alert and
was applicable for notification to law enforcement, the assigned juvenile probation officer (JPO),
education, and the youth’s post-residential services counselor. There were no other applicable
youth with gang identification since the last annual compliance review. Reviewed documentation
for the one applicable record verified the local law enforcement was notified of suspected gang
activity. A gang alert was entered into the internal alert system and the Department’s Juvenile
Justice Information System (JJIS) upon identification for the one applicable record. There was
documentation the youth’s gang status was shared with the local school district providing
services at the residential program, and the youth’s assigned JPO. Program staff were informed
during staff briefings, treatment team meetings, entries in the logbook, and through postings on
the internal alert board.
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 written policy and procedures for 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’s policy and procedures addressed providing youth
an opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang.
Five youth case management records were reviewed, and one youth was applicable for being
identified as a gang member, or affiliated. There were no other applicable youth with gang
identification since the last annual compliance review. Documentation supported the applicable
youth participated in gang prevention and intervention strategies. The youth’s performance plan
included goals and objectives related to gang intervention strategies to be completed prior to
release from the program. The program utilizes Impact of Crime (IOC) and Thinking for a
Change (T4C) curricula for prevention and intervention awareness efforts provided to the youth
at the program. Group sign-in sheets were reviewed and found the youth participated in gang
prevention and intervention activities. An interview with the interim facility administrator (FA)
confirmed the program has an alert board in the conference room to notify staff of youth gang
status. In addition, unannounced contraband searches are conducted in the youth rooms to
detect suspected gang involvement. The interim FA stated the program utilizes T4C and IOC for
gang intervention programming.
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Office of Accountability and Program Support Page 24 of 71 (Revised September 2022)
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a written policy and procedures to assess each youth using the Residential
Assessment for Youth (RAY) within thirty days of admission, as well as a RAY Reassessment
every ninety days thereafter. Five youth case management records were reviewed, and each
contained an initial RAY completed within thirty days of the youth’s admission to the program.
Each RAY was appropriately maintained in the Department’s Juvenile Justice Information
System (JJIS). Five youth case management records were reviewed for RAY Reassessments.
Each record was applicable for RAY Reassessments, and all were completed within ninety days
of the initial RAY. The program maintained each initial RAY and RAY Reassessment
documentation in the youth’s official case record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
The program has a written policy and procedures for the completion of a Youth Needs
Assessment Summary (YNAS) on each youth within thirty days of admission. A review of five
youth case management records documentation supported each youth’s YNAS was completed
within thirty days of admission and was documented in the Department’s Juvenile Justice
Information System (JJIS).
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a written policy and procedures regarding the development of performance
plans, goals, and transmittals. A review of five youth case management records documentation
supported each youth’s Individualized Performance Plan (IPP) was developed within thirty days
of the youth’s admission and developed after the initial Residential Assessment for Youth
(RAY). Each IPP was completed after the initial assessment with the intervention and treatment
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Office of Accountability and Program Support Page 25 of 71 (Revised September 2022)
leader, youth, administration representative, living unit representative, treatment staff, education
staff, and parent/guardian. One plan was applicable for the participation of the youth’s
Department of Children and Families (DCF) caseworker, and participation was validated.
Documentation showed each of the four completed IPPs were mailed to the youth’s
parent/guardian or DCF caseworker requesting a signature; however, none were returned to the
program at the time of the annual compliance review. Each of the youth case management
records documented the parent/guardian participated by telephone. Each reviewed IPP included
all individualized goals for each youth based upon the prioritized needs identified during the
initial assessment reflecting the risk and protective factors identified during the initial
assessment process. Each IPP addressed the youth’s three top criminogenic needs, based on
the RAY results with measurable outcomes which will decrease the youth’s criminogenic risk
factors and promote strengths, skills, and support to reduce the likelihood of the youth
reoffending. Each IPP outlined program staff responsibilities and target dates for goal
completion. Each of the five IPPs were sent to each youth’s committing court judge, juvenile
probation officer (JPO), parent/guardian, and applicable DCF counselor, within ten days of
completion. Five youth were interviewed and stated they participated in the development of their
performance plan. Each youth knew the goals on their performance plan and were able to state
some of their goals. Each youth stated a copy of the plan was received.
2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
The program has a written policy and procedures in place outlining revisions to a youth’s
Individualized Performance Plan (IPP). Five reviewed youth case management records were
applicable for and documented revisions to the performance plans based on the Residential
Assessment for Youth (RAY) Reassessment, and newly acquired information. None of the five
records were applicable for youth demonstrating lack of progress toward completing a goal
and/or facilitating transition activities during the last sixty days of the youth’s stay.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a written policy and procedures outlining the completion of performance
summaries and transmittals. Five reviewed youth case management records were applicable for
performance summaries. Each youth record had performance summaries which were
completed within ninety days of the completion of the initial performance plan. All five youth
case management records documented the youth received a copy of their performance
summary. All five performance summaries included the youth’s status on each performance
plan goal, overall treatment progress, academic status, behavior, and level of
motivation/readiness to change. Each summary was reviewed and signed by all treatment team
members. All five youth’s performance summaries were mailed to the committing court, juvenile
probation officer (JPO), parent/guardian, and/or applicable Department of Children and Families
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counselor. Three closed youth records were reviewed for release summaries. Each record
contained the original summary, which included the reason for release from the program. All
three closed records documented a performance summary and Pre-Release Notification (PRN)
were submitted at least forty-five days prior to the tentative release date. Each closed record
documented notification to the youth’s parent/guardian of the youth’s release date once the
program obtained the approved PRN from the youth’s committing court. Each record contained
a Residential Assessment for Youth (RAY) exit assessment. Each record had a Victim
Notification of Release letter sent to the victim, or designee, at least ten days prior to the youth’s
release.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a written policy and procedures outlining the process to encourage
parent/guardian involvement in case management services. A review of five youth case
management records confirmed all five demonstrated the parents/guardians were informed of
the youth’s treatment team schedule for the duration of their stay in the program. Reviewed
documentation found each applicable youth’s case management record reflected the program
encouraged and facilitated involvement of youth’s parents/guardian in case management
activities, to include the assessment process, development of the youth’s performance plan, and
monthly progress reviews. Documentation supported the program provided an advanced notice
of formal treatment team meetings and transition planning. Documentation supported the
program reached out to the parents/guardians to facilitate involvement by hosting family days,
inviting parents/guardians to participate in treatment team meetings, and through family therapy
sessions. An observation of treatment team validated the program’s practice of telephonic
parent/guardian participation. The interviewed interim facility administrator (FA) reported case
managers attempt to contact the parent/guardian during the intake process along with mailing
various correspondence as it pertains to the program. Five interviewed youth reported their
parent/guardian was involved with case management activities.
2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
The program has a written policy and procedures regarding the referencing and/or incorporating
of other treatment plans into the youth’s Individualized Performance Plans (IPPs). Each of the
five-reviewed youth case management records had separate performance plans, education
plans, and treatment plans. Each reviewed IPP referenced and/or incorporated education and
treatment plans. There was one applicable youth with the Department of Children and Families
(DCF) and the applicable plan was addressed and/or incorporated into the performance plan.
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2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
The program has a written policy and procedures outlining the required treatment team
members. The transition services manager and the youth’s assigned case manager oversee the
coordination of the treatment team and are responsible for leading the treatment team meetings.
A review of five active youth case management records found each youth participated in an
initial treatment team meeting and formal treatment teams at least every thirty days. Reviewed
treatment team documentation validated the reviews included the youth’s name and date of the
review. Each record confirmed each of the required treatment team members, to include the
youth, administrative representative, treatment staff, juvenile probation officer (JPO),
parent/guardian, and educational staff, participated in treatment teams. The youth’s
parent/guardian and JPO were invited to participate in treatment team meetings through
correspondence mailed prior to the meetings. One youth was applicable for being in the care of
the Department of Children and Families (DCF). Documentation indicated the DCF worker was
involved in the youth’s treatment team. Treatment team meetings included comments from
treatment team members, a brief synopsis of the youth’s progress, performance plan revisions,
progress on goals, behaviors, assessment results, and afforded the youth an opportunity to
demonstrate acquired skills. All formal treatment team documentation was maintained within the
youth’s record. A review of informal treatment team documentation supported informal meetings
were held at least bi-weekly and included all required information. Observations of a treatment
team during the annual compliance review week validated the program’s treatment team
practices. Five interviewed youth reported staff review their progress and behavior during
treatment team meetings.
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2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a written policy and procedures to ensure the intervention and treatment team
is planning for each youth’s successful transition to the community upon release from the
program. The policy outlines the process for transition planning, conferences, and Community
Re-Entry Team (CRT) meetings. A review of three closed youth case management records
documented each youth had a transition conference at least sixty days prior to the youth’s
targeted release date. Transition conference documentation reflected the youth, treatment team
leader, facility administrator or designee, and other applicable team members were in
attendance. Notification documentation supported the youth’s juvenile probation officer (JPO)
and parent/guardian were encouraged to participate. No youth were applicable for the
attendance of a human trafficking specific service provider. Transition documents supported the
conference included a review of transition activities, necessary performance plan revisions,
additional transition activities, target completion dates, and persons responsible for transition
activities. Transition conference documentation contained acknowledgement of transition goals
and responsibilities of members through signatures of participants. A copy of each transition
plan was sent to the assigned JPO and any members sharing responsibility of plan completion.
Each of the reviewed three closed records documented a CRT invitation was sent and a
meeting was held prior to the youth’s release.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a written policy and procedures regarding the assembly of an exit portfolio for
each youth to assist the youth with transitioning back into the community. A review of three
closed youth case management records was conducted. Each record contained an exit portfolio
which contained a copy of the youth’s transition plan, a calendar of upcoming appointments, a
Social Security card, birth certificate, educational/vocational certificates earned at the program,
school transcripts, a sample employment application, and applicable résumé. One of the three
closed records contained a copy of a valid Florida identification card for the youth. The other two
youth did not have an identification card available due to their younger age. Documentation
supported each youth’s exit portfolio was verified during the exit conference, provided to the
youth upon release, and forwarded to the assigned juvenile probation officer (JPO).
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2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a written policy and procedures for the review and finalization of transition
conference items and release plans by way of the exit conference. A review of three closed
youth case management records was completed. Each reviewed record documented an exit
conference was held after the program notified the assigned juvenile probation officer (JPO) of
the youth’s release and at least fourteen days prior to release. Conference documentation
included a summary of pending transition goals and the date, and signatures of attendees.
Attendees included the team leader, parent/guardian, education representative, JPO, youth, and
other pertinent parties. Documentation supported the exit conference was held separately from
the transition conference and Community Re-Entry Team (CRT) meeting for each youth. A
review of the Department’s Juvenile Justice Information System admission and release dates
confirmed they corresponded with the youth’s record.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a formal process for the promotion of constructive input of youth. The program
encourages youth input though “Let’s Talk” forms, daily meetings, quarterly surveys completed
by the program, and treatment team meetings. A review of logbooks verified the program was
conducting daily meetings with all program youth as scheduled. An interview with the interim
facility administrator (FA), reported there is a youth advisory board which meets monthly. The
peer group speaks with their peers and provides feedback to staff regarding programmatic and
systemic issues. In addition, there is a daily meeting where the youth are allowed to voice
concerns or issues in the program. Five interviewed youth stated they provide input about what
happens in the program by talking with staff, or during the daily meeting.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a written policy and procedures to ensure the instruction of a career education
curriculum which provide youth program content and an orientation to the broad scope of career
choices, based upon personal abilities, aptitudes, and interests. The interviewed lead teacher
reported the program is identified as a Type 2 career education program. The course
programming includes instruction of interpersonal skills, communication skills, and decision-
making skills. This programming is age appropriate for the youth and is suitable to their current
educational level as well as to their length of stay within the program. The Polk County School
District and the program operate an aquaculture/horticulture program. In this program, youth
grow fish in a large tank. The waste from the fish is used as nutritive fertilizer for the attached
horticulture components. In addition, the program has a beekeeping program in conjunction with
the school. The bees are kept in hive stacks in the back corner of the property. Between the two
programs, youth are educated on various biology and earth science topics. Both programs are
managed by the youth under staff supervision. Three closed youth records were reviewed. One
of the three closed records contained a copy of a valid Florida identification for the youth. The
other two youth did not have an identification available due to their younger age. All three
records contained documentation the parent/guardian and juvenile probation officer (JPO) were
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aware of the vocational plan for the youth, as well as evidence the case manager and
parent/guardian were aware of the plan, documents, and post-release discharge plans. The
Florida Career and Professional Education (CAPE) courses were not provided at the program
due to the youth not staying in the program for the minimum time of nine months. Both the
interim facility administrator (FA) and lead teacher were interviewed and verified the career
education offerings were taking place as required.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures which address educational access. A review
of the school calendar and documentation indicated each youth in the program was provided a
minimum of 240 days of instruction during the calendar year and each calendar week contained
a minimum of twenty-five hours of classroom instruction. Ten days are used for teacher
planning and/or training, which equals to a total of 250 days in a calendar school year. Youth
receive credits for the educational and training experience while in the program. A review of the
program’s daily academic schedule indicated the youth attend school for 330 minutes each
instructional day, for a total of twenty-seven and a half hours a week. A review of logbook
entries for three days, and three days of reviewed video footage verified classes were being
conducted with minimal interference, youth arrived to and departed school on time, and classes
were conducted as scheduled. Five youth were interviewed, and each youth confirmed school
was taking place as scheduled with minimal interference. The interviewed lead teacher verified
the program’s educational instruction is adhered to, and youth take part in the various career
education offerings at the program.
2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program has a written policy and procedures which address the Education Transition Plan
to be created upon admission. Three closed youth records were reviewed, and each record
verified the individualized Education Transition Plan was developed with the youth based on the
youth’s post release goals during admission to the program. All key personnel related to
transition activities were developed with the youth, parents/guardians, program, education, and
aftercare staff. The transition plans placed specific monitoring responsibilities on individuals
responsible for the reintegration and coordination of the provision of support services upon the
youth’s release. Each record documented the youth’s case manager and parent/guardian were
aware of the plan. Each plan was based solely upon the youth’s individual assessed needs,
performance, as well as their post release goals, whether they be a continuation of their
education or employment. In addition, each plan included key monitoring responsibilities and
were acknowledged by individuals who are responsible for the reintegration and coordination of
the provision of support services for the youth upon release from the program. The transition
plan also addressed the services and interventions provided to each youth which were based on
their individual needs and performance while in the program. Five interviewed youth stated they
were involved in the development of their Education Transition Plan. When asked how well the
youth thought the program was preparing them for a high school equivalency diploma (GED),
high school, vocational school, employment, and/or college, all five youth responded they were
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being very well, or well prepared. The interviewed lead teacher confirmed the practice of
developing the Education Transition Plan with the youth. The plan addresses the continuation of
education and, depending on the youth’s age, will address employment upon release from the
program.
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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 maintains a written policy and procedures requiring a designated mental health
clinician authority (DMHCA) to work as a full-time staff who is on-site at least forty hours each
week. The DMHCA is responsible for the coordination and implementation of mental health and
substance abuse services in the program. As part of the assigned responsibilities, the DMHCA
shall ensure consistent and appropriate mental health and substance abuse services in addition
to being on call twenty-four hours each day for emergency consultation. The program had two
DMHCAs since the last annual compliance review and the program’s current DMHCA was hired
on September 5, 2023, and was in the position for two months prior to the annual compliance
review. The current DMHCA is a licensed clinical social worker with a free and clear license in
the State of Florida with an expiration date of March 31, 2025. The current DMHCA’s license
was displayed within the program, as required. The interviewed DMHCA verified the program
provides Mental Health Overlay Services (MHOS). Reviewed documentation showed the
previous and current DMHCA were on-site for forty hours a week, as contractually required. An
interview with the current DMHCA verified they are on-site weekly to ensure appropriate
coordination and implementation of mental health and substance abuse services provided to the
youth, as required by the contract. The program is licensed under Chapter 397 through the
Department of Children and Families to provide substance abuse services to adolescents. The
reviewed license confirmed it was valid with an expiration date of December 25, 2023. The
back-up DMHCA is a licensed clinical social worker in the State of Florida with a free and clear
license which expires on March 31, 2025. The DMHCA stated the program provides individual,
family, and group clinical services to the youth. The DMHCA also reported crisis intervention,
ongoing clinical supervision and support to the therapeutic staff, and support to each youth is
provided as needed. Additionally, the DMHCA reported meeting with the clinical staff once a
week for at least an hour or more and being available seven days a week either in person, by
cellular telephone and by email to the program 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 program maintains a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program’s
licensed designated mental health clinician authority (DMHCA) serves as the program’s
supervisor for all on-site clinical staff. The program is licensed under Chapter 397 by the
Department of Children and Families to provide substance abuse services to adolescents. The
Chapter 397 license expires December 25, 2023. A review of mental health licenses found one
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volunteer therapist was a licensed mental health counselor (LMHC) with an active and clear
license expiring on March 31, 2025. The psychologist is on-site as needed. The psychologist
has a license which is active and clear in the State of Florida with an expiration date of January
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 program maintains a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The interviewed
designated mental health clinician authority (DMHCA) confirmed their responsibility for ensuring
non-licensed clinical staff are working under their supervision and performing services they are
qualified to based on education, training, and experience. The program’s practice is to complete
group and/or individual clinical supervision for the two non-licensed clinicians and one
recreation therapist. A review of clinical supervision logs from November 16, 2022, to November
9, 2023, verified clinical supervision was documented on the supervision logs and included all
elements on the Department’s Licensed Mental Health Professionals and Licensed/Certified
Substance Abuse Professionals Direct Supervision Log form. Documentation verified each non-
licensed clinical staff received clinical supervision for each week they provided services. The
program is licensed under Chapter 397 through the Department of Children and Families to
provide substance abuse services to adolescents. A review of the license reflected it was
displayed in the lobby with the program’s physical address listed. The reviewed license expires
on December 25, 2023. The program’s contract requires one DMHCA, one recreation therapist,
and two non-licensed mental health clinicians. The program did not have any clinical staff
vacancies during the annual compliance review period. A review of the two non-licensed staff’s
education documentation reflected each held a master’s-level degree from an accredited
university or college in the field of counseling, social work, psychology, or a related human
services field. Each non-licensed staff providing clinical services was employed by a service
provider which was licensed under Chapter 397. Each of the two non-licensed clinical staff
received training in the administration of the Assessment of Suicide Risk (ASR), or Crisis
Assessments conducted on-site in the physical presence of the licensed mental health
professional. All training was documented on the Department’s Non-Licensed Mental Health
Clinical Staff Person’s Training in Assessment of Suicide Risk form.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program maintains a written policy and procedures which establish the system for gathering
important treatment and emergent needs information prior to each youth’s entry into the general
population. The program’s policy requires the staff to administer a mental health and substance
abuse screening, including a suicide risk screening, upon a youth’s admission to the program.
The program utilizes the Massachusetts Youth Screening Instrument, Second Version (MAYSI-
2) for initial screening. Each of the five reviewed MAYSI-2s reflected the screening was
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completed in the Department’s Juvenile Justice Information System (JJIS) on the day of the
youth’s admission. All five records documented staff conducting mental health and substance
abuse admission screenings reviewed each youth’s commitment packet information and records
for existing documentation of mental health and substance abuse problems or history of human
trafficking. All clinical staff administering the MAYSI-2 were trained, as confirmed in the
Department’s Learning Management System (SkillPro). A review of five youth records verified
each completed MAYSI-2 included the date, name of staff completing the MAYSI-2, was
completed on the day of admission, and was conducted in a confidential manner. None of the
reviewed MAYSI-2’s indicated an assessment was needed due to the “suicide ideation”
category; however, it is the program’s practice to conduct an Assessment of Suicide Risk (ASR)
on all youth upon admission to the program. All five youth records verified each youth was
referred for an ASR and comprehensive evaluation, and each included the reason for the
referrals. The program does not utilize a separate clinical mental health and substance abuse
screening. The program’s interim facility administrator (FA) is responsible for the implementation
of the standardized admission/intake mental health and substance abuse screening process.
The reviewed policy confirmed the process includes a review of commitment packet information,
reports and records, administration of the MAYSI-2 in JJIS by a qualified professional, and a
referral of youth identified by screenings as in need of further evaluation or immediate attention.
The policy outlines administration staff training and a standardized process for youth requiring
immediate attention and transfer to a Baker Act or Marchman Act receiving unit. The
interviewed interim FA reported upon entry into the program an adolescent suicide screening
assessment is completed, and a MAYSI-2 is completed with the youth at intake.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a written policy and procedures to address the provision of mental
health and substance abuse assessments/evaluations. A review of five youth mental health and
substance abuse records found each youth received a comprehensive mental health
assessment prior to admission into the program. The program’s practice is to complete a new
comprehensive mental health and substance abuse evaluation within thirty calendar days of
each youth’s admission. All five youth evaluations were completed within thirty calendar days of
their admission to the program. Four of the five youth evaluations were completed by non-
licensed clinical staff and one evaluation was completed by the designated mental health
clinician authority (DMHCA). Documentation indicated each of the four evaluations completed
by non-licensed clinical staff were reviewed and signed by the DMHCA within ten calendar days
of the evaluation being conducted. The mental health evaluation included youth demographics,
reason for the evaluation, relevant background information, behavioral observations, Mental
Status Examinations, procedures administered, discussions of findings, diagnostic impressions
including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
diagnosis, and recommendations. A review of five youth records verified each youth received a
new substance abuse assessment within thirty days of admission. Each youth record included
the reason for the substance abuse assessment, all relevant background information,
behavioral observations, methods of assessment, patterns of alcohol and substance abuse,
impact of alcohol and substance abuse on major life areas, risk factors, clinical impression
including the DSM-5 diagnosis, and recommendations. All five reviewed youth records indicated
the mental health/substance abuse assessment addressed the original referral reasons. In all
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five youth records signed consents were documented for substance abuse treatment, release of
treatment records to the judicial court and parent/guardian, and consent for urine collection and
analysis.
3.06 Mental Health and Substance Abuse Treatment (Critical) Limited Compliance
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a written policy and procedures outlining the program’s mental health
and substance abuse treatment services. A review of five youth records reflected an initial
treatment plan was developed within seven days of each youth admission. Each reviewed initial
treatment plan was documented on the program’s form and included all elements of the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Three of the five
youth initial treatment plans were completed by non-licensed clinical staff, and two were
completed by the designated mental health clinician authority (DMHCA). Documentation
indicated the three initial treatment plans completed by non-licensed clinical staff were signed
by the DMHCA within ten days of completion. Each initial treatment plan was signed by all
treatment team members who participated in the development of the plan. Each plan was
signed by the youth and documented the juvenile probation officer (JPO) and parent/guardian
participated by telephone. Additionally, in one youth record there was a signed initial treatment
plan by the youth’s parent/guardian, which was mailed back to the program. Three of the
reviewed records indicated the youth were on psychotropic medications at the time of the initial
plan creation and the medication details were included in their plan, and one youth’s initial plan
documented psychotropic medications history pending psychiatric services. Each initial
treatment plan included the need for a psychiatric evaluation. The program’s practice is to refer
all youth for a new psychiatric evaluation regardless of medication status. Each of the five
reviewed youth mental health and substance abuse records contained an Individualized Mental
Health and Substance Abuse Treatment Plan, which was developed within thirty days of
admission. The Individualized Mental Health and Substance Abuse Treatment Plans were
developed on a provider form containing all the requirements from the Department’s
Individualized Mental Health/Substance Abuse Treatment Plan form. Four of the five
individualized plans were completed by a non-licensed clinical staff and signed by the DMHCA
within ten days of completion, and one was completed by the DMHCA. Each of the five plans
were signed by all treatment team members who participated in the development of the plan.
Reviewed documentation indicated each youth’s plan was mailed to the parent/guardian for
signature and one of the five was returned with a signature. Three youth were applicable for
being on medication at the time of the individualized plan development and one youth had a
psychotropic medication history and was placed on medication after admission to the program.
Each plan clearly listed the medication details and monitoring frequency. In the five records
reviewed, documentation verified each treatment plan review was completed every thirty days.
All treatment plan reviews were documented on the program’s form which contained all
elements on the Department’s Individualized Mental Health/Substance Abuse Treatment Plan
Review form. Each record contained reviews which were completed at least every thirty days
following the development of the individualized treatment plan. Prescribed services included
individual, family, and group therapy for all five youth, and psychiatric services and medication
management for four youth. The treatment plan goals and objectives were individualized for
each youth. A review of the program’s groups indicated the program was not providing mental
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health groups as required in contract. Three days were selected for video review of mental
health groups. Video observations and group sign-in sheets did not coincide with the time
documented. The three days of video review did not confirm mental health groups services were
provided as scheduled. Additionally, a review of group notes for two youth who participated in
groups did not coincide with the video observations. The program was notified, and the incident
was reported to the Department’s Central Communications Center (CCC).
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program has a written policy and procedures addressing treatment and discharge planning.
A review of five youth records reflected each youth was assigned a treatment team on the day
of arrival to the program. Reviewed treatment plan documentation and the treatment team
assignment form for each reviewed record confirmed the treatment teams were comprised of
the youth, program administration, residential living unit, education, medical staff, mental health
and substance abuse staff, and applicable parent/guardian. A review of the five youth records
reflected each was applicable for a substance abuse diagnosis and treatment. The program is
licensed through the Department of Children and Families under Chapter 397 to provide
substance abuse services to adolescents. A review of three closed records was conducted for
discharge plans. Each record contained an executed Authority for Evaluation and Treatment
(AET) form or a court order. Additionally, each youth record contained a signed Youth Consent
for Substance Abuse Treatment, and Youth Consent for Substance Abuse Treatment Records
form. All reviewed mental health or substance abuse treatment notes were documented on the
program’s form and included all the information on the Department’s Counseling/Therapy
Progress Notes form. Reviewed progress notes confirmed treatment services included
individual psychotherapy and psychosocial skills training. A review of treatment plans in
comparison with progress notes confirmed each youth received services as stipulated on their
treatment plan. Three closed records were reviewed for discharge summaries. All three
discharge summaries were completed on the Department’s Mental Health/Substance Abuse
Treatment Discharge Summary form. None of the three closed records were applicable for the
youth being released while on suicide alert/precautions. Each of the three reviewed summaries
documented the services needed for daily maintenance of the positive improvement in
behavioral, emotional, and social skills made by the youth during treatment. Each reviewed
discharge summary documented the telephone participation of the assigned juvenile probation
officer (JPO) and parent/guardian. Reviewed documentation verified the program emailed a
copy of the summary to each assigned JPO and provided a copy to the youth and
parent/guardian upon release.
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3.08 Specialized Treatment Services (Critical) Limited 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 maintains a written policy and procedures to establish a delivery protocol for
Mental Health Overlay Services (MHOS). The program provides daily group therapy, bi-weekly
individual therapy, monthly family therapy, and psychiatric services. The program’s required
clinical groups are Anger Management for Substance Abuse and Mental Health (MH/SA),
Skillstreaming the Adolescent, Thinking, Feeling, and Behaving, and Strategies for Anger
Management according to the contract. The program is providing Thinking, Feeling, and
Behaving, Skillstreaming the Adolescent, and Anger Management for MH/SA Clients to the
youth in the program. A review of the programs contract and an interview with the designated
mental health clinician authority (DMHCA) confirmed the program was providing groups as
required; however, documentation on each of the five youth records supported therapy groups
were not limited to ten or fewer youth for mental health treatment groups. Documentation
showed mental health groups ranged from eleven to seventeen youth based on weekly
progress notes. The program administrators reported retraining will be conducted on group size
to all the clinical staff facilitating mental health groups. Documentation indicated therapeutic
services are held at least five times a week. All metal health clinicians working at the program
were qualified to provide substance abuse treatment and education services. The program
provides urinalysis drug testing when necessary. A review of counselor caseloads verified the
caseloads are limited to no more than sixteen youth for MHOS. The program has an agreement
with a psychologist to provide services as needed who was not utilized since the last annual
compliance review. The program has an agreement with a psychiatrist for the completion of
psychiatric evaluations and medication management needs. A review of the clinical staff
schedules verified clinical staff were scheduled to be on-site seven days each week, as
required. An interview with the DMHCA verified clinical staff are on-site seven days a week, and
group services and crisis intervention services are provided. All five interviewed youth reported
they participated in family and/or individual counseling. Five interviewed staff stated direct care
staff do not facilitate any mental health or substance abuse groups and only therapists facilitate
groups.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
The program maintains a written policy and procedures for the provision of psychiatric services
within the program. The program’s contracted psychiatrist is responsible for psychiatric
evaluations, consultation, medication management, and medical supportive counseling. The
program maintains an agreement with a medical doctor for psychiatric services. The reviewed
license showed it was free and clear in the State of Florida with an expiration date of January
31, 2024. Reviewed documentation confirmed the completion of psychiatric evaluations,
medication reviews, and treatment team participation. The program does not utilize a psychiatric
advanced practice registered nurse (APRN). The psychiatrist is scheduled to be on-site bi-
weekly and provides medication evaluations and on-going monitoring of psychiatric
medications. A review of the attendance logs from November 10, 2022, through November 9,
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2023, documented the psychiatrist has been providing on-site services bi-weekly. Each
reviewed attendance log documented the psychiatrist signed-in and signed-out. The psychiatrist
is available for emergency consultation twenty-four hours a day, seven days a week. Five youth
records were reviewed and four were applicable for psychiatric services. Documentation in all
four applicable youth records indicated the psychiatrist was actively managing and supervising
each youth’s psychotropic medication services. The program has a back-up psychiatrist with a
clear and active license expiring on January 31, 2025. The program did not utilize a back-up
psychiatrist since the last annual compliance review. An interview with the psychiatrist reported
meetings are held quarterly with the program’s interim facility administrator (FA) and healthcare
staff to review important medical issues pertaining to the youth, and meetings with the
designated mental health clinician authority (DMHCA) occur bi-weekly. The psychiatrist reported
evaluations are provided, as well as groups, individual sessions, and treatment team meetings.
Five youth mental health and substance abuse records were reviewed, three were applicable for
youth admitted on prescribed psychotropic medications, and one youth had a psychotropic
medication history and was pending psychiatric services. Documentation indicated each youth
entering the program received a diagnostic interview within fourteen days of admission. Each
youth’s Initial Diagnostic Psychiatric Interview included history of the youth, a mental health
status examination, and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) diagnosis, prescribed medications, and explanation of the need for psychotropic
medication. A review of each applicable youth record indicated each youth was prescribed
psychotropic medication which was related to the youth’s diagnosis. Each diagnostic interview
included target symptoms, initial treatment goals, potential side effects, risk, benefits of taking
the medication, and the frequency of medication management. A review of each applicable
youth’s treatment plan verified the plan was consistent with the DSM-5 diagnosis and included
the treatment recommendations. The Initial Diagnostic Psychiatric Interview was documented
on the Department’s Clinical Psychotropic Progress Note (CPPN) which was clearly identified
as the Initial Diagnostic Psychiatric Interview for each applicable youth. Five youth records were
reviewed, and three youth were admitted into the program with psychotropic medication and
one youth started taking psychotropic medication three months after admission to the program.
Each of the four applicable youth records documented youth were seen for medication reviews
by the psychiatrist at least once every thirty days. The psychiatric evaluations were documented
on the Department’s CPPN form for each youth. The Department’s CPPN included the youth’s
identifying data, diagnosis, target symptoms of each medication, effect of prescribed
psychotropic medication on target symptoms, side effects of the medication, and the youth’s
adherence to the medication regime. In addition, each of the four CPPN’s included the youth’s
height, weight, and blood pressure. The psychiatrist signed and dated each of the four reviewed
CPPNs. Three of the four youth prescribed psychotropic medications required the monthly
monitoring of Tardive Dyskinesia and reviewed documentation supported the nursing staff
documented monitoring on a monthly basis. The program does not utilize tele-psychiatry
services.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a policy and procedures regarding the implementation of a Suicide Prevention
Plan. The plan shall provide guidelines for the identification, management, and assessment of
potentially suicidal youth. The program maintains a Suicide Prevention Plan which was last
signed and reviewed by the designated mental health clinician authority (DMHCA) and the
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interim facility administrator (FA) on November 6, 2023. A review of the plan reflected it included
identification, assessment, staff training, suicide precautions, levels of supervision, referral,
communication, notification, documentation, immediate staff response, and a review process.
The review process for suicide attempts and mortality review included circumstances
surrounding the event, procedures relevant to the incident, relevant training received by
involved staff, pertinent medical and mental health services involving the victim, possible
precipitating factors, and recommendations.
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.
The program maintains a Suicide Prevention Plan which outlines the methods used for suicide
precautions which include observing, monitoring, and housing youth identified as a suicide risk.
A review of five youth records indicated two were applicable for suicide risk. The program
provided one additional applicable record for review. Each of the three applicable youth were
identified as a suicide risk through staff observations. All three applicable youth were placed on
precautionary observation status and assessed the same day, and each Assessment of Suicide
Risk (ASR) was completed on the Department’s ASR form. Two of the three youth’s ASRs were
completed by the licensed designated mental health clinician authority (DMHCA), and one was
completed by the non-licensed clinical staff and was reviewed by the DMHCA within twenty-four
hours of completion. All three applicable youth were maintained on constant supervision upon
immediate completion of their ASR. Documentation verified the parent/guardian and assigned
juvenile probation officer (JPO) were notified of the youth’s potential suicide risk. Each youth’s
record documentation supported mental health staff provided supportive services. Two of the
three applicable youth records indicated a Follow-Up ASR was completed on the Department’s
Follow-Up ASR form and one was not needed. Each Follow-Up ASR indicated suicide
precautions could be discontinued for both applicable youth, and both youth were stepped down
to close supervision. Each reviewed youth’s ASR and Follow-Up ASR clearly documented the
time, date, and results of a conference held with the facility administrator (FA) and the licensed
mental health staff prior to stepping the youth to close supervision. A review of the Department’s
Juvenile Justice Information System (JJIS) reflected alerts were initiated and closed, as
required. A review of the program’s logbooks and assessments supported the administration
staff provided instructions regarding suicide precaution decisions. Documentation supported all
three youth on suicide precautions were able to participate in select activities with other program
youth in the specified safe housing areas. The program does not utilize secure observation. The
program’s camera footage is only stored for thirty days. Documentation indicated only one youth
was placed on precautionary observation within the last thirty days prior to the annual
compliance review week. Reviewed camera footage and corresponding documentation for the
date and times of youth placed on precautionary observation status showed the program staff
ensured proper supervision was maintained for the youth. The interviewed DMHCA described
the procedures for notification to the facility administrator, parent/guardian, and other applicable
agencies regarding potentially suicidal youth, or for youth who have attempted suicide. The
DMHCA reported once a youth is determined to be suicidal, the clinical director or therapist will
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notify the FA. The direct care staff are alerted during shift briefing, an alert is placed on the
communication board in the shift briefing areas, and in the logbook. Parents/guardians are
notified by the therapist or clinical director by telephone. An alert is also placed in JJIS and the
youth's JPO is notified by telephone or email.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a Suicide Prevention Plan which outlines levels of supervision and the
process for recording observations of youth on suicide precautions. A review of five youth
records indicated two were applicable for suicide risk. One additional youth record was provided
by the program and reviewed for suicide prevention services. Each youth record contained
documentation where a Suicide Precaution Observation Log was maintained for the duration the
youth was on precautions. Youth behaviors were documented in real time and not exceeding
thirty-minute intervals for each youth. Each youth was applicable for warning sign observations
and notification to the mental health clinician was clearly documented. Each of the five reviewed
logs were reviewed and signed by the shift supervisor and mental health staff. All five youth logs
documented safe housing requirements.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a written Suicide Prevention Plan which outlines suicide prevention
training requirements. The program’s Suicide Prevention Plan requires six hours of annual
training which includes two hours of training in the Department’s Learning Management System
(SkillPro) and four hours of instructor-led training. A review of five pre-service and five in-service
training records documented program staff completed the required six hours of suicide training.
The program has a total of two suicide kits which were located in the laundry room and
administration hallway. The suicide kits are co-located with the program’s first-aid kits. The
program is required to complete one mock suicide drill for each shift at least quarterly. A review
of suicide drills since the last annual compliance review reflected the program conducted a
quarterly drill on each shift as required. Reviewed drills consistently included the use of
lifesaving measures to include the use of cardiopulmonary resuscitation (CPR), suicide kits,
first-aid kits, and an automated external defibrillator (AED). All drills were simulated, and the
program youth were not utilized in the simulated drills. The program has a practice to review drill
scenarios and procedures with any staff who was not present during a quarterly suicide drill
during staff meetings. The interviewed interim facility administrator (FA) reported monthly mock
drills are conducted for all staff which include emergency response to suicide attempts or self-
inflicted injuries. The interim FA also reported staff are allowed an opportunity to participate in
the drills and drills occur on each shift once a month. Five staff were interviewed, each reported
medical emergency and suicide drills are conducted monthly on each shift, they have
knowledge on what to do when a youth expresses suicidal thoughts, and the staff knew what
they are responsible for. All five staff knew the location of the suicide response kits.
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3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written policy and procedures to outline operation procedures for crisis
intervention. The program’s Crisis Intervention Plan addresses mental health crisis intervention
services and Crisis Assessments. A review of the plan verified it included notification and alert
systems, means of referrals including youth self-referral, Crisis Assessment and follow-up,
communication, supervision, documentation, mental health supportive services, and review.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a written Crisis Intervention Plan which addresses mental health crisis
intervention services and Crisis Assessments. A review of five youth records indicated none
were applicable for Crisis Assessments. The program reported having two applicable youth who
required completion of a Crisis Assessment since the last annual compliance review.
Documentation indicated one of the two Crisis Assessments was completed by the designated
mental health clinician authority (DMHCA) on the date the youth was determined to be in crisis.
The second Crisis Assessment was completed by the non-licensed clinical staff on the date the
youth was determined to be in crisis, which was reviewed and signed by the DMHCA on the
date of completion. Both youth were assessed and determined to not be in crisis; therefore, an
alert was not required to be entered into the Department’s Juvenile Justice Information System
(JJIS), and both youth remained on standard supervision. One of the two youth’s
parent/guardian was notified by telephone, and one was not notified. Both youth’s Crisis
Assessments included the reason for the assessment, Mental Status Examination and
interview, determination of danger to self and/or others, initial clinical impressions, supervision
recommendations, treatment recommendations, recommendations for further evaluation, and
parent/guardian notification. The program had no youth applicable for an off-site Crisis
Assessment since the last annual compliance review.
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3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written policy and procedures outlining the mental health and
substance abuse procedures for youth who are believed to be in imminent danger to
themselves or others because of mental illness or substance abuse impairment. The
Emergency Response Plan for Mental Health and Substance Abuse Emergencies requires
youth to receive the highest quality of care, safety, and management. The program’s
Emergency Response Plan was last signed and dated by the designated mental health clinician
authority (DMHCA) and the interim facility administrator (FA) on November 6, 2023. A review of
the plan validated it included immediate staff response, notifications, communication,
supervision, authorization to transport for emergency mental health and substance abuse
services, transport for emergency Baker Act, transport for emergency Marchman Act,
documentation, training, and review.
3.17 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a written policy and procedures to address the safety planning process
for each youth. A review of five youth mental health records was conducted in reference to
safety planning. Reviewed documentation found the program has developed a program’s Safety
Plan form which identifies stimuli which included positive and negative effects on the youth. The
program’s Safety Plan form included an initial and a review planning process. The initial
planning process is initiated by each youth’s therapist within fourteen days of the youth’s
admission to the program. The safety plans are jointly prepared by the youth, parent/guardian or
family member, behavioral specialist, case manager, and clinical staff. The plans are reviewed
and signed by all staff involved and the youth. Thereafter, the youth’s safety plan is reviewed
and updated every thirty-days to include signatures and date of the youth and staff. The
program’s Safety Plan form included the youth’s warning signs, baseline behaviors gathered
from collateral contacts, crisis recognition, jointly developed coping strategies, intervention
strategies, and debriefing preferences. All five youth safety plans incorporated
recommendations of previous and current clinical assessments, as required. All five youth
safety plans were updated every thirty days and documented any significant behavioral or
mental health event identified by the youth’s intervention and treatment team. The youth’s safety
plans were maintained in the youth’s mental health and substance abuse records and within a
centralized binder inside the master control room easily accessible to all staff. Five interviewed
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youth reported they contributed to the development of their safety plan. An interview with five
staff indicated they were aware of the process for reviewing each youth’s safety plan and plans
were reviewed when there is a new youth, weekly, or as needed. The interviewed interim facility
administrator (FA) reported youth safety plans were updated monthly unless the youth
experience some type of crisis.
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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 maintains a written policy and procedures which require a contracted health
authority to provide on-site medical services to youth in the program. The program maintains an
independent contractor agreement with a State of Florida physician to serve as the designated
health authority (DHA). The DHA has a clear and active license in the State of Florida, which
expires on January 31, 2024, with specialty training in internal and family medicine. A review of
the Florida Department of Health records documentation showed the DHA had no current
disciplinary cases and/or public complaints on record. The DHA is required by contract to be on-
site for a minimum of two hours a week with no more than nine days passing between on-site
visits. A review of sign-in sheets since the last annual compliance review showed the DHA was
on-site as required with no more than nine days between site visits. The program has a back-up
DHA who has a clear and active license in the State of Florida expiring on January 31, 2025.
Reviewed documentation and an interview with the health services administrator (HSA) stated
the back-up DHA was utilized on three dates during the annual compliance review period. The
program does not utilize an advanced practice registered nurse (APRN) or physician’s assistant
(PA). A review of the program’s contract and the program’s policy and procedures showed there
was no provision for or approval from the Department’s Office of Health Services for tele-
medicine/tele-health services. An interview with the DHA stated their role in the program is to
complete Comprehensive Physical Assessments (CPAs) within seven days of a youth’s arrival
to the program and every year thereafter. Youth with chronic problems are to be seen every two
months. An interview with the DHA confirmed weekly on-site visits and availability by telephone
twenty-four hours a day, seven days each week.
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 maintains a written policy and procedures for all health-related procedures and
protocols utilized. The program has one registered nurse (RN) who serves as the health
services administrator (HSA), one licensed practical nurse (LPN), and one part-time, pro re nata
(PRN) LPN. The program provides on-site medical coverage seven days a week from 8:00 a.m.
to 4:30 p.m. A review of licenses for the HSA and current nursing staff providing services at the
program found each had a clear and active license in the State of Florida. Reviewed
documentation found all nurses held current certification in cardiopulmonary resuscitation
(CPR).
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has medical facility operating procedures (FOPs) for all health-related procedures
and protocols utilized. The program’s designated health authority (DHA) conducts an annual
review of all health-related policies, procedures, and protocols. Reviewed documentation
showed the DHA reviewed, signed, and dated the FOPs on July 3, 2023. The facility
administrator (FA) and the psychiatrist both signed on July 3, 2023. The DHA reviewed and
signed all nursing protocols on June 27, 2019. The nursing staff signed a cover page
acknowledging review of all FOPs and treatment protocols on November 29 and December 2,
2022, and February 21, 2023. There was one noted applicable policy change during the annual
compliance review period which was reviewed by all healthcare staff. The program had one new
healthcare staff since the last annual compliance review. Reviewed documentation validated the
one new staff received a comprehensive clinical orientation.
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 maintains a written policy and procedures requiring the completion of the Authority
for Evaluation and Treatment (AET) for all youth admitted into the program. A review of five
youth Individual Healthcare Records (IHCRs) confirmed each youth had a valid AET with four
having the word, “Copy” stamped on the youth’s AET, and one which was an original. Each of
the five reviewed AET forms were signed by the youth’s parent/guardian and by a Department
representative. There were no youth applicable for being eighteen years of age or older, or in
the care of the Department of Children and Families (DCF) with parental/guardian rights
terminated. An interview with nursing staff confirmed new admissions are discussed with the
case management staff prior to the youth’s arrival, and if needed the juvenile probation officer
(JPO) would be contacted through case management to obtain a new AET. The program serves
youth ages ten through sixteen.
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 maintains a written policy and procedures requiring notification to the
parent/guardian of significant changes in the youth’s condition and to obtain consent when new
medications and treatments are prescribed. A review of five youth Individual Healthcare
Records (IHCRs) validated a consent was provided by each youth’s parent/guardian for over-
the-counter (OTC) medications. All five reviewed youth records were applicable for youth taking
psychotropic medications. Reviewed documentation in all five records confirmed a staff
witnessed all telephone calls whenever a new psychotropic medication was prescribed or
discontinued, or changes were made requiring parental/guardian verbal consent. None of the
five youth were applicable for being in the care of the Department of Children and Families
(DCF) with parental/guardian rights terminated. Each of the five reviewed IHCRs documented
the program received and verified the youth’s vaccination records on the date of admission.
None of the youth were applicable for requiring new vaccinations or requesting religious
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exemption. An interview with the health services administrator (HSA) revealed verbal consent is
obtained for any OTC medication which is not listed on the signed Authority for Evaluation and
Treatment (AET), for new prescriptions, significant dosage changes, or discontinuation of a
medication. Medical staff will then follow-up by mailing a written parental/guardian notification.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program maintains a written policy and procedures regarding healthcare screening for each
youth upon admission into the program. A review of five youth Individual Healthcare Records
(IHCRs) documentation showed each youth received a Facility Entry Physical Health Screening
(FEPHS) upon admission, by the program’s licensed healthcare staff. One of the five youth was
applicable for a change in physical custody greater than twenty-four hours and the program
completed a new FEPHS rescreening of the youth on the date the youth returned to the
program. An interview with the health services administrator (HSA) indicated newly admitted
youth are seen by medical staff immediately following the initial search, which is normally within
fifteen minutes of the youth’s arrival to the program. The HSA stated new intakes are discussed
prior to admission in collaboration with the administration team. The HSA also confirmed the
admission screenings are completed by the healthcare staff on-site at the time of each youth’s
admission.
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 maintains a written policy and procedures to ensure each youth admitted into the
program receives a healthcare orientation. A review of five youth Individual Healthcare Records
(IHCRs) confirmed each youth received an orientation to healthcare services at the program
upon admission. Each youth’s orientation included topics such as access to medical care, sick
call process, emergency situations, medication process, right to refuse care, what to do in case
of sexual assault or attempted sexual assault, the non-disciplinary role of healthcare staff, and
standard universal precautions. All topics were documented on the Health Education form, and
each was signed and dated by each youth.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program maintains a written policy and procedures requiring notification to the designated
health authority (DHA) by telephone, text message, or verbally, if on-site, of each youth
admitted into the program identified with chronic health conditions or youth in need of
emergency care. A review of five youth Individual Healthcare Records (IHCRs) reflected all five
youth were applicable for having a known or suspected chronic condition. Documentation
showed the DHA was notified of each youth’s admission within twelve hours. After referral, one
youth was noted to not have a chronic condition leaving four youth with a chronic condition.
Three of the five youth were taking psychotropic medication upon admission, and each record
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documented notification to the psychiatrist was made. An interview with the health services
administrator (HSA) confirmed the nurse contacts the DHA upon each youth’s admission to the
program to obtain admission orders.
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 maintains a written policy and procedures to address the completion of the Health-
Related History (HRH) form prior to the completion of the Comprehensive Physical Assessment
(CPA) upon each youth’s admission to the program. A review of five youth Individual Healthcare
Records (IHCRs) validated a HRH was completed within seven days of admission and prior to
each youth’s CPA, as required. Documentation showed the designated health authority (DHA)
reviewed the HRH form in each of the five records. An interview with the health services
administrator (HSA) stated 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 maintains a written policy and procedures ensuring each youth admitted shall
receive and/or shall have on record a current Comprehensive Physical Assessment (CPA) and
Health-Related History (HRH) form no later than seven calendar days of admission into the
program. A review of five youth Individual Healthcare Records (IHCRs) documentation showed
each youth had a new CPA completed by the designated health authority (DHA) within seven
days of admission, using the Department’s form. There was documentation each youth’s
Medical Grade was documented on the CPA. There was no sign of any missing/incomplete
elements on the reviewed forms. All five youth refused part of the exam. Each youth’s CPA
documented the refusal, and each youth signed a refusal form which reflected the refused
portion of the CPA on the date of the exam. All sections of the CPA were completed in full
utilizing an “O” and/or applicable “X” markings except for sections numbered nineteen through
twenty-two, as those sections were not applicable to the male program. Documentation
confirmed the results of each youth’s Tuberculosis Skin Test (TST) were documented on the
CPA and the Department’s Infectious and Communicable Disease (ICD) form and on the
program’s TST/Purified Protein Derivative (PPD) form. An interview with the health services
administrator (HSA) confirmed the initial CPA is completed by the DHA within seven days and
annually thereafter. The HSA stated the process and time frame for the TB screening is to be
completed upon admission and after applicable re-entry to the program. The program maintains
a medical tracker to monitor TST/PPD due dates.
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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 maintains a written policy and procedures ensuring all youth admitted shall be
clinically screened and medically evaluated for sexually transmitted infections (STIs) and human
immunodeficiency virus (HIV). The policy requires all youth at risk for HIV infection to be offered
counseling, testing, education, prevention counseling, and a referral for medical treatment. A
review of five youth Individual Healthcare Records (IHCRs) showed each youth was clinically
screened and evaluated for STIs. One youth was applicable for further evaluation and was
referred to the designated health authority (DHA); however, the youth refused consent for
testing. Five reviewed youth IHCRs documented each youth was offered counseling and testing
for HIV and all five youth declined consent for testing. Any youth consenting to testing is tracked
on the program’s HIV Testing Tracking Log stored in the medical clinic. A review of the
program’s HIV Testing Tracking Log indicated it is the program’s practice to track each youth
referred for testing and the tracking log validated the program had no youth who consented to
HIV testing since the last annual compliance review. The health services administrator (HSA)
stated the DHA provides the pre and post-counseling, when applicable. All five interviewed
youth stated they can request a HIV test. The interviewed HSA stated all youth admitted to the
program are screened for possible STIs by completing the STI Screening form. If a youth
screening indicates a need for further evaluation the youth will be referred to the DHA to receive
a physician order for testing. When all youth testing has been provided and results are received,
the youth results are to be maintained in the youth’s IHCR in the laboratory section of the
record.
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 maintains a written policy and procedures stipulating all youth shall be able to
make sick call requests and have their complaints treated appropriately through the sick call
system. The program’s sick call hours are from 12:00 p.m. to 12:40 p.m. daily and are posted on
the medical clinic door. A review of the program’s contract and the activity schedule found the
program is providing sick call hours as required. Sick call forms were observed in the dayroom
hallway and easily accessible by youth. A locked sick call box was observed in the dayroom hall
next to the sick call forms. A review of five youth Individual Healthcare Records (IHCRs)
reflected two of the five youth were applicable for having completed a sick call request form;
therefore, one additional record applicable for sick call requests was reviewed in order to reach
the minimum required sample size. Reviewed documentation indicated none of the three youth
were applicable for presenting with a similar sick call complaint three or more times within a two-
week period. Two youth were applicable for a licensed practical nurse (LPN) having conducted
the sick call and there was documentation each sick call was reviewed by the program’s
registered nurse (RN). All sick calls were documented on the Department’s Sick Call Index, the
Sick Call Referral Log, and each was filed within the youth’s IHCR in reverse chronological
order. None of the youth were applicable for being in restricted housing as the program does not
utilize restricted housing. During the annual compliance review week, no observation of sick call
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was conducted due to the program not having any sick call requests submitted during the week
of the annual compliance review. The interviewed health services administrator (HSA) indicated
when a healthcare staff is not on-site, all Sick Call Request forms are to be promptly turned into
the shift supervisor for review within two hours after the request was submitted, and the shift
supervisor is to determine when a sick call requires immediate attention. If the shift supervisor
cannot determine the needs of the youth, the licensed healthcare staff on-call will be notified
and consulted by telephone to determine if the sick call requires immediate attention and/or for
instructions. The licensed healthcare staff would then consult with the designated health
authority, as needed. The HSA indicated youth can submit a sick call at any time by placing a
request form in the sick call box. Five staff were interviewed and four staff stated the nurse
reviews sick calls, while one indicated the doctor reviews sick calls. All five interviewed youth
stated they can see the nurse within one day after submitting a sick call.
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 maintains a written policy and procedures regarding the provision of episodic and
emergency care. A review of five youth Individual Healthcare Records (IHCRs) reflected three
youth were applicable for episodic care encounters. Each of the three episodic care events were
conducted by the registered nurse (RN) and documented in subjective, objective, assessment,
and plan (SOAP) notation. None of the episodic or first-aid care was provided by non-healthcare
staff. None of the applicable youth were sent off-site for emergency care. Each applicable
youth’s episodic care event was documented in the progress chronological notes and tracked
on the Episodic Care Log. The program has four first-aid kits located in areas throughout the
program. The kits are located in administration hallway, the classroom, and the laundry room.
One first-aid kit is maintained for use in the program’s transportation vehicle(s), and the kit is
kept in the secure key cabinet until each transport departure. The program has a prescribed
contents list for each first-aid kit. The list is maintained in each first-aid kit and has each item
noted with an expiration date. Reviewed documentation validated the nurse checks the first-aid
kits weekly. Observations of one first-aid kit were conducted and the kit contained the required
items. The program had one automated external defibrillator (AED) located in a wall-mounted
cabinet in the program’s administration hallway. The AED procedures are located with the AED.
Reviewed documentation confirmed the AED is checked by the nursing staff monthly. Reviewed
documentation confirmed the AED batteries expire on May 17, 2025, and the pads expire on
October 22, 2024. The batteries and pads were last changed on May 17, 2021, and June 27,
2022, respectively. Observations of a self-test of the AED showed the AED was operating
correctly and there were no issues. The program operates with three shifts. A review of the
program’s documentation indicated an announced or unannounced mock emergency medical
drill was conducted monthly on each shift for the previous twelve months. Emergency medical
drills included the demonstration of cardiopulmonary resuscitation (CPR) and AED more
frequently than the minimum annual requirement on each shift. A review of five staff training
records documentation confirmed all five staff held current CPR/first-aid, and AED certifications.
The program has a list of emergency numbers posted in the medical clinic, which is accessible
by non-licensed and licensed staff. Emergency phone numbers were inaccessible to youth.
Observations of an episodic care event were not completed as no episodic care event took
place during the week of the annual compliance review. The program maintains NARCAN® in a
locked medical cabinet in the secure medical clinic. The health services administrator (HSA)
reported all medical staff are trained on how and when to use NARCAN®. The HSA stated
NARCAN® is inventoried when conducting the medication count along with all other
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medications. An interview with five staff stated they are personally allowed to call 9-1-1 if a
youth had a medical emergency. All five interviewed youth stated they can see a dentist or the
doctor, if needed.
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 maintains a written policy and procedures for the provision of off-site emergency
and non-emergency referrals for medical care and treatment. A review of five youth Individual
Healthcare Records (IHCRs) reflected two youth were applicable for receiving off-site care. The
program provided one additional record for review in order to achieve the minimum required
sample size. All three youth had their emergency care documented on the Episodic Care Log.
Documentation validated each youth’s parent/guardian was notified of the youth’s off-site care
event. Each of the three youth IHCRs had a Summary of Off-Site Care Consultation Report
which was filed in the IHCR with any applicable additional documents. The designated health
authority (DHA) reviewed and signed all forms as required. Two of the three youth required a
follow-up appointment, and documentation showed one youth received the follow-up
appointment in a timely manner. The program documented attempts to secure an appointment
for the other youth, for which an appointment in January 2024 was scheduled during the week
of the annual compliance review. An interview with the health services administrator (HSA)
stated the DHA signs off on all off-site summary forms, when the youth return from the off-site
visit, and if a follow-up appointment is needed the nurse documents the appointment on the
nursing calendar and medical tracker.
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 maintains a written policy and procedures ensuring youth who have chronic
illnesses receive regularly scheduled evaluations with the required follow-up. A review of five
youth Individual Healthcare Records (IHCRs) reflected four youth were applicable for having a
chronic condition. None of the youth were documented as having a communicable disease. All
four youth were taking medication on an ongoing basis. One youth was undergoing treatment
for a physical health condition. Each youth was placed on the chronic illness list and periodic
evaluations were conducted when applicable, at least every ninety days. The program maintains
a tracking log for youth with chronic conditions and evaluation dates. The tracking log indicated
each youth’s next scheduled appointment. None of the youth were applicable for taking anti-
tuberculosis medications. Periodic evaluations were conducted prior to a prescription renewal,
change, or expiration, when applicable. None of the reviewed youth were applicable for an off-
site evaluation. There were no documented lapses in care or missed periodic evaluations in any
of the reviewed records. The Department’s Problem List for each youth was updated in
accordance with policy. An interview with the interim facility administrator (FA) indicated medical
issues and medications are discussed daily during morning management meetings. An
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interview with the nursing staff and the designated health authority (DHA) confirmed the process
for the completion of periodic evaluations.
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 maintains a written policy and procedures which outline the process of how
medications are to be received, stored, inventoried, and administered in a safe and effective
manner. A review of five youth Individual Healthcare Records (IHCRs) reflected four youth were
applicable for being on medication, all of whom were on medication prior to admission.
Medication was verified for all four youth prior to their admission into the program. Each
prescription verification was documented in each youth’s IHCR. There was documentation the
designated health authority (DHA) and psychiatrist were contacted to obtain orders to resume
medications. The medications for all four youth had current, valid orders, and were administered
pursuant to the current prescription, and each youth had a Practitioner Order form filed in their
IHCR for continued or new medication. Documentation showed each youth had a standard
Department Medication Administration Record (MAR) to document all medication and treatment.
A review of the MAR for all four youth reflected two instances where a non-healthcare staff
assisted in the delivery of medication when licensed healthcare staff were not on-site, and each
was initialed by the youth and the staff. Each IHCR documented medical staff initialed each
medication entry, and documented weekly side-effect monitoring. Two of the four records were
applicable for the youth having refused medication, and in each instance, there was clear
documentation on the MAR along with a signed Refusal of Treatment form. Each reviewed MAR
documented all required elements, including youth name, Department identification number,
date of birth, allergies, precautions, Medical Grade, medical alerts, and an attached current
picture of the youth. None of the reviewed youth were applicable for parenteral medication.
Documentation showed each youth received an Initial Diagnostic Psychiatric Interview within
fourteen days of admission, as required, and each youth received medication monitoring every
thirty days, as required. There was no sign of any type of standing orders for psychotropic
medications, emergency treatment orders for psychotropic medications, or any pro re nata
(PRN) orders for psychotropic medications. One medication pass was observed during the
annual compliance review week with no noted issues. The youth was escorted to medical by
direct care staff. The Six Rights of Medication Administration were verified by the nurse. The
nurse administered the medication as required and did not pre-pour any of the medications.
Five youth were interviewed, and four youth stated the nurse gives medication and one youth
indicated they do not take medication. Five staff were interviewed, and all five staff stated the
nurse dispenses medication. One staff clarified medications are dispensed by the nurse while
staff are present. An interview with the health services administrator (HSA) indicated only
nurses’ complete healthcare admissions to the program. All medications are verified with the
records sent with the youth from the juvenile detention center and medications are also verified
with the parent/guardian and youth during the intake process.
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4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program maintains a written policy and procedures regarding the requirements for the
storage and inventory of medications and sharps requiring all medication to be inaccessible to
youth at the program. Observations of the medication cart demonstrated it was clean and
organized, with stock items separate from youth specific medications. An observation of the
medication cart found all medications were stored in the locked cart which is kept in the locked
medical clinic. All non-controlled medications were stored in a separate, secure, locked
medication cart. Narcotics and other controlled medications are securely stored and double
locked within the medication cart. Observations found all medications were securely stored in
the medical clinic inaccessible to youth. The program had no medications requiring refrigeration
during the annual compliance review week; however, the program has a refrigerator which is
used only for medication, if needed. A review of documentation showed the program’s over-the-
counter (OTC) medications are inventoried using a perpetual inventory daily. An interview with
the health services administrator (HSA) confirmed the program’s practice. Perpetual inventories
with running balances are maintained on all controlled substances with shift-to-shift inventories
conducted by the nurses. Syringes and sharps are counted through a perpetual inventory and
are verified weekly. Observations of counts were conducted with the nurse during the annual
compliance review week. The program had three youth prescribed narcotic or controlled
medications and the reviewed inventories were accurate. A review of three OTC medications
was conducted which validated the inventories were accurate. Three sharps were reviewed, and
inventories were accurate. An interview with the HSA indicated it is the program’s practice to
destroy Class I medications on-site, with the consultant pharmacist, using a pharmaceutical
medication disposal chemical. Medications may also be returned to the pharmacy for
destruction.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program maintains a written policy and procedures for infection control which includes an
Exposure Control Plan and is written in accordance with Occupational Safety and Health
Administration (OSHA) and the Centers for Disease Control and Prevention (CDC) guidelines.
The policy for infection control was signed by the facility administrator (FA) and the designated
health authority (DHA) on July 3, 2023. The plan included common infectious diseases of
childhood, self-limiting, episodic contagious illnesses, viral or 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 anti-biotic resistant micro-organisms, food-borne illnesses, bio-terrorist agents, and
chemical exposures. The program also has Hepatitis B immunizations available to staff along
with access to protective equipment. An interview with the program’s health services
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administrator (HSA) confirmed since the last annual compliance review there were no instances
where the local county health department, CDC, and/or the Department’s Central
Communications Center (CCC) needed to be notified of any infectious disease; however, the
program has a separate file containing documents for youth and staff who have experienced an
occupational exposure. The plan includes a process for needle stick post-exposure evaluation.
An interview with the interim FA stated the infection control and exposure plans are located in
the FA’s office and the medical clinic. An interview with the HSA indicated infection control and
exposure control training for staff is conducted by the HSA, and the training for youth is provided
during the youth admission process.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a written policy and procedures to address youth supervision and requiring all
program staff to promote safety and security by maintaining active supervision of youth to
include interacting positively with youth, engaging youth in a full schedule of constructive
activities, closely observing behavior of youth, and consistently applying the program’s behavior
management system (BMS). The program has a daily youth activity schedule which was posted
throughout the program. The program staff are required to account for the whereabouts of youth
under their supervision and ensure staff-to-youth ratios are in compliance with contract
requirements. The program’s contract requires a staff-to-youth ratio of one-to-twelve during
sleep hours, one-to-five for off-site activities, and one-to-eight during awake hours.
Observations of staff supervision during the annual compliance review week included classroom
activities, line movement, school breaks, youth head counts, mental health groups, and
outdoor/indoor recreation activities. The observations ensured staff-to-youth ratios were
maintained, as required. Activities observed during the annual compliance review consisted of
supervision of youth during school hours, youth in the dining area, and youth movement through
the program. Staff were observed to be positioned to ensure proper supervision and to ensure
there were no physical obstructions in their view of the youth. Informal interviews with three staff
while on the floor were conducted. Staff were asked how many youth they were actively
supervising, and each staff was immediately able to report the accurate number of youth they
were assigned to supervise. Observed staff and youth were appropriately attired. Observations
of interactions between program staff and youth reflected the interactions included positive
contact, positive reinforcement, structured activities, predictable movements, and timely
response to youth everyday needs. A review of the program’s logbooks validated head counts,
movements, perimeter checks, and room checks were conducted, as required since the last
annual compliance review. An interview with five staff, indicated each staff was knowledgeable
of the program’s procedure for when youth counts cannot be reconciled. The program’s daily
activity schedule was posted and available to youth.
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 written policy and procedures addressing the implementation and training of
the program’s behavior management system (BMS). The program utilizes a positive
performance system (PPS) for their BMS. The PPS promotes youth rights, positive and negative
consequences, constructive disciplinary action, opportunities for reinforcement, positive
dialogue, and peaceful resolutions, as well as provides youth with pro-socially acceptable
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alternative behavior, maintains order and security, and minimizes the separation of youth from
the population. It is a multi-level point system designed to enhance youth treatment, to increase
healthy pro-social behavior using positive reinforcement, and to decrease unhealthy behaviors
through natural consequences. A variety of rewards and incentives are utilized to encourage
youth participation and completion of the program. Positive and negative behaviors are
identified throughout each day and incentives are in place to encourage youth to improve their
behavioral choices. Youth who display negative behaviors and receive consequences may
remain on orientation level until the youth engages and demonstrates positive progress. Special
treatment teams are conducted when serious infractions of the PPS occur. The PPS provides
for constructive discipline and a system of positive and negative logical consequences to
encourage youth in meeting expectations for behavior, provides for positive reinforcement and
recognition for accomplishments and positive behaviors at a minimum ratio of four-to-one
positive to negative consequences, promotes socially acceptable means for youth to meet their
needs, and includes processes which address the needs of and cognitive capacity of youth.
Observations confirmed the PPS was posted in the youth’s dormitory, administration, and in the
multi-purpose room. The PPS is clearly explained in the youth handbook, which is provided to
youth upon intake. The program’s PPS details the rules and the positive and negative
consequences for actions. Five youth case management records were reviewed, and each
record contained documentation to support each youth received an orientation to the program
which included the explanation of the PPS and an explanation of youth expectations,
responsibilities, and consequences. The PPS is correlated to each youth’s individual
performance and treatment plan goals. Each youth begins the program at the orientation level
and earns points to be progressively promoted to each of the four higher levels of rookie, pro,
hall of fame, and all-star. Daily and weekly incentives are determined by the level achieved by
each youth. Five staff pre-service training records were reviewed for pre-service training, and
found all staff completed training on the BMS. Observations made during the annual compliance
review week confirmed program staff adhered to the implementation of the PPS when
interacting with youth throughout each day. An interview with the interim facility administrator
(FA) indicated the program utilizes a system of a series of levels which allows youth to advance
levels and earn daily, weekly, and monthly incentives. Youth earn points to receive increased
privileges and are able to participate in concession stands and utilize points to purchase items.
The PPS fosters accountability for behavior and compliance with the program’s rules and
expectations, and the program utilizes a tracker to track points and rewards. The tracker is
reviewed with the staff during daily morning meetings. All behavioral infractions received by
youth are signed by the supervisors and reviewed by management in an effort to ensure the
system is being utilized according to policy. Additionally, the interim FA indicated staff are
monitored for the implementation of the PPS through fidelity checks to ensure staff are adhering
to the PPS system, administering it fairly, and positive reinforcements outnumber
consequences. Additionally, staff receive performance evaluations, which include a review of
their implementation of the PPS, at ninety-days after their hire date, and annually thereafter.
Five interviewed staff confirmed having received training and had some understanding of the
BMS. All of the five interviewed staff indicated the BMS is a point system with levels, and each
staff was aware of how the BMS is to be implemented and how the daily point system is used by
the program. Each staff indicated earned items cannot be taken away from the youth as a
consequence. Five youth were interviewed and explained the consequences used in the
program included level freezes, special treatment team meetings, placement on security alert,
and having incentive privileges suspended. Five youth were interviewed, and each reported
rewards and incentives include daily and weekly incentives, snacks, and meal incentives. Five
of the interviewed youth were able to explain the difference between each level and how to
move level to level. All interviewed youth denied being able to punish other youth. Each youth
indicated they felt staff were consistent in the use of rewards. Three of the five interviewed
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youth indicated they felt the behavior management system was good and two youth indicated it
was fair.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program’s policy, procedures, and practice confirm the program does not use room
restriction; 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 written policy and procedures in place to conduct and document ten-minute
checks during sleep hours or at other times, such as during an illness. The program has a total
of thirty-seven video surveillance cameras from which video recordings are maintained for at
least thirty days. During the annual compliance review week, all cameras were operational. Staff
are required to conduct room checks every ten-minutes and document the time of the check on
the Ten-Minute Check Log when youth are sleeping. Checks are documented on the program’s
Ten-Minute Check Logs with the time of each check noted in real time along with the initials of
the staff conducting each check. A review of nine separate video footage samples of ten-minute
checks and Ten-Minute Check Logs, documented by staff, reflected there were no
discrepancies. An interview with the interim facility administrator (FA) and observations
confirmed all the cameras were functional during the week of the annual compliance review.
Five staff were interviewed, and all indicated room checks are completed every eight to ten
minutes.
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5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program has a written policy and procedures to ensure youth are always accounted for
through a system of physically counting youth at various times throughout each day. The
program’s policy indicates headcounts will occur and shall be documented at a minimum of six
times within a twenty-four-hour period. The program utilizes the logbook to document the youth
counts and movements conducted throughout the day. Counts are conducted at the beginning
of each shift, after outdoor activities, and in emergency situations. The program also documents
and tracks youth intakes, releases, and all movements outside of the program. The program
utilizes an alert board located in the program’s conference room for tracking of the daily counts
of all youth in and out of the program. Observations during the annual compliance review week
and a review of program logbooks for the last twelve months showed the youth daily census
counts, head counts, and youth movements were documented at the beginning of each shift,
and after each outdoor activity. In addition, the program logbooks included documentation of
new admissions, releases, transfers, and youth temporarily away from the program.
Observations conducted during the annual compliance review week confirmed staff were aware
of all youth whereabouts and were able to provide the proper counts to the annual compliance
review team. Five staff were interviewed, and each were aware of what the youth census was
on the day of the interview and each staff was able to explain when counts and emergency
counts are conducted.
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 written policy and procedures requiring a chronological record of routine
events, incidents, activities, and emergency situations in a logbook in accordance with Florida
Administrative Code. A review of the program logbooks confirmed the program’s logbooks were
bound with pre-printed numbered pages. Observations and a review of logbooks since the last
annual compliance review found logbook entries were documented in ink with no erasures or
white-out areas. Errors were typically struck through with a single line, dated, and initialed by
the staff correcting the error. Reviewed documentation of randomly selected days within the
logbooks reflected each entry included the date and time of the event, the names of the staff
and youth involved, a brief description of the event, and the name and signature of the staff
making the entry. The program utilizes shift reports to summarize the events, incidents, and
activities documented in the program’s logbook and to brief all incoming staff. A review of the
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logbooks and shift reports demonstrated staff documented the required events, incidents, and
activities. The logbook included documentation of incidents, counts, perimeter checks, youth
transports, emergency situations, admissions, releases, and calls to the Florida Abuse Hotline
and the Department’s Central Communications Center (CCC).
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a written policy and procedures for key control and security which include the
assignment, inventory, tracking, storage, replacement of damaged keys, and accountability of
all keys used in the program. All program keys are maintained within the administration area,
which is located at the entrance of the program, and are housed within a central key cabinet,
which remains locked when not in use. All key rings are tagged to record the ring number, keys
assigned, and number of keys on the ring. A review of the inventory matched the key rings in
use. Each set of keys has an assigned key hook and tracking number. In order to provide strict
accountability of program keys, shift supervisors are responsible for the inventory, issuance,
inspection, return, and documentation of active keys. The keys are assigned to staff according
to their department and position at the program. Key control logs documented the issuance and
return of keys on a consistent basis. Staff sign-out the program keys at the start of the shift and
sign-in the program keys at the end of their shift. The program maintains all restricted keys,
temporary keys, and visitor keys separate from each other, within the locked cabinet. The
program has a list of staff who are assigned permanent keys. Permanent keys are issued, and
staff sign an acknowledgment form indicating a key identification number and the number of
keys issued. Permanent issued keys are assigned to the facility administrator (FA), the assistant
facility administrator (AFA) and to the physical plant manager. Observations made throughout
the annual compliance review week found all staff and visitors surrendered their personal keys
upon entering the program and keys were stored in the locked cabinet. A review of three staff
and their assigned keys during the annual compliance review week verified keys matched the
key log. All observations during the annual compliance review week found personal keys were
secured and staff were aware of program keys in their possession. A review of Department’s
Central Communications Center (CCC) reports verified there were no instances of a staff losing
their program keys since the last annual compliance review. An Informal interview with the
master control operator confirmed each set of keys has an assigned key hook and tracking
number. The master control operator indicated, in order to provide accountability of program
keys, only supervisors, master control, FA, AFA, or designees are responsible for the inventory,
issuance, inspection, return, and documentation of active keys. The operator indicated keys are
assigned to staff according to their department and position at the program. When staff sign-out
keys, the logs inventory the program keys at the start of the shift, and sign-in the program keys
at the end of their shift. Additionally, staff are not allowed to leave the program with program
keys, unless it’s a permanent key issued to approved staff. Five interviewed staff confirmed they
had knowledge of key control policies and procedures.
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5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a written policy and procedures to ensure the safety and security of
youth, staff, the program, and the public through effective search practices which include
detection and removal of contraband. The program’s policy specifies items and materials
defined as contraband and unauthorized items, which are also detailed in the program’s youth
handbook, which are never allowed to be in a youth’s possession. A review of the policy and
youth handbook confirmed prohibited items included 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-program issued electronic equipment or devices to include
smartwatches, metals, personal non-program issued cellular devices, unauthorized currency or
coin(s), and any keys not issued by the program. The program’s policy also includes a list and
quantity of approved youth items. Additionally, a contraband notice is posted at the entrance of
the program and states law enforcement will be contacted for anyone bringing in contraband
and a criminal report will be filed. The policy states any staff who is found in possession of
contraband in a program will be subject to disciplinary action up to, and including, dismissal, as
well as procedures regarding notification of law enforcement for items considered illegal as
defined in Florida Administrative Code. The policy outlines the program’s responsibilities,
standards for searches of youth, and program searches. Program searches include youth
rooms, common areas, and the program perimeter. A review of the contraband logs found
contraband searches were conducted on a weekly basis on each shift since the last annual
compliance review. Unannounced random youth searches are conducted, as well as searches
of common areas prior to and after use by youth. The program’s perimeter security is checked
on each shift. Searches and search findings are documented in the program’s logbook. The
policy dictates all illegal contraband will be surrendered to law enforcement, and unlawful
activity will be reported to law enforcement. The policy and handbook outline the consequences
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for youth found with contraband, which is also outlined in the behavior management system.
Additionally, reviewed documentation included the procedures for searching incoming and
outgoing mail. Observations of daily searches during the annual compliance review week
included line movements to and from educational classes, meals, breaks, and other movements
within the program, which validated the program’s practice. An interview with the interim facility
administrator (FA) indicated contraband searches are completed on an unannounced basis. The
interviewed interim FA reported any contraband which is illegal is turned over to law
enforcement and a criminal report would be filed. A review of the Department’s Central
Communications Center (CCC) incidents related to contraband, indicated there was one
reportable contraband incident during the annual compliance review period. An interview with
the compliance manager indicated any unauthorized items/illegal contraband is documented on
the log, reported, and disposed of properly. Any findings of illegal contraband are reported to
law enforcement and to the CCC. Five staff were interviewed, and all were knowledgeable of
and able to explain the program’s process for youth room checks.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a written policy and procedures requiring searches and full body visual
searches to be conducted according to Florida Administrative Code at the time of admission,
after off-campus activities, and visitation. Parents/guardians are notified of searches during
visitation by way of the parent/guardian intake letter, which is sent at the time of each youth’s
admission. Youth are searched before all movement, during a new admission, during
readmission, after returning from visitation, when returning from off-campus activities and/or
appointments, when suspected of having contraband, or when a youth is determined to be a
security risk. The program conducts searches as a method to prevent the introduction of
contraband and unauthorized items into the program. Policy indicates searches of youth are
conducted after off-site transports, after visitation, before moving youth from an outside area
into the building, and prior to moving youth from the building to an outside area. There were
observations of searches made for a transport and a new admission during the annual
compliance review week. During the annual compliance review week, the program did not have
any visitations or after off-site searches available; therefore, no observations of searches were
conducted during any of these events. Youth search and full body visual search forms were
reviewed and confirmed the program conducts full body visual searches at the time of
admission and other off-site appointments. Searches were documented in the program’s
logbook. Observations during the annual compliance review week included pat searches
conducted before and after line movements, to and from educational classes, meals, and
hygiene breaks which validated the program’s practice. Observations made throughout the
annual compliance review week validated youth are provided instructions regarding the search,
searches were conducted by staff of the same gender as the youth, were conducted in a
manner as not to degrade the youth, and were based on the Protective Action Response
(PAR)/Right Interactions (RI) training manual. Five staff were interviewed, and each staff was
knowledgeable of the program’s policy regarding the search procedures. Five interviewed youth
reported youth searches occur when returning from off-campus, after outdoor activities, after
visitation, after meals, when items are missing, and after work detail.
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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 written policy and procedures requiring the program vehicles to be properly
maintained, contain safety and emergency equipment, and be operated in a safe manner. 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 seatbelts, a seatbelt cutter, a
window punch, a fire extinguisher, and an approved first-aid kit. At the time of the annual
compliance review, the program had two operable vans used to transport youth. Both
transportation vans had installed safety screens and were equipped with a fully charged fire
extinguisher, seatbelt cutters, a window punch, and operable seatbelts for each passenger. The
vehicle first-aid kits are stored in program administration to be checked out each time a vehicle
is in use. Both vans passed inspections during the annual compliance review period and were
conducted on December 15, 2022, and on August 29, 2023. The program maintains a log which
had documentation of completed weekly vehicle inspections. The results of the weekly
inspections are documented and stored in the program’s vehicle maintenance log/binder. A
review of the weekly inspections showed all were completed, as required. A random check of
ten personal vehicles and the program’s transportation vehicles was conducted during the
annual compliance review and each vehicle was found to be locked. There was a transportation
available for observation during the annual compliance review week and no issues were noted.
Two of five interviewed youth indicated during transports youth are secured within the vehicle
with seatbelts, handcuffs, and shackles. Three youth indicated they have not utilized or been
transported in the program’s vehicles. Three of five interviewed staff indicated during transports
youth are secured within the vehicle with seatbelts, handcuffs, and shackles. Two staff indicated
they have not participated in any transportation of youth.
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 written policy and procedures to ensure the safety and security of youth and
the community during transportation of youth, and to ensure the appropriate staff-to-youth ratio
is maintained while youth are transported off program grounds. The program has an approved
transport list which is updated monthly to ensure staff driver’s licenses are valid. The approved
driver list is located in the administrative area by the facility administrator’s (FAs) office.
Reviewed documentation verified all approved drivers had a valid driver’s license. The program
does not provide secure transportation for high-risk and secure maximum-risk youth determined
to be at greater risk. An observation was conducted of the vehicles, and they were found to be
in working order. The transport vehicles are equipped with a safety screen separating the driver
from the passenger’s compartment. A random check of ten personal vehicles conducted in the
program’s parking lot over the course of four days found each vehicle was securely locked.
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Observations of a transport, during the week of the annual compliance review, confirmed the
staff-to-youth ratio was within the contract requirements. An informal interview was conducted
with three staff regarding the staff-to-youth ratios maintained during transports, and each staff
was able to provide the correct ratio and further indicated the program’s practice is to have two
staff with youth during transports. Five youth were interviewed, and all said they felt safe while
being transported and have not seen any staff place contraband in a transport vehicle. Five staff
were interviewed, and four staff indicated they would utilize the program’s cellular telephone
when transporting youth and one staff indicated they have not transported a youth. Five staff
were interviewed and three indicated the safety equipment in the transport vehicles consists of a
first-aid kit, fire extinguisher, and window punch, and two staff indicated they have not
transported youth. All staff reported transport vehicles are searched for contraband prior to and
after each use, and they are not allowed to use personal vehicles to transport youth. Three of
five staff indicated the emergency response process consists of notifying the program, the FA,
or the assistant facility administrator (AFA), and calling emergency services (9-1-1), and two
staff indicated they have not transported youth.
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 written policy and procedures requiring the maintenance of a safe and
secure physical plant, grounds, and perimeter. The program has designated the physical plant
manager as the person responsible for conducting the weekly safety and security audits. The
weekly safety and security audits include the inspection of the program’s cameras,
radios/communication, keys, locks and doors, vehicles, and living areas to include youth rooms
and bathrooms. The weekly safety audits are kept in a binder. A review of the program’s
Preventative Maintenance Checklist and Safety Inspection Logs for the past twelve months
confirmed the physical plant manager conducts weekly safety/security inspections. Findings are
documented on the Weekly Safety Inspection Report and provided to the facility administrator
(FA) for review. All deficiencies are tracked, and efforts are made to correct any deficiencies
noted. During the annual compliance review period, there were no inspections missing or any
discrepancies. The forms documented safety and maintenance repairs needed and the date
and time the repairs were completed, or due to be completed. All inspection forms were
reviewed and signed by the FA. The program had documentation of on-going efforts for any
repairs. An interview with the physical plant manager stated all work orders are submitted for
each issue identified and are tracked for resolution. An interview with the interim FA confirmed
safety and security audits are conducted on a weekly basis. Additionally, the interim FA stated
all deficiencies are documented and a time frame is given to have the items corrected and
deficiencies identified are discussed during the morning meetings.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a written policy and procedures to address the proper identification, control,
and management of tools to ensure youth do not use tools or equipment as weapons or security
breaches. The reviewed policy addresses the issuance, inventory, and control of equipment and
tools. The policy prohibits specific tools including machetes, bowie knives, and long blade
knives. The program has a policy and procedures for missing/lost tools and for tools requiring
disposal. The program has identified the physical plant manager as the program’s tool control
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manager. The policy classifies tools into two categories, Class A tools and Class B tools. Class
A tools are hazardous with sharp edges or points with a high potential to be used as a weapon
to inflict serious bodily harm such as knives, hammers, screw drivers, and electric drills. Class B
tools do not have sharp edges or points such as brooms, mops, and scrub brushes. A review of
inventory logs and the tool storage room verified tools are securely stored when not in use,
easily marked for identification, and inventoried prior to, and following work activities. Class A
tools are secured in the maintenance office and are inventoried daily when in use. Observations
found the maintenance office to be organized, neat, and clean. All tools were observed to be
maintained in a secured location. All Class A tools were stored on the maintenance office walls
with a photo of the tool and a number to identify the tool was stored in the proper place. All
Class A tools were in good repair and accounted for. All Class A tools are inventoried daily by
the plant manager except on days when the maintenance office is not accessed. Class B tools
are inventoried daily by program staff. The facility administrator (FA) reviews the inventories
monthly. A review of the inventory sheets validated this practice. The program has a sign-in and
sign-out log for Class A and Class B tools. All tools were properly identified and inventoried
during the annual compliance review period. A review of twenty tools and corresponding
inventories validated inventories were accurate. A review of five pre-service training records
indicated all staff were trained on the safe use of tools. During an informal interview, the
program’s plant manager was aware of the proper procedures to follow if tools are missing or
damaged. Further indicating, if a tool is missing while youth are in the area, staff will notify
administration, the program will stop all youth movement, and the program will be searched until
the tool is found. Additionally, the plant manager stated there were no tools which were currently
damaged or out of use. A review of the Department’s Central Communications Center (CCC)
reports verified there were no instances of missing/lost tools since the last annual compliance
review.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries to themselves, other youth, and staff. The program’s
policy and procedures included supervision requirements, issuing tools to youth and staff, and
activities involving tools. Class B tools which include mops, brooms, toilet brushes, and scrub
brushes are inventoried daily by staff to ensure each is accounted for. A review of the Class B
Tool Inventory Log sheets confirmed the program’s practice. A risk assessment of each youth’s
risk to self and others is required to determine their eligibility to use Class B tools. Use of Class
B tools and participation in work projects is based upon each youth’s level within the program’s
behavior management system (BMS). Five youth case management records were reviewed,
and all indicated youth have been trained on the proper usage of tools. A signed
acknowledgement form is filed in each youth’s case management record. An informal interview
with program staff indicated risk assessments are completed monthly and risk reassessments
are completed if youth require to go off-site for an off-site scheduled activity, such as a home
visit or for community service. During the annual compliance review week, there were no work
projects which involved youth and the use of tools; therefore, no youth were observed handling
tools. Five youth interviews confirmed youth are allowed to use a rake, scrub brush, mop, and
broom. Five staff were interviewed, and each confirmed youth are allowed to use a mop, broom,
scrub brush, and the agricultural rake. One staff indicated youth are allowed to use a hammer
and screwdriver with the completion of a risk assessment and if they are of no security risk;
however, indicating they have not seen a youth utilize these types of tools.
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5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a written policy and procedures establishing guidelines for outside contractors
who come on-site to complete repairs. When a contractor or vendor enters the program, they
sign the Outside Contractor On-Site Work Project Log which lists unauthorized items. The
physical plant manager or designee inspects all tools upon the arrival of outside contractors and
is responsible for providing approval if such tools are required. The program’s guidelines for
external workers include checking of tools upon arrival and departure, searching of all vendors
prior to entering the program, tool restriction while in the program, missing tool follow-up, and
restriction of youth from the work area. The outside contractor completes the program’s Outside
Contractor form upon entrance to the program, where they list what tools are needed to
complete the work order. Maintenance will review the form and sign once the tools are
inventoried and approved. Upon exiting the program, the Outside Contractor form is reviewed,
all tools are verified, then the form is signed. Any tools required to be used within the program
are inventoried and recorded on the contractor’s agreement form before and after the repair is
completed. Reviewed documentation for three project invoices showed the vendors signed
contractor agreements and an inventory of tools was completed and documented.
Documentation for the outside contractor forms verified the forms were completed and all
requirements were met. A review of the work project logs since the last annual compliance
review verified the contractors signed the log confirming notification of what items are
considered unauthorized. If any unauthorized items are needed by the contractor while in the
program, approval is obtained by the facility administrator (FA) or designee.
5.16 Fire, Safety, and Evacuation Drills Limited Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a written policy and procedures to ensure fire safety and evacuation drills are
conducted, and youth and staff are prepared for immediate implementation or mobilization in the
event of an emergency or disaster. A review of the program’s Continuity of Operations Plan
(COOP) revealed the program conducts monthly fire drills and monthly COOP drills on a
rotating basis on each shift. A tour of the program, during the annual compliance review week,
found fire evacuation routes and egress plans were posted throughout the program. The
program has seven fire extinguishers and reviewed documentation reflected all were inspected
annually. Additionally, during the annual compliance review week, an annual fire inspection was
conducted. A review of drill documentation for the annual compliance review period indicated
the program conducted one monthly fire and a COOP drill, as required, on each shift. The
program conducted monthly COOP drills which includes emergency drills, riot, disturbances,
escapes, bomb threats, chemical spills, medical situations, and severe weather. Reviewed
documentation for all drills contained the type of drill, date and time, participants, brief scenario,
findings, and recommendations. An interview with the interim facility administrator (FA) and
compliance manager, confirmed COOP drills and fire drills are conducted monthly on each shift.
Additionally, each drill is reviewed monthly in the program’s staff meetings. Five interviewed
youth reported they do not participate in fire drills and did not know what to do in the case of a
fire. One youth reported the youth do not line up or evacuate the building during drills. A review
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of the youth’s interviews and logbooks indicated the documentation did not document the youth
followed evacuation procedures during fire drills. Fire drills were documented within the thirty
days of camera storage; however, the program was unable to provide any video footage of
youth following evacuation procedures during a fire drill to the annual compliance review team.
The program conducted a fire drill on day three of the annual compliance review week and
observations of the drill showed youth were escorted out of the building. Four of five interviewed
staff said they have participated in at least one COOP drill which included a weather, major
disturbance, chemical spill, escape, and fire drills. One staff indicated they had not participated
as they were a new staff. An interview with the interim facility administrator (FA) confirmed the
program conducts monthly fire and COOP drills on all shifts.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program has a written policy and procedures requiring the development of a Continuity of
Operations Plan (COOP) which is updated as necessary and maintained for the continuity of
mission essential functions of the provider in the event an emergency prevents occupancy of
the primary program location, in compliance with state law and the Department’s policy. The
COOP addresses phases of a disaster plan as well as emergency management including
preparedness, response, and recovery. The COOP addressed emergencies including fire
prevention and evacuation, severe weather, major disturbances, bomb threats, hostage
situations, chemical spills, flooding, terrorist threats or acts, staff roles and responsibilities, any
equipment and supplies needed, information about youth which may be needed, alternative
housing arrangements, provisions for continuity of care and custody of youth, and provisions for
public protection. The COOP details alternative housing plans in case the program is required to
vacate due to an emergency or disaster. A review of the COOP validated the plan was
submitted and approved by the Department on February 15, 2023, and provides for basic care
and custody of youth in the event of an emergency or disaster. The interviewed interim facility
administrator (FA) indicated the staff have access to the program’s COOP and it is located in
FA's, assistant facility administrator (AFA), and master control offices. The program has the
necessary supplies readily available in case of an emergency evacuation maintained within the
conference room. The program maintains an administrative hard copy for each youth in case of
emergency. The program’s hard copy records are easily accessible and mobile in the event of
an emergency resulting in the program relocating quickly or in the event needed information
cannot be accessed electronically for all youth in the program. A review of five youth case
management records confirmed each contained the youth’s name, a photograph, Department
identification number, admission date, date of birth, gender and race, overall health status,
address, and parent/guardian contact information which included name, address, telephone
number of the person with whom the youth resides and their relationship to the youth, and
person(s) to notify in case of an emergency. In addition, the records contained the youth’s
assigned juvenile probation officer (JPO), committing judge, state attorney, public defender, and
victim notification contact information.
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5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program has a written policy and procedures addressing storage and inventory, to ensure
all youth and staff are safe from the effects of the unauthorized use of flammable, poisonous,
toxic, and caustic materials. The program’s physical plant manager maintains a monitoring
system to ensure compliance with flammable, poisonous, and toxic items. The program’s
flammable, poisonous, and toxic materials are stored in a flame-resistant locked cabinet within
the locked maintenance office. A review of the flammable, poisonous, and toxic items list
verified the items were securely stored. A copy of each current Safety Data Sheet (SDS) is
maintained in the maintenance office for each substance. A complete chemical inventory is
completed daily and documented on the Monthly Chemical Inventory Sheet. A tour of the
program and observations found the program stored all toxic items and materials in the cabinets
within the maintenance office and other chemicals were stored within a secure cabinet, in a
fenced perimeter area, inaccessible to youth. All inventory forms, sign-in and sign-out forms,
and SDSs were accurate to the chemicals maintained. A review of five items verified inventories
were accurate. The program also stores cleaning supplies in a locked storage room. The
storage room is locked at all times and can only be accessed by the plant manager,
supervisors, and administration. The items in this storage room are inventoried and have an
accompanying SDS located in the binder, as well as a perpetual inventory for staff to sign-in and
sign-out items with each use. An informal interview with the plant manager indicated the
program has an approved list of staff authorized to handle flammable, poisonous, and toxic
items. Furthermore, the plant manager reported the program does not keep any bleach, gas, or
any antifreeze.
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 written policy and procedures prohibiting youth from handling any
flammable, poisonous, and/or toxic items or materials. Program youth are strictly prohibited to
use, handle, or clean dangerous or hazardous chemicals, respond to chemical spills or clean,
handle, or dispose of any other person’s biohazardous material, bodily fluids, or human waste.
Observations confirmed all chemicals were maintained behind at least one locked door/cabinet
and youth do not have access to areas where items are being stored. Youth do not have access
to these items and are supervised by staff during daily cleaning. During the annual compliance
review, there were no observations of youth cleaning and/or using any chemicals. Two of five
interviewed youth reported not using any chemicals and/or cleaning products, and three youth
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reported having used paint. The informally interviewed physical plant manager indicated staff
handle cleaning products and youth are only able to wipe with a cleaning cloth. They
additionally indicated youth do not handle chemicals.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a written policy and procedures for the disposal of flammable, toxic, caustic,
and poisonous items. The policy prohibits chemicals from being poured on the ground or being
disposed of by any method other than what is outlined by the biohazard guidelines. The
program reported liquid waste, including dirty mop water and unused beverages, is disposed of
in the laundry room plumbing drains. The program’s physical plant manager, facility
administrator (FA), and assistant facility administrator (AFA) are the only staff authorized to
handle flammable, poisonous, and toxic items. Reviewed documents confirmed the program’s
disposal procedures of chemicals were created in accordance with Occupational Safety and
Health Administration (OSHA) standards. The program does not have a working kitchen;
therefore, does not dispose of any grease or frying oil. The program maintains a Safety Data
Sheet (SDS) Log to track the disposal of such items. An interview with the physical plant
manager indicated the program has not needed to dispose of any chemicals. A review of the
Disposal Logs confirmed the program did not have any chemicals disposed of since the last
annual compliance review. The program’s plant manager was interviewed on the proper
procedures of disposing chemicals and stated all items for disposal are collected by the local
county waste disposal department. An interview with the interim FA validated this practice.
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
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• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures to allow youth to have visitation and communication
with family members while in the program. The program assists youth and families in
maintaining connections in a visitation environment which provides monitoring, control of
movement, and security practices to ensure visitor, youth, staff, and program safety. The
program’s policy provides each youth opportunities to promote communication and engagement
which fosters family reunification and community connections. The program also maintains a list
of approved visitors; however, attorneys, representatives of the court, juvenile probation officers
(JPOs), other agency representatives, and clergy are authorized to visit at any time. Searches
of visitors will be conducted upon entry and all youth shall be searched following visitation
sessions. The program’s visitation policy indicated consideration for requests of alternative
visitation arrangements with parents/guardians, if needed. Youth are informed about visitation
upon their admission to the program during the orientation process. The visitation and
communication procedures are covered in the youth handbook, parent/guardian handbook, and
addressed on the orientation checklist. The visitation procedures are posted in the lobby.
Visitation is held two days a week on Saturdays and Sundays. Youth are given opportunities to
communicate with their family in person, by telephone, and by mail. Youth are provided with
writing materials and stamped self-addressed envelopes to send letters to approved family
members. The program maintains a Correspondence Log for each youth which documents
incoming and outgoing mail, which is inspected by staff. The Correspondence Logs are
maintained in each youth’s case management record. Youth are permitted weekly telephone
calls. Youth’s use of the telephone is documented in each youth’s case management
chronological documentation. A review of the logbooks, visitation sign-in logs, and outgoing and
incoming mail logs verified the program allows visitation and mail for approved family members.
A review of the telephone chronological notes verified youth have consistent telephone
communication with family members. It is the program’s practice for the assigned case manager
to follow-up with the JPO regarding human trafficking victims to determine whether the
parent/guardian should be permitted to communicate with the youth; however, there were no
youth applicable with a history of human trafficking since the last annual compliance review.
Five youth were interviewed, and each confirmed they are able to call and/or send letters to
their parent(s)/guardian(s). Five youth were interviewed, and each indicated they did not know
what services the program utilizes for youth who do not speak English, as English is their
primary language. In an interview with the interim facility administrator (FA), it was stated the
program utilizes a language interpreter system for youth, if English is not their primary language.
Five staff were interviewed and three indicated the program utilizes a language interpreter or
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Office of Accountability and Program Support Page 69 of 71 (Revised September 2022)
would use a translator for youth, when English is not their primary language. Two staff indicated
they had not had the need to utilize an interpreter and were not sure what was utilized.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a written policy and procedures to ensure each youth has a variety of
recreation and leisure activities. A review of the staff roster confirmed the program has a
recreation therapist, who met all requirements for the position. The program’s recreation
calendar designates an activity for the youth to participate in during outdoor recreation each
day, as well as a calendar of alternative activities if recreation is indoors. The program’s activity
schedule is posted throughout the living units and common areas of the building. All activities
promote social and cognitive skill development, creativity, teamwork, healthy competition,
mental stimulation, and physical fitness. Youth are provided with at least one hour of large
muscle activity daily. Five youth case management records were reviewed, and recreation
therapy was included in each youth’s individualized treatment plan. Reviewed documentation of
the logbook and daily activity schedule confirmed the program has a range of supervised and
structured indoor and outdoor recreation and leisure activities for the youth, for at least one hour
daily. Observations made throughout the annual compliance review week validated youth are
provided with at least one hour of indoor or outdoor recreation and leisure time. Five interviewed
staff indicated the program provides youth with at least one hour each day. Each staff indicated
the outdoor activities consist of basketball, football, soccer, volleyball, and kickball. The indoor
activities consist of board games, indoor games, and other card games. Five youth were
interviewed, and each youth indicated the program allows youth the opportunity to exercise,
play outside, or inside depending on the weather and one youth further indicated, they are
allowed recreation unless there is a security alert, or a youth has a sports restriction. Each youth
indicated they are allowed to participate in basketball, football, volleyball, soccer, or kickball
while outside, and when inside they participate in board games and/or can watch television.
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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5.26 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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Office of Accountability and Program Support Page 71 of 71 (Revised September 2022)

report_type: QI Residential

rule: Indicator 3.06

rating: Limited Compliance

rule: Indicator 3.08

rule: Indicator 5.16

excerpt: Fire, Safety, and Evacuation Drills