summary: QI Residential - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Hillsborough Girls Academy
TrueCore Behavioral Solutions, LLC
(Contract Provider)
9506 East Columbus Drive
Tampa, Florida 33619
Review Date(s): December 12- 15, 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:
Jesin Miah, Office of Accountability and Program Support, Lead Reviewer (Standard 1 and 5)
Rob Aguis, Office of Education, Deputy Director (Standard 1)
Belinda Alexander, Office of Education, Central Educational Coordinator (Standard 2) Marvin
Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 2 and
Standard 5) Kara Brown, Office of Accountability and
Program Support, Deputy Regional Supervisor (Standard 3)
Melissa Johnson, Office of Accountability and Program Support, Regional Supervisor (Standard
1, Standard 3, and Interviews) Cindy Jones, Office of
Education, Deputy Director of Education (Standard 2) Gustavo Mazorra, Office of
Accountability and Program Support, Regional Monitor (Standard 4 and Standard 5)
Alexis Sapp, Office of Accountability and Program Support, Regional Monitor (Standard 3)
April Walker, Detention Services, Senior Management Analyst II (Standard 5)
Program Name: Hillsborough Girls Academy MQI Program Code: 1224
Provider Name: TrueCore Behavioral Solutions, LLC Contract Number: 10788
Location: Hillsborough County / Circuit 13 Number of Beds: 22
Review Date(s): December 12-15, 2023 Lead Reviewer Code: 193
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
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 68 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 68 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 68 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 68 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education 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 7 of 68 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage 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 Satisfactory
5.25 Controlled Observation Satisfactory
5.26 Controlled Observation Safety Checks and Release Procedures 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 8 of 68 (Revised September 2022)
Program Overview
The Hillsborough Girls Academy is a twenty-two bed program, for fourteen to twenty-one year
old females, located in Tampa, Florida. The program is operated by TrueCore Behavioral
Solutions, LLC, through a contract with the Department. The program provides services
including Substance Abuse Treatment Overlay Services (SAOS) and Mental Health Overlay
Services (MHOS). In addition, the program fosters each youth by providing Career and
Technical Education (CTE) to include career-themed courses addressing business education,
career planning through Choices, Culinary Arts/ServSafe Food Handler certification,
Occupational Safety and Health Administration (OSHA) certification, and cardiopulmonary
resuscitation (CPR)/first-aid certification. In conjunction with the Children’s Home Society, youth
shall participate in the Supporting Partnerships to Assure Ready Kids (SPARK) thirteen-week
program. The program assists youth with job training placement and an annual Career Day with
various agencies in the local and surrounding areas. The youth are offered self-sufficiency
planning. The program works with a community partner to provide youth with a mentor to assist
in building healthy relationships. Curriculums used by the program include Aggression
Replacement Training (ART), Cannabis Youth Treatment (CYT), the Dialectical Behavioral
Therapy Skills Manual for Adolescents, Living in Balance (LIB), and Impact of Crime (IOC).
ART, CYT, IOC are primary services. Additional treatment services provided include family
therapy, individual therapy, recreational therapy, Program administration is comprised of a
facility administrator (FA), assistant facility administrator (AFA), Director of Clinical Services who
serves as the designated mental health clinician authority (DMHCA), designated health authority
(DHA), health services administrator, and a director of case management. Case management
services are provided by the director of case management, one case manager, one transitional
case manager, and one recreational therapist. Mental health staff at the program includes the
clinical director, a licensed marriage and family therapist who serves as the DMHCA, one
licensed therapist, and one unlicensed therapist. Medical services are provided by a health
services administrator (HSA) who is a registered nurse (RN), and two full-time RNs. The
program also has two additional RNs which the program uses pro-re-nata (PRN), if needed. The
contract requires for the HSA to work forty hours weekly, and two RNs to be on-site for a total of
eighty hours weekly. The HSA and two additional RNs provide coverage from 7:00 a.m. to 7:00
p.m., seven days a week, with a minimum of two RNs on duty at all times, which fulfills
contractual requirements. The program has an agreement with a medical doctor (MD) to serve
as the designated health authority (DHA). The DHA is responsible to oversee the medical
services provided at the program and is on-call for emergency consultation twenty-four hours a
day. The DHA is on-site weekly for at least two hours. The program has a contracted
psychiatrist who provides psychiatric services and medication management at the program
every other week. Educational services are provided by the Hillsborough County School Board.
The layout of the program is one building which includes an administration area, master control,
a multipurpose room, two classrooms, a medical clinic, and two dormitories. The program has
thirty-eight operating security cameras providing coverage. At the time of the annual compliance
review, the program had four vacant positions including three youth care worker Is and one
recreational therapist.
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Office of Accountability and Program Support Page 9 of 68 (Revised September 2022)
Strengths and Innovative Approaches
• The program has celebrated the successful graduations of 8 youth with a ceremony
which included the community and their families and honored all the hard work the youth
have put towards their education.
• Cancer Care Delivery Bags - The youth at the program participated in an outing to
deliver care bags for cancer patients. The bags were delivered by three youth, three
staff, and the facility administrator. Each bag consisted of socks, a card, water bottles, a
head wrap, a throw, a pen, and journal tailored to the patient’s treatment with a checklist
and appointment/medication reminders. The youth were able to see how grateful the
office staff and patients appreciate their act of kindness.
• Pink Barbie Breast Cancer Awareness Incentive - The youth at HGA were able to
participate in a Barbie Pajama Party Brunch which was led by the facility administrator
and attended by all program staff. Staff members dressed up as different barbies and
the youth had personalized Barbie Support Squad T-Shirts. The youth learned the
importance of breast screening.
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Office of Accountability and Program Support Page 10 of 68 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures in place regarding initial background screenings for
all staff members and volunteers. The program had fourteen staff and six volunteers applicable
for an initial background screening during the annual compliance review period. All fourteen
staff and six volunteers received an eligible background screening from the Agency for
Healthcare Administration (AHCA) Clearinghouse system prior to contact with youth and
confidential youth records. Criminal history reports were reviewed for all fourteen staff and six
volunteers, and none of the staff or volunteers required an exemption prior to working with
youth. Ten of the fourteen staff were direct care applicants, and a pre-employment assessment
tool was administered to each direct care applicant. A pre-employment assessment tool passing
score was documented in eight of the ten applicable records. The remaining two staff received a
second interview and were approved by the facility administrator for hire, which is the program’s
practice if a staff does not earn a passing score. Two staff had break in service and one of the
two staff had a new background screening completed prior to rehire. The remaining staff had an
eligible rating in the AHCA Clearinghouse system and had a break in service less than ninety
days; therefore, the staff was rehired under the current screening. This was also clarified with
the Department’s Background Screening Unit (BSU) by the annual compliance review team
during the week of the annual compliance review which clarified the provider could rehire the
staff under the current screening. All fourteen staff and six volunteers were added to the
Clearinghouse employee roster. The program’s Annual Affidavit of Compliance with Level 2
Screening Standards was completed and submitted to the BSU on December 15, 2022, meeting
the annual requirement. The Annual Affidavit of Compliance with Level 2 Screening Standards
for education staff was completed and submitted on December 9, 2022, meeting the annual
requirement.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures in place for completing a background rescreening on
all existing staff members and volunteers every five years after their initial screening date. Two
staff and one volunteer were applicable for a five-year rescreening during the annual
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Office of Accountability and Program Support Page 11 of 68 (Revised September 2022)
compliance review period, and each of the two applicable staff and one volunteer received a
five-year rescreening within the required time frame. A rescreening was submitted to the
Agency for Healthcare Administration’s Clearinghouse system at least ten business days prior
to the five-year anniversary date, as required, for each of the two applicable staff and one
volunteer.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
 The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
 All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
 Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
 The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
 A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures for the provision of an abuse-free environment
including the requirement for any staff who has knowledge of or has a reasonable suspicion a
youth has been in danger of being abused, should immediately report it to the Florida Abuse
Hotline. Staff can never prevent youth from reporting abuse. The program youth have a direct
dial telephone to call the Florida Abuse Hotline which is located in the multi-purpose room. Staff
shall make an abuse call if they suspect abuse. The facility administrator (FA) indicated all staff
receive training on abuse reporting guidelines during new hire training. All youth receive
information during orientation on how to report abuse. Postings for the Florida Abuse Hotline
and the Department’s Central Communications Center (CCC) were observed throughout the
facility during the week of the annual compliance review. A review of five staff personnel records
revealed each staff adheres to a code of conduct as indicated in the receipt of the staff
handbook. The program completed the Trauma Responsive and Caring Environment (TRACE)
self-assessment on February 20, 2023. The program had two incidents of abuse allegations
against staff during the annual compliance review period and each incident was reported, as
required. None of the allegation incidents were substantiated. None of the incidents included a
potential human trafficking victim, child sexual exploitation, or labor trafficking. Five youth were
interviewed, and each said they feel safe at this program. Each said they have never been
stopped from calling the Florida Abuse Hotline. Each said they know the location of the Florida
Abuse Hotline number. Four youth said staff are respectful and the remaining youth said some
staff are respectful and some staff use profanity. Two youth said they never heard staff using
profanity, two said they heard occasional profanity, and the remaining said the youth heard
profanity by staff once. All five youth said they never exchanged email, telephone number, or
social media contact information with staff. A follow-up informal interview was conducted with
the FA and the FA indicated program staff care about youth and are not allowed to use profanity
towards youth. In addition, a review of the grievances during the annual compliance review
period found no grievances against staff for using profanity. Five staff were interviewed, and
each was familiar with the process for calling the Florida Abuse Hotline. Each said they never
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heard any coworker telling a youth they cannot call the Florida Abuse Hotline and they never
heard any staff using profanity. Each staff was aware about the location of the Florida Abuse
Hotline number. The FA was interviewed and indicated physical abuse, threats, or profanity
towards the youth are considered critical offenses according to the program’s policy. Critical
offenses are subject to progressive discipline including immediate termination. Discussions are
held monthly regarding trauma responsive practices during the safety plan review.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program has a policy and procedures to ensure the program takes immediate action to
address incidents of physical, psychological, and emotional abuse. The program had two
incidents of abuse allegations against staff during the annual compliance review period.
Reviewed documentation validated the program management took immediate actions to
address each incident. None of the incidents were substantiated and no corrective action was
required for any staff. The program director was interviewed and indicated there have been no
staff disciplined for abuse allegations towards youth during the annual compliance review
period.
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 has a policy and procedures to ensure incidents are reported to the Department’s
Central Communications Center (CCC) in a timely manner. The program reported fourteen
incidents to the CCC during the annual compliance review period. A review of five reportable
CCC incidents revealed each incident was reported to the CCC within the required time frame
and each incident was documented in the logbook. A review of internal incidents and grievances
for the annual compliance review period found no additional incident which should have been
reported to the CCC. The program experienced an increase of one CCC compared to the last
annual compliance review period.
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 had two Protective Action Response (PAR)/Right Interactions (RI) incidents during
the annual compliance review period. Reviewed documentation validated the PAR/RI Reports
were completed by the end of the staff workday for both incidents and both PAR/RI Reports
included statements from all staff involved. None of the PAR/RI incidents required the use of
mechanical restraints and none of the PARs/RIs resulted in injury to youth or staff. None of the
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PAR/RI incidents resulted in an allegation of abuse. Both PAR/RI Reports were reviewed by a
PAR/RI certified instructor/supervisory staff. A post-PAR/RI interview was conducted for both
PAR/RI incidents and a PAR/RI medical review was not required for any incident based on the
post-PAR/RI interview. Both reports were reviewed by the administrator or designee within
seventy-two hours of the incident, as required, and a copy of each report was maintained in the
program’s centralized file within forty-eight hours of approval by the administrator or designee.
Reviewed documentation validated the program maintained and submitted monthly PAR/RI
summaries to the Department within the required time frame during the annual compliance
review period. The program’s PAR/RI plan was updated on January 6, 2023, and approved by
the Department on January 9, 2023. The program experienced an increase of two PAR/RI
incidents compared to the last annual compliance review period. The program’s PAR/RI rate
during the last quarter was 0.00, which is below the statewide Residential PAR/RI rate of 1.82.
The facility administrator (FA) was interviewed and indicated all PAR/RI incidents are reviewed
by the FA for appropriateness and then discussed by the entire management team during the
daily morning management meeting. The youth will receive a special treatment team (STT), if
warranted, for their behavior. The STT is processed by the management team. Five staff were
interviewed. Four staff said they used PAR/RI and were familiar with the PAR/RI process. The
remaining staff said they have not used PAR/RI.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program has a policy and procedures for pre-service trainings for newly hired staff. Five
staff pre-service training records were reviewed, and each staff completed at least 120 hours of
pre-service trainings within 180 days of hire, as required. Each staff completed all required
essential pre-service trainings which must be completed prior to any contact with youth. In
addition, reviewed pre-service training documentation validated each of the five reviewed pre-
service staff completed all other required and applicable pre-service trainings according to the
Florida Administrative Code and program’s contract. All trainings were entered into the
Department’s Learning Management System (SkillPro). None of the five reviewed staff were
returning direct care staff. Reviewed documentation validated all instructors who provided
trainings were trained to deliver the training provided. The program considers the facility
administrator, assistant facility administrator, master control staff, youth specialists, transporter,
case management staff, and transition manager to be direct care staff and counts them in the
staff-to-youth ratio.
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 has a policy and procedures to ensure all staff receive the required in-service
training each year. Five staff in-service training records were reviewed, and each staff
completed at least twenty-four hours of annual in-service trainings, as required. Reviewed in-
service training documentation validated each of the five reviewed in-service staff completed all
required and applicable in-service trainings within the required time frame according to the
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Florida Administrative Code and the program’s contract. Two of the five reviewed training
records were for supervisory staff, and both reviewed supervisory staff received at least eight
hours of annual supervisory trainings, as required. All trainings were entered into the
Department’s Learning Management System (SkillPro). Reviewed documentation validated all
instructors who provided trainings were trained to deliver the trainings provided. The program
maintains an approved in-service training plan which was required to be approved by December
1 of the year preceding implementation; however, the program’s in-service training plan was
approved on December 30, 2022. The program has an annual in-service training calendar,
which is updated as changes occur.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures regarding the program’s grievance process which
include the training requirements for the grievance process. All newly hired staff receive training
on the grievance process during their pre-service training. The program’s grievance process
includes an informal phase which includes verbal communication and My Voice Matters forms.
The informal phase encourages youth to resolve disputes and complaints through informal
verbal communication. Youth are encouraged informal communication with the staff, staff make
every reasonable effort to resolve the dispute informally, encourage open communication, and
handle informal complaints as expeditiously as possible. In addition, the grievance process
includes a formal phase and appeal phase where a youth completes a formal grievance form.
The program maintained copies of the grievances for the annual compliance review period, and
the program had one grievance filed during the annual compliance review period. The one
applicable grievance was reviewed, the grievance was resolved, and the program’s practice
correlated with the program’s grievance process. Five youth were interviewed. Each youth was
familiar with the process to file a grievance and indicated they can ask for assistance to file a
grievance. Five staff were interviewed, and each staff was familiar regarding the program’s
grievance procedure. The facility administrator (FA) was interviewed and indicated youth should
attempt to talk over the problem with the staff member directly involved or shift manager on duty
and attempt to reach an agreement before filing a formal grievance. The youth may decide to
file a grievance form if the issue cannot be resolved verbally. The youth should provide a written
appeal to the FA if the youth does not agree with the solution offered.
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.
A review of the program’s contractually required interventions included Girls in Real Life
Situations, Girls Circle, Savvy Sisters, Mean Girls, Girls Moving On, Essential Art Therapy
Exercises, and ARISE. During the annual compliance review period Girls Circle was facilitated
by the therapists for one day then stopped based on the directive received by the Department.
Savvy Sisters and Girls Moving On curriculums were facilitated by the therapists and were also
stopped after the directive was received. During the annual compliance review period there was
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no need to facilitate the Mean Girls curriculum or the Essential Art Therapy Exercises. The
curriculum Girls in Real Life Situations, was offered on a regular basis by the therapists.
Documentation supported three master’s-level therapists facilitated this group during the annual
compliance review period. The staff’s education and work experience were considered by the
program when determining staff delivery of the intervention service. Training documentation for
all three staff supported they were trained to facilitate the curriculum on December 22, 2022. A
review of the program’s activity schedule, the group sign-in sheets, and documentation
supported groups were being conducted as scheduled. An interview with the facility
administrator indicated Impact of Crime (IOC) is the delinquency prevention model used at the
program and is considered a primary service. An interview with the designated mental health
clinician authority (DMHCA) indicated mental health groups are provided four days a week for
forty-five to sixty minutes. If a mental health overlay service youth has a substance abuse
diagnoses, the therapists will substitute one of the groups for a weekly substance abuse group.
At the time of the annual compliance review the program did not have any Substance Abuse
Treatment Overlay Service (SAOS) youth. The standardized group curriculums used are
evidence-based and approved by the Department.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures addressing life and social skills training provided to
the youth. The transition services manager (TSM) facilitates the Overcoming Obstacles
curriculum for life and social skills training. This curriculum addresses communication skills,
interpersonal relationships, anger management, and critical thinking to include problem-solving
and decision-making. Youth also learn life and social skills through attending the Dialectical
Behavioral Therapy (DBT) groups facilitated by the therapists. By attending the DBT group, the
youth learn coping strategies. The behavior management system, the Positive Performance
System (PPS) is also based on developing life and social skills. These various interventions
address skills such as communication, interpersonal relationships and interactions, conflict
resolution and anger management, and critical thinking skills such as problem-solving and
decision-making. The TSM works with youth on an individual basis throughout each week when
the youth are not attending school and on weekends. Additional life skills were taught to the
youth through making cancer care delivery bags for individuals within the community. Youth
then go out into the community to deliver the bags and build social skills by interacting with
individuals. Treatment team documentation supported these skills are discussed during each
youth’s individual treatment team meeting. Progress notes also support these skills are
addressed with each youth while working with clinical staff. The designated mental health
clinician authority (DMHCA) indicated youth learn life and social skills first through theoretical
and conceptual lessons, practice the learned skills in the program, and master the skills while in
the community. The DMHCA also indicated a lot of the life and social skills are geared towards
teaching the youth self-sufficiency planning. The DMHCA indicated these skills are also taught
to the youth through community groups who visit the program such as the dog training classes
and the youth ministry. Five youth were interviewed, one youth indicated they made a big
breakfast and learned how to talk to people. One youth indicated they participate in girl’s group,
learned how to fill out applications, participate in health group, and participated in
cardiopulmonary resuscitation (CPR) and Occupational Safety and Health Administration
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(OSHA) training as well. The third youth indicated they have learned empathy, how to express
themself, how to control anger, and vocational and pro-social skills. The youth indicated they
participate in role play and talking activities. The fourth youth indicated they had to attend
mandated groups such as Impact of Crime (IOC) and girl’s group. The youth indicated they
asked staff for parenting classes and independent living classes and hasn’t received them. The
youth said staff indicated these classes are not their specialty. The fifth youth said they learn life
skills like etiquette, life skills, how to carry oneself and act lady like, how to approach people,
and how to interview for a job in mental health groups. The facility administrator indicated the
program meets the needs of a targeted gender group through treatment planning based on the
individualized needs of the youth and gender responsive
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 services the program is required to provide according to the contract are My Voice Matters,
Goals Group, Positive Performance System (PPS), special treatment team meetings, daily
meetings, Youth Advisory Board, daily, weekly, and monthly incentives, exposure to victim
services, delinquency intervention groups, and plans for reintegration. These restorative justice
interventions provide delinquency interventions which are an evidence based, promising
practice, or a practice with demonstrative effectiveness, as identified on the Department's
website. These groups/activities are incorporated through the daily schedule. The daily
schedule includes daily meetings, mental health groups, recreation time, and specific groups to
include Impact of Crime (IOC) and Thinking For a Change (T4C) which are conducted twice a
week. Nightly incentives are provided each evening after group and weekly PPS incentives are
conducted on Friday evenings. Access to the boutique is provided on Saturdays and Sundays.
Sign-in sheets were reviewed and confirmed groups were provided as scheduled. In addition to
the restorative justice groups, the program incorporated additional restorative justice activities to
include creating bags for the homeless to make them feel cared for, writing letters to victims,
making blankets for babies in the neonatal intensive care unit (NICU), and making and
delivering cancer care delivery bags and going out into the community to deliver the bags and
spend time with the patients. The facility administrator (FA) indicated IOC groups are held on
Mondays from 2:30 p.m. to 3:45 p.m. The FA indicated youth do not receive additional groups if
they have already received IOC. Youth are permitted to participate in restorative justice
activities based on review of the youth's risk assessment and approved court order. The FA
explained how the administrative staff have worked hard in order to obtain the approval of the
courts to participate in off-site community service projects. Five youth were interviewed, and one
youth indicated they learned about victim blaming, driving under the influence, and sexual and
domestic violence. The youth indicated they work on community service hours during IOC
group. The second youth indicated during IOC groups they talk about responsibilities and if they
get into trouble they need to pay restitution. The third youth indicated they participate in IOC and
Aggression Replacement Therapy (ART) groups and complete community service. The fourth
youth indicated they participate in IOC and ART groups. The fifth youth said they participate in
IOC group and can earn community service hours by helping clean, pick up trash outside, and
write essays. During these groups they learn definitions of terms, role play, watch episodes of
shows, and discuss how those episodes relate to real life situations. The designated mental
health clinician authority (DMHCA) provided a list of groups provided during the annual
compliance review period.
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1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures which outline how alerts are identified, documented,
updated, and communicated to staff. Youth are screened at admission for all possible alerts and
all applicable alerts are entered/updated in the internal alert system and the Department’s
Juvenile Justice Information System (JJIS) by the appropriate staff member. Five youth records
were reviewed for youth alerts in JJIS and the program’s internal alert system. Each of the five
reviewed youth were identified with alerts and each alert was consistent with the program’s
internal alert system and JJIS, in accordance with the program’s policy and procedures. A
review of alerts for all five youth from their date of admission to the program and logbooks
confirmed each alert was entered/updated as required by the appropriate staff and documented
in the logbook, if applicable, for each youth. Alerts for all five youth were consistent with the
program’s internal alert system, and the alerts in JJIS and internal alert system matched for
each youth. An interview was conducted with the facility administrator (FA) and the FA indicated
a communication board is utilized as the internal alert system. The board is updated as needed
by medical, clinical, and case management staff. Nursing, case management, and the clinical
departments are responsible for entering, updating, and closing alerts in JJIS as needed. An
interview with the nursing staff revealed the healthcare staff are responsible for updating
medical alerts. An interview with five program staff revealed alerts are shared with staff in shift
briefing, through the alert board, and in the alert binder.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains separate individual case management, individual mental health and
substance abuse, and Individual Healthcare Records (IHCRs). Five youth case management,
mental health and substance abuse, and IHCRs were reviewed, and each reviewed record
contained all required and applicable information and sections. Each record was labeled
“Confidential.” All records are securely maintained in locked cabinets labeled “Confidential”
within the responsible program area office.
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1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a community advisory board (CAB) which is scheduled to meet on a quarterly
basis. Reviewed documentation during the annual compliance review period validated a CAB
meeting was held at least every ninety to 120 days, as required. No CAB meeting was cancelled
or needed to be rescheduled during the annual compliance review period. A review of the list of
CAB members, sign-in sheets, agendas, meeting minutes, and meeting invitation found the
program recruited or solicited involvement from all required and applicable community partners.
An interview with the facility administrator revealed CAB meetings are held quarterly and include
members from multiple aspects of the community. CAB members are encouraged to visit and
tour the program and make suggestions on services they can provide or can assist in obtaining
for the program. A board member was interviewed during the week of the annual compliance
review. The board member confirmed active participation and involvement in the advisory board
activities and indicated CAB meetings are held quarterly.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures regarding staff performance. The policy requires each
staff to receive evaluations annually. A staff may receive more than one evaluation a year as
deemed appropriate by the supervisor. Each staff shall be evaluated once annually and a
ninety-day evaluation after their introductory period. A review of position descriptions for five
staff revealed each staff’s performance standards were clearly identified and the performance
standards matched the job descriptions. Five staff personnel records were reviewed, and each
staff received an annual performance evaluation based on established performance standards,
in accordance with the program’s policy and procedures. A review of the program’s contract
revealed the program maintained all contractually required positions during the annual
compliance review period. Five staff were interviewed; one said they receive a performance
evaluation yearly, one said every six months, one said monthly, one said very rare, and the
remaining staff did not know how often. The facility administrator was interviewed and indicated
annual performance evaluations are completed to provide feedback to the staff regarding their
performance over the prior year to include implementation of the Positive Performance System
and overall job specific duties, and goals are identified for the next year.
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1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s special contract conditions include youth self-sufficiency planning, discharge and
transition services, specific living environment requirements, and staff retention.
The program will assist youth with self-sufficiency planning by developing a plan and assisting
with living arrangements for the youth where independence is a more realistic option. The
program shall offer an annual career day with various agencies for youth to practice interview
skills and find potential career paths. It was confirmed during the annual compliance review
week while youth are in the program, all youth are to receive mental health and substance
abuse counseling to assist the youth with reintegration back to the community, job training
through soft skills, aftercare services, and self-sufficiency skills. Youth are able to earn their
cardiopulmonary resuscitation/first-aid certification. Some youth have earned a hair braiding
certification and youth are receiving training in dog care and handling. Youth are taught
budgeting skills by earning "HGA" money and being able to spend it on different items in the
boutique and activities. Youth receive a checkbook and a check register to learn how to utilize a
checkbook. Youth are taught how to write a check and practice this skill when placing orders at
the program boutique. Prior to youth leaving the program they receive assistance in establishing
a recruiting account on a particular job-search engine. This account will assist them in locating
employment. The program will assist the youth by taking them to job interviews while they are
still in the program. When the youth are released from the program they are provided with a full
bag of hygiene products, a professional outfit, and a leisure outfit. None of the youth have been
in need of independent living arrangements throughout the annual compliance review period.
Sign-in sheets were reviewed and confirmed volunteers with a local mentoring company have
been on-site weekly as scheduled. At the time of the annul compliance review, staff were
planning an annual career day to be held at the program at a future date. The purpose of the
annual career day is to introduce various types of careers to the youth as well as giving the
youth the opportunity to interact with representatives from various careers to enhance the
youth’s communication skills. The case management staff and transitional staff work with the
court system to allow the youth to go into the community during their transitional phase to
practice self-sufficiency skills learned at the program. At the time of the annual compliance
review, none of the youth in the transition phase required a court order to participate in
community outings.
The program provides discharge and transition services to include having each youth participate
in the development of a community based safety plan to serve as a guide of safety and success
once back in the community. The transition services manager (TSM) shall provide each
transitioning youth with the Overcoming Obstacles curriculum. Each youth shall work with their
therapist to create a relapse prevention plan and the TSM will work with youth and families to
create a thirty-day post release activity and appointment calendar. It was confirmed during the
annual compliance review week each youth receives a community-based safety plan when they
enter the transition phase of the program. The plan includes safe alternative locations if the
youth feels unsafe at school or home. The TSM works with each youth on completing the
Overcoming Obstacles curriculum. The TSM uses this curriculum in tandem with self-sufficiency
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skill building. The TSM will choose the lessons from the curriculum which best meet the needs
of the individual youth. Each youth works with the TSM throughout their stay in the program to
build, assess, and re-asses mastery of skills to determine the youth’s post-release needs.
These identified needs are addressed during the Community Re-Entry Team (CRT) meeting as
the youth gets closer to transitioning out of the program. During the transition phase of the
program, the therapists will work with the individual youth to develop a relapse prevention plan.
As the youth develops the plan, they identify triggers and skills to avoid the triggers. Support
members and community resources are identified for the youth to utilize to assist with coping
strategies once back out in the community. The TSM develops a thirty-day post-release activity
and appointment calendar with input from the youth and the youth’s family. Appointments and
activities include reintegrating back into school if applicable, scheduling medical and mental
health appointments, and job placement activities or appointments if applicable.
The program’s living environment includes youth bedrooms having individualized comforters,
decorative walls with personal cards, and pictures specific to each youth. The day room shall be
decorated with comfortable sitting, artwork, and other items which provide a safe and welcoming
atmosphere. The program shall ensure youth have access to appropriate reading materials and
shall maintain a diverse media center. Family visitation shall be held every Saturday and
Sunday. In the event of any limitation to face-to-face visitation, alternative platforms for visitation
shall be provided. The program shall provide regular faith-based opportunities and quarterly
documented attempts to provide religious services and education. It was confirmed during the
annual compliance review week all youth rooms were painted, with a designated wall area to
post photos and personalized artwork. Each youth had colorful comforters on their beds. The
program did not have any inspirational murals painted throughout the facility; however, there
were colorful posters and inspirational sayings posted throughout the facility. Reading materials
were observed to be in different areas of the facility. Reading materials were in the education
classrooms, the therapist offices, and the youth’s room. Reading materials must be approved by
program administration before the materials are allowed to be introduced to the youth. The
program does not have a specific area designated as the media center; however, program staff
and education staff have the resources needed to offer the youth diverse media options as
needed. The program holds visitation every Saturday and Sunday. The program’s schedule
indicated visitation is from 2:30 p.m. to 4:45 p.m. The program indicated if any youth has family
who cannot attend during the scheduled times, they will conduct a visit virtually at another time
or coordinate another time for an on-site visit with the youth’s therapist. The program indicated
they have alternate platforms available if face-to-face visits are limited for any reason. They
utilize video calls to ensure the youth are still able to visit with their families. During special
family days on holidays, the program has offered families who were traveling long distances a
one-night stay at a local hotel so the families could participate in the holiday celebration. Youth
and staff interviews confirmed spiritual opportunities are provided on a regular basis. The
visitation logs supported these religious groups visit weekly on a regular basis.
The program provides a variety of measures to recruit and retain staff. A probationary review
status of new staff will be completed with all newly hired staff. The program will have a staff
mentoring process with designated staff. The program provides a competitive compensation
package to the staff which includes performance-based pay, 401K, various types of health
insurance options, and reimbursements for continuing education units and licensure. The
program provides staff with referral bonuses, monthly raffles at staff meetings, incentives for
meeting benchmarks, and random incentives for staff exceeding expectations, and an employee
of the month. After a year of employment, staff are eligible for the tuition reimbursement
program. Administrative staff work with applicable staff to develop a succession development
plan. The plan includes goals, objectives, start dates, target dates, and completion dates. The
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program has a designated supervisor who provides mentoring to and serves as the program
coach for all new staff. This staff coach ensures the new staff training plan is completed and, if
applicable, retraining is completed. If staff require additional coaching and plans for remediation
the program has a “coaching” option in their personnel system. This option is established to
assist the staff in becoming successful in meeting performance expectations. Ninety-day
performance reviews are completed to assist new staff in learning the program’s policy and
procedures correctly and assist them in being effective staff.
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.
Career and Technical Education (CTE) shall be provided either directly by the local school
district in which the juvenile justice program is located, or through a contract between the local
school district and its selected provider. The services the provider is required to offer from the
contract amendment includes Florida Ready to Work Soft Skills, Occupational Safety and
Health Administration (OSHA) 10, cardiopulmonary resuscitation (CPR)/first-aid and an industry
certification approved on the Master Credential List. The original contract states employability
and career-themed courses shall be available based upon the need and interest and shall
include business education, career planning through Choices, Culinary Arts/ServSafe Food
Handler Certification, OSHA, and CPR/first-aid. During the annual compliance review week,
youth certifications were reviewed. Two youth were in progress of completing the Florida Ready
to Work Soft Skills certification. Two youth have completed the OSHA-10 program and four
youth were still in the process of completing this certification. Eleven youth successfully
completed CPR/first-aid training. The industry certification is still a work in progress. At the time
of the annual compliance review the program had signed an agreement with Certiport to offer
Entrepreneurship and Small Business as their pathway towards an industry certification. Two
youth are signed up for this program. All CTE services were provided by qualified individuals.
CTE is age appropriate for the youth in the program, appropriate for the abilities and goals of
the youth in the program, and appropriate for the length of stay and classification of youth in the
program. Participation in CTE was unable to be observed during the annual compliance review
week. Five youth indicated they participate in math, reading, working on business and résumés,
job applications, and how to communicate with customers. When asked how often do the youth
participate in CTE, the responses varied from when youth get closer to leaving to pretty
regularly. Youth indicated they were not participating in CTE because there is no internet
service and no computer. The facility administrator indicated youth are taught how to complete
applications and résumés. Through the Hillsborough County School system youth are also able
to receive a Certiport (Microsoft Office Specialist) certificate and participate in the Florida Ready
to Work program which tests and scores job skills and work habits. Youth who have completed
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high school are able to take college classes through Hillsborough Community College with
assistance from the Project Anchor program with registering youth for college in their area.
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 provider and program use an internal database and dashboard system allowing daily data
entry. The data is then aggregated into weekly and monthly totals which are displayed on the
dashboard specific to the program. Dashboards are updated on a weekly basis. Corporate uses
the data to complete trend analysis. Regional compliance managers are responsible for
completing fidelity monitoring to ensure the integrity of the data reported by the program. The
program uses the corporate electronic record system to run specific reports giving up-to-date
information to assist with trend analysis. The program utilizes an online survey system to survey
youth, staff, and youth’s families on a quarterly basis. The surveys are anonymous. The survey
results are reviewed by the provider’s chief of compliance officer and then with regional and
program staff. Data gathered from trend analysis and the TRACE survey are analyzed and
policy, procedures, and processes are revised and updated based on the findings. Information
is shared with stakeholders during quarterly board meetings. A review of morning management
meeting sign-in sheets and meeting minutes, staff meeting minutes, quarterly board meeting
minutes, and survey questions supported the program’s practice.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures which require notification of the youth’s
parent/guardian by telephone within twenty-four hours of the youth’s admission, followed by
written notification within forty-eight hours of admission. In addition, the program must notify the
youth’s committing court, the assigned juvenile probation officer (JPO), and post-residential
services case manager, if applicable, in writing within five working days of any admission. Five
youth case management records were reviewed, and all contained documentation which
confirmed the parent/guardian was contacted by telephone and informed of each youth’s arrival
and program information. All five case management records contained a copy of a written
notification which was mailed to the parent/guardian on the day of intake informing the
parent/guardian of each youth’s admission. In addition, all five youth case management records
contained written notification of intake to the JPO and committing court.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures which state the program shall provide each youth an
orientation to the program’s rules, expectations, goals, and services, which is to begin on the
day of each youth’s admission. Five youth case management records were reviewed, and all
contained documentation verifying each youth received an orientation on the day of admission.
The documentation contained all the elements required to be reviewed during orientation. The
program had no youth admissions during the annual compliance review week; therefore,
orientation was not observed Five interviewed youth said orientation started within twenty-four
hours of arrival to the program, and included program rules, procedures, and schedules. Two
youth mentioned they can read the handbook, and two youth stated they were verbally told
about the program rules and level system. All youth were able to explain the orientation
process.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures requiring 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
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or mental health screenings, assessments, or treatment. None of the five reviewed youth were
over the age of eighteen. A review of the two additional applicable case management records
confirmed they contained documentation signed by each youth allowing the release of
information regarding physical or mental health screenings, assessments, and/or treatment with
their parent/guardian.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a policy and procedures which outline the classification system. This system is
used for the purpose of assessing each youth admitted to a living unit, sleeping room, and
group or appointing of a staff advisor. Youth are also reassessed and reclassified, if warranted,
prior to considering an increase in privileges or freedom of movement, participation in work
projects, other activities involving tools or instruments which may be used as potential weapons
or means of escape, or participation in any off-campus activity. The procedures also required for
all admitted youth to be screened for Vulnerability to Victimization and Sexually Aggressive
Behavior (VSAB) prior to room assignment. Room assignments by staff shall ensure a youth’s
potential for victimization or predatory risk has been reviewed. The program’s classification
forms included the physical characteristics of the youth, age, maturity level, identified special
needs, history of violence, gang affiliation, criminal behavior, sexual aggression, VSAB results,
the youth’s perception of vulnerability, any history of potential or verified human trafficking,
suicide, medical, escape, and/or security risks. Five youth case management records were
reviewed, and each contained a copy of the admission classification form, which was completed
on the day of admission, and addressed all suspected risk factors. A review of the Department’s
Juvenile Justice Information System (JJIS) confirmed alerts were entered for any issues
affecting classification. All youth were classified for purposes of assigning to a living area,
sleeping room, and youth group or a staff advisor. Any youth identified with a medical, mental
health, substance abuse, security risk factors, and/or special needs during or after the
classification process immediately had the appropriate alert entered into the program’s internal
alert system and JJIS. Three of the five reviewed youth records contained documentation which
confirmed reassessments were completed whenever there was an increase of the youth’s
privileges, participation in work projects or other activities involving tools or instruments which
may be used as weapons to provide a means of escape. The facility administrator was
interviewed and advised all factors are taken into consideration during classification to ensure
youth are placed in the most secured environment which best fits their needs.
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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 policy and procedures in place to gather information on youth with any
involvement in gangs and share this information with law enforcement. Five youth case
management records were reviewed, and none of the youth were applicable for gang
involvement. One additional youth record was reviewed and found to be applicable for gang
involvement. The applicable record contained documentation which confirmed notifications were
made to the local sheriff’s office. The applicable youth’s residential commitment placement was
not in their home county. Law enforcement in the youth’s home county was notified of the
youth’s gang affiliation. An alert was updated in the Department’s Juvenile Justice Information
System and the program’s internal alert system. Information of the youth’s gang status was
shared with the education department and the youth’s juvenile probation officer.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures in place for the implementation of gang prevention
and intervention strategies. The program provides intervention strategies when youth are
identified as a criminal street gang member, are affiliated with any criminal street gang, or are at
high-risk for gang involvement. Five youth case management records were reviewed, and none
of the youth were applicable for gang involvement. There was one additional youth case
management record of youth with gang involvement to review. The youth is not enrolled in any
gang intervention because the one being used has been removed from the approved
intervention list. The program contacted the Hillsborough County Sheriff’s Office who will be
supplying the program with the Community Anti-Gang Expansion and Enhancement curriculum.
Once approved by the Department, they will implement the curriculum. The facility
administrator’s interview confirmed they are researching finding a new curriculum.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures which require the initial Residential Assessment
for Youth (RAY) be completed within thirty-days of admission and reassessments be completed
at least every ninety-days. The program is to ensure any other updates or reassessments are
completed by the intervention and treatment team to effectively manage the youth’s case. Five
youth case management records were reviewed, and all had the RAY completed within thirty-
days of admission. The initial assessments were all maintained in each youth’s case
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management record as well as in the Department’s Juvenile Justice Information System. None
of the five youth were applicable for reassessments. Three additional youth records were
reviewed for ninety-day reassessments. All three applicable youth for reassessments had all
reassessments completed within ninety-days from the time the last reassessment was
completed. All reassessments were maintained in each youth’s case management 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 policy and procedures requiring the Youth Needs Assessment
Summary (YNAS) be completed within thirty-days of admission. Five youth case management
records were reviewed, and all had the YNAS completed within the first thirty-days of each
youth’s admission. All summaries were documented in the Department’s Juvenile Justice
Information System.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a policy and procedures which require the intervention and treatment team,
including the youth, to meet and develop the performance plan, based on the findings of the
youth’s initial assessment, within thirty-days of admission. The performance plan shall include
the target date for completion of each goal, in addition to the youth’s responsibilities to
accomplish the goal, and the program’s responsibilities to enable the youth to complete the
goal. 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, within ten working
days of completion of the performance plan. Five youth case management records were
reviewed, and all records contained documentation of the Individualized Performance Plan (IPP)
being developed within thirty-days of each youth’s admission. All performance plans were
developed following each youth’s initial Residential Assessment for Youth (RAY) and the Youth
Needs Assessment Summary. All members of the treatment team were present during the
development of the IPP, as indicated by their signature on the plan. Two of the five youth were
under the care of the Department of Children and Families (DCF), and the assigned
caseworkers participated in the development of the performance plan. The three remaining
youth had their parent/guardian attend by telephone, and a copy of the signature sheet was
mailed to each parent/guardian, but none had been returned. The signature sheets for all youth
were filed in each youth’s case management record. In all five youth records reviewed, the
performance plans included the individualized goals and were based upon the prioritized needs
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reflecting the risk and protective factors identified during the initial assessment process, each
youth’s three top criminogenic needs, delinquency interventions based on RAY results,
measurable outcomes which are intended to decrease the youth’s criminogenic risk factors and
promote strengths, supports to reduce the likelihood of the youth reoffending, target court-
ordered sanctions which could be completed while in the program, transition activities targeted
for the last sixty-days of the youth’s stay, youth and program staff responsibilities to accomplish
and complete goals, and target days for completion. For all five youth reviewed, a transmittal
letter and copy of the performance plan were sent to the committing court and the JPO within
ten-days of completing the plan. All five of the youth had a copy of their performance plan
mailed to their parent/guardian within ten days of completing the plan. A copy of the
performance plan was mailed to the DCF caseworker for two applicable youth within ten days of
completing the plan. Five youth were interviewed. All five knew their performance plan goals.
Five youth said they had a copy of their performance plan.
2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
The program has a policy and procedures in place to ensure the performance plans are
reviewed monthly and revised as necessary. Five youth case management records were
reviewed, all five were applicable and contained documentation showing the performance plans
were reviewed every thirty days during the youth’s formal treatment team review. Four of five
applicable youth case management records contained revisions which were a result of each
youth demonstrating progress towards completing a goal. One youth was not applicable for
revisions to the Individualized Performance Plan due to not being in the program for ninety-days
or more.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a policy and procedures which require the treatment team to 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. The treatment team shall also prepare a Performance Summary prior to the youth’s
release, discharge, or transfer from the program. These summaries shall be distributed within
ten working days of signing. Five youth case management records were reviewed and none of
the five youth were applicable for having a ninety-day performance summery. Three additional
youth records were reviewed and all three contained documentation confirming Performance
Summaries were being completed within the required time frame. All Performance Summaries
included each youth’s status on performance plan goals, each youth’s overall treatment
progress, each youth’s academic status, behavior, level of motivation/readiness for change,
interaction with peers, interaction with staff, overall behavior adjustment to the program, and any
significant positive or negative events. All three records indicated each youth was allowed to
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read and add comments to the Performance Summary prior to signing, and verified each youth
received a copy. The original Performance Summaries are maintained in each youth’s case
management record. All the Performance Summaries were signed by the treatment team
leader, staff who prepared the summary, the facility administrator or designee, and each youth.
A copy of the summary was sent to the court and the juvenile probation officer (JPO) within ten
working days for all three of the youth. A sample of three closed youth case records were
reviewed to ensure release summaries were being completed as required. A review of three
records confirmed the release summaries included the original summary, along with justification
for release which were sent with Pre-Release Notification (PRN) to the JPO. The release
summary and PRN were sent prior to each youth’s planned release, with a signed copy retained
in each youth’s case management record. The court did not object to the youth’s release in any
of the three closed records reviewed. Once the release was approved, the program provided
written notification to each youth’s parent/guardian and completed a Residential Assessment for
Youth. There were no youth case management records eligible for the Sexually Violent Predator
Program. None of the three closed youth case management records were applicable for victim
notifications.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to encourage and facilitate the involvement of the
youth’s parent/guardian in the case management process. The program encourages
parent/guardian involvement in the assessment process, in the participation of the performance
plan, during progress reviews, during treatment team meetings, and during transition planning. If
the parent/guardian is unable to attend any of these meetings in person, they are given the
opportunity to participate by telephone and can provide verbal or written input as well. There
was one treatment team meeting observed during the week of the annual compliance review. All
members of the treatment team were involved, the juvenile probation officer (JPO) and
parent/guardian were on the telephone. The program provides family visitation, and the case
managers and therapists encourage parents/guardians to visit whenever they speak to them
during treatment team meetings. The facility administrator was interviewed and advised
parents/guardians are encouraged to attend and are invited to participate in all aspects of the
youth’s treatment in the program. Five youth were interviewed and four said their
parents/guardians are involved in their case management. One youth indicated their
parent/guardian does not participate in treatment team and does not participate in program
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 policy and procedures in place to ensure the youth’s performance plan
references or incorporates the youth’s treatment or care plan. Five youth case management
records were reviewed, and all contained plans in addition to the performance plans, which
included academic and treatment plans. The performance plans referenced and incorporated
the additional plans for each youth. Each youth has a separate treatment plan, such as medical,
mental health, or substance abuse. Two of the five youth were under the supervision of the
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Department of Children and Families (DCF), and had case plans through DCF, which were
coordinated with each of the applicable youths’ performance plans.
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 policy and procedure governing treatment team meetings and their
composition. The procedures require treatment teams to meet bi-weekly, alternating between
formal and informal, to review each youth’s performance, to include Residential Assessment for
Youth (RAY) results, progress on Individualized Performance Plan goals, and positive and
negative behaviors. Five youth case management records were reviewed for formal and
informal treatment team meetings. All five youth had formal reviews conducted at least every
thirty days The documentation for formal treatment team meetings included each youth’s name,
date of review, required attendees, comments from members, a brief synopsis of the youth’s
progress in the program, performance plan revisions and progress of the goals, any behaviors
which resulted in physical interventions, treatment progress, and RAY Reassessment results.
All formal treatment team documentation was contained in each youth record reviewed.
Documentation was reviewed which confirmed informal treatment team meetings were
conducted for four of the five youth bi-weekly each month, alternating with the formal treatment
team meetings, which resulted in each youth having an informal or formal treatment team
meeting every two weeks. One of the five youth had their first formal treatment team during the
annual compliance review week and was not applicable for having an informal review at the
time. The informal treatment team meetings documented each youth’s name, date of review,
required attendees, comments from members, a brief synopsis of the youth’s progress in the
program, performance plan revisions and progress of the goals, any behaviors which resulted in
physical interventions, treatment progress, and RAY Reassessment results. In all formal and
informal treatment team meetings, each youth was provided an opportunity to demonstrate skills
acquired in the program. The youth’s juvenile probation officer, parent/guardian for youth under
the age of eighteen, and any other pertinent parties were invited and given the opportunity to
provide input. During the annual compliance review week, a treatment team meeting was
observed for one youth. All required staff were present, and there was a review of the treatment
plan to determine each youth’s anticipated release date. Five youth were interviewed and asked
if staff review youth performance to include progress on performance plan goals, positive and
negative behavior, and treatment progress, and all stated yes. The five youth stated they were
given an opportunity during treatment team meetings to demonstrate any skills they have
learned in the program.
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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 policy and procedures in place to ensure the intervention and treatment
team is planning for the youth’s successful transition to the community upon release from the
program. Three closed youth records were reviewed, and all had documentation confirming
each youth attended a transition conference at least ninety-days prior to the youth’s targeted
release. The transition conferences were attended by each youth, treatment team leader,
assistant facility administrator (AFA) or designee, the youth’s juvenile probation officer (JPO),
the parent/guardian, and education staff. During the transition conference, the participants
reviewed each youth’s performance plan for transition activities, revised the activities, if
necessary, identified additional activities/services, if needed, and identified target completion
dates with persons responsible for completion. The treatment team leader obtained the dated
signatures from all attendees except for the AFA on one of the youth’s transition plan. A copy of
the plan was sent with a request for return with signature from anyone who did not attend the
meeting, and the plan was transmitted electronically to the JPO, with the return email
acknowledgement printed and filed with the plan. No youth were applicable for having a revision
to their transition plan. Community Re-Entry Team (CRT) meetings were also conducted prior to
each youth’s release. Each closed youth record contained copies of the invitation for
participation in the CRT meeting, and each CRT meeting was attended by the youth and case
manager at a minimum.
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 policy and procedures requiring for the assembly of an exit portfolio for each
youth to assist them once released back into the community. Three closed youth records were
reviewed, and all contained an exit portfolio which had been discussed and initiated for each
youth during the transition conference. The exit portfolios contained a copy of each youth’s
state-issued identification card, a copy of the transition plan, and a calendar with dates, times,
and locations of upcoming community appointments. A copy of each youth’s Social Security
card was not found in any of the youth closed records, however, letters asking the
parent/guardian for a copy could be found in all three. The parents/guardians refused to provide
a copy. Two of the three youth’s birth certificates were in their records, the remaining one was
requested but never received. The exit portfolio also contained educational and vocational
certificates, educational records, a résumé, and sample of completed employment applications.
All exit portfolios were verified during each youth’s exit conference, and the documentation
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indicated the exit portfolio was completed and given to each youth upon release, with the exit
portfolio information forwarded to the juvenile probation officer. There was one secure or
maximum risk eligible youth and documentation provided found the youth to have been provided
clear instructions and forms on how to obtain information, and who will be responsible for
working on those items with the youth. There were no special contract requirements for the exit
portfolio.
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 policy and procedures which require an exit conference to be conducted, a
formal or informal meeting to review the status of any goals developed during the transition
conference, and to finalize release plans. Three closed youth records were reviewed, and all
had an exit conference which was conducted at least fourteen days prior to each youth’s
release, and after the program notified the juvenile probation officer (JPO) of the youth’s
release. A review of the documentation confirmed the date of each conference, signatures of
the attendees, and a summary of transition goals. Each youth’s date of admission and date of
termination documented in the case record matched with the dates in the Department’s Juvenile
Justice Information System. The exit conferences were attended by the treatment team leader,
parent/guardian, education representative, JPO, and each youth. The exit conference was held
separately from the transition and the Community Re-Entry Team meetings.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a formal process which promotes constructive input by youth. The program
uses the Chatty Kathy form, grievance procedures, daily meetings, weekly community meetings,
and the youth advisory board meetings. Youth advisory board meeting agendas, minutes, and
notes, Chatty Kathy forms, and grievance logs were reviewed during the annual compliance
review week. The youth advisory board meetings are held monthly at the program. Five youth
said they can provide constructive input about things which happen in the program by speaking
to their group/youth advisory board member, using Chatty Kathy forms, the grievance process
or talking to staff. The facility administrator was interviewed and advised youth input is obtained
during the monthly youth advisory board meetings, weekly community meetings, daily meetings,
surveys which are completed by youth, and treatment team meetings.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures to provide for career education. The program
provides a Type 3 vocational competency development program required for programs with a
contracted length of stay of nine months or longer. The facility administrator’s interview
indicated the career opportunities provided to the youth include developing a résumé and
completing employment applications. They also indicated the youth can participate in career
technology education through an Entrepreneurship & Small Business certification and
participate in the Florida Ready to Work program which tests and scores job skills and work
habits. Youth who have completed high school are able to take college classes through
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Hillsborough Community College with assistance from the Project Anchor program, which will
register youth for college in their home areas, as well as provide career assistance. The courses
are all age appropriate and aligned with the youth’s educational abilities and goals. Three
closed youth case management records were reviewed, and all included sample completed
employment applications and a résumé, a State of Florida identification (ID) card, as well as
information on the youth’s local Career Source Center’s location and hours of operation. The
program is also offering Occupational Safety and Health Administration (OSHA) 10 and
CPR/first-aid certifications, which were included in the case management files.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide for educational access. The program
integrates education into the daily schedule in such a way to ensure the integrity of the required
minimum instruction time distributed over a twelve-month period. The district approved calendar
and daily school schedule were reviewed and it was determined the program incorporated the
required 250 days of instruction, with ten days used for teacher planning, and a minimum of
twenty-five hours of instruction weekly. Youth are enrolled in academic courses through
Hillsborough County Schools and receive credit, as appropriate, when courses are completed.
In reviewing the youth interviews, three of the five youth indicated there are no interruptions
during the school day, however, two youth indicated there are interruptions, and they result
mainly from youth arguing with staff. There was also a statement indicating they do not do
anything in class. An interview with the lead educator indicated the school schedule is followed
daily. Random samples of logbook reviews showed the school schedule is being followed. The
logbook review did reveal a two-week period, at the end of August, where the school schedule
was not being followed. Further inquiries confirmed the educational component had provided a
modified schedule for those two weeks due to youth testing. Three days of video review also
verified the school schedule is being followed with little deviation.
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 policy and procedures to provide for an Educational Transition Plan. Three
closed youth records were reviewed, and all had an Education Transition Plan developed upon
entry based on each youth’s post-release goals. All key personnel related to transition activities
were included and the plans were developed with each youth, parents/guardians, program,
education, and aftercare staff involved. 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. All files also included a copy of each
youth’s Electronic Educational Exit Plan which comprises the next education placement
information. All five interviewed youth indicated they were involved in the development of their
Education Transition Plans. The lead educator stated the plans are shared with staff during
treatment team and with the director of case management and the transition coordinator. 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, four of
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the five youth responded they were being very well or well prepared, while one responded with
not well as they felt the teachers did not provide one-on-one instruction when the youth did not
understand something.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program has a policy and procedures indicating they must have a single licensed mental
health professional working as the designated mental health clinician authority (DMHCA) to
coordinate and implement mental health and substance abuse services in the facility. The
program’s DMHCA is a licensed marriage and family therapist whose license expires on March
31, 2025. The DMHCA is a full-time position, as required by contract and outlined in the position
description. The DMHCA works forty hours a week, Sunday through Thursday. The program
has a back-up DMHCA who can provide coverage in the DMHCA’s absence whose license
expires on January 31, 2025; however, the back-up was not required during the annual
compliance review period. The DMHCA was interviewed and indicated they are responsible for
ensuring mental health and substance abuse services at the program meet the requirements
required by contract, completing admission assessments, providing mental health and
substance abuse services at the program, providing weekly supervision to non-licensed clinical
staff, and being on call twenty-four hours a day, seven days a week.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures ensuring clinical staff are performing services they
are qualified to provide based on education, training, and experience. The program’s designated
mental health clinician authority (DMHCA) is responsible for ensuring licensed clinical staff
working under their supervision are performing services they are qualified to provide. The
program has one licensed clinical staff, in addition to the DMHCA, who is a licensed mental
health counselor (LMHC) whose license expires on March 31, 2025. The LMHC works forty
hours a week, Monday through Friday.
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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 has a policy and procedures ensuring mental health and substance abuse
services are provided by individuals with appropriate qualifications. The program’s designated
mental health clinician authority (DMHCA) is responsible for ensuring non-licensed clinical staff
working under their supervision are performing services they are qualified to provide. The
program has one unlicensed therapist who holds a master’s-level degree in an appropriate field,
and works forty hours a week, Tuesday through Saturday. The program has a Chapter 397
license, allowing non-licensed staff under the direct supervision of a qualified professional, to
provide substance abuse services. The program’s Chapter 397 license expires on September 6,
2024, and is posted in the front window of master control. A review of Direct Supervision Logs
found the non-licensed clinical staff received a minimum of one hour a week, on-site, face-to-
face, direct supervision by a licensed mental health professional for the purpose of overseeing
and directing the mental health and substance abuse services provided in the program during
the annual compliance review period. The non-licensed staff conducted Assessments of Suicide
Risk (ASRs) during the annual compliance review period. A review of the non-licensed staff’s
Non-Licensed Mental Health Clinical Staff Person’s Training in Assessment of Suicide Risk form
found the staff completed twenty hours of training and supervised experience in assessing
suicide risk, mental health crisis intervention, and emergency mental health services, which
included administration of five ASRs conducted on-site in the physical presence of a licensed
mental health professional. The program’s contract requires one full-time recreation therapist;
however, this position has been vacant since August 3, 2023. Prior to August 3, 2023, the
program had a recreational therapist who worked forty hours a week and held a bachelor’s-level
degree in human performance and sport, meeting contractual requirements. During the annual
compliance review week, the program was in the process of hiring a recreational therapist who
holds a bachelor’s-level degree in kinesiology, exercise science and will be scheduled to work
forty hours a week.
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 has a policy and procedures indicating youth mental health and substance abuse
needs will be identified through a standardized comprehensive screening process ensuring
referrals are made to the appropriate provider or professional when youth have identified needs
or are identified as a possible suicide risk. Five youth mental health records were reviewed, and
each youth was screened by trained staff the day of admission utilizing the Massachusetts
Youth Screening Instrument, Second Version (MAYSI-2). The MAYSI-2 was entered in the
Department’s Juvenile Justice Information System (JJIS) on the day of admission for three
youth. One youth’s MAYSI-2 was entered in JJIS the day after admission and the remaining
youth’s MAYSI-2 was entered in JJIS eight days after admission. Documentation found the
screener reviewed applicable information, including the commitment packet and reports and/or
records for existing documentation of mental health or substance abuse problems or history of
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human trafficking for each youth. Four of the five completed MAYSI-2s indicated further
assessment was required and staff believed all five youth had a mental health or substance
abuse problem or were a suicide risk. The program’s practice is to refer each youth for a
comprehensive assessment and an Assessment of Suicide Risk (ASR). All five reviewed youth
were referred for both, the reason for referral was documented, and the facility administrator
and designated mental health clinician authority (DMHCA) were notified. Each reviewed youth
received an ASR within twenty-four hours. The facility administrator (FA) was interviewed and
confirmed the program utilizes the MAYSI-2 to identify youth at risk for mental health and
substance abuse issues. The FA indicated each youth’s commitment packet is reviewed prior to
admission and a Comprehensive Mental Health and Substance Abuse Evaluation is completed
on each youth within thirty days of admission.
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 has a policy and procedures ensuring youth who are identified as in need of
further evaluation are referred for a Comprehensive Mental Health and Substance Abuse
Evaluation. Five youth records were reviewed, and the program completed a new combined
mental health and substance abuse evaluation for each youth. Each youth was referred the day
of admission and an evaluation was completed within thirty calendar days of admission for
each. Two of the evaluations were completed by licensed staff. The remaining three evaluations
were completed by non-licensed clinical staff and a licensed mental professional reviewed and
signed all three within ten calendar days. Each youth’s evaluation included identifying
information, the reason for evaluation, relevant background information, behavioral
observations, Mental Status Examinations, methods of assessment, patterns of alcohol and
other drug abuse, impact of alcohol and other drug abuse on major life areas, risk factors of
continued alcohol and other drug abuse, interview or procedures administered, a discussion of
findings, diagnostic impression/formulation and clinical impression including Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, and recommendations.
Consent was obtained for substance abuse services for all five youth.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures indicating each youth who has a serious mental
disorder or substance abuse impairment and is receiving mental health or substance abuse
treatment in a program shall have an initial or individualized mental health or substance abuse
treatment plan completed when treatment is initiated. Five youth records were reviewed and an
initial treatment plan, including all required elements, was developed and signed on the day of
admission for each. Each initial treatment plan was completed and signed by a licensed clinical
staff. Each plan was also signed by the youth and all treatment team members who participated
in the development of the plan. Each youth’s initial treatment plan was sent their
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parent/guardian for them to sign and return; however, none of them had been returned at the
time of the annual compliance review. Each youth’s initial treatment plan included the youth’s
psychiatric needs, including medication and frequency of monitoring by the psychiatrist, if
applicable. Each reviewed youth had an individualized treatment plan, including all required
elements, developed within thirty days of admission. Each individualized treatment plan was
signed by the clinical staff completing the plan, all treatment team members who participated in
the development of the plan, and each youth. Two of the five plans were completed by non-
licensed clinical staff, and both were reviewed by licensed staff within ten days of completion.
Each youth’s individualized treatment plan was sent to their parent/guardian to sign and return
to the program. Three reviewed youth were receiving psychotropic medications, and each of
their individualized treatment plans included the medications they were prescribed and the
frequency of monitoring by the psychiatrist. Each youth’s individualized mental health or
substance abuse treatment plan was reviewed every thirty days utilizing a form which included
all required information. Each youth’s individualized treatment plan included an outline of
prescribed services. Goals and objectives were individualized for each youth. A review of video,
logbooks, and group sign-in sheets found mental health and substance abuse groups were
facilitated by the appropriate clinical staff, for the required length of time, with the appropriate
number of youth.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
Five youth mental health records were reviewed, and each youth was assigned to a treatment
team including the youth, program administration, a member from the residential living unit,
education staff, medical staff, mental health and substance abuse staff, and the parent/guardian
upon admission. Each reviewed youth was determined to be in need of mental health and
substance abuse treatment. Each reviewed youth had a properly executed Authority for
Evaluation and Treatment (AET) form and a signed Youth Consent for Substance Abuse
Treatment form. The program has a valid Chapter 397 license, allowing non-licensed staff under
the direct supervision of a qualified professional to provide substance abuse services. A review
of Weekly Progress Note forms found each reviewed youth received group and family
counseling, if applicable, provided by clinical staff as stipulated on their individualized treatment
plans. Three reviewed youth received individual counseling by clinical staff as stipulated on their
individualized treatment plans. The remaining two youth each missed one bi-weekly individual
counseling session during the annual compliance review period.
Three closed mental health records were reviewed for discharge summaries. Each reviewed
youth had a discharge summary documented on the Department’s Mental Health/Substance
Abuse Treatment Discharge Summary form which documented the services needed for daily
maintenance of the positive improvement in behavioral, emotional, and social skills made by
each youth during treatment. None of the reviewed youth were on suicide precautions at the
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time of release. Documentation in each youth’s record found the discharge plan was discussed
with the youth and parent/guardian during the exit conference. Each youth, juvenile probation
officer (JPO), and parent/guardian were provided a copy of the Mental Health/Substance Abuse
Treatment Discharge Summary form.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program’s contract indicates they shall provide Mental Health Overlay Services (MHOS)
and Substance Abuse Treatment Overlay Services (SAOS) to youth who qualify for such
services. At the time of the annual compliance review, all program youth were required to
participate in MHOS. The program did not have any youth requiring SAOS during the annual
compliance review period. The program’s contract indicates their mental health clinical groups
include Aggression Replacement Therapy (ART) and Dialectical Behavioral Therapy (DBT)
Skills Manual for Adolescents and their substance abuse clinical groups include Cannabis Youth
Treatment (CYT) and Living in Balance. The contract also includes supplemental clinical
curriculums including Seeking Safety, Don’t Let Emotions Run Your Life, Group Treatment for
Substance Abuse, Teen Addictions and Recovery Workbook, Mindfulness-Based Substance
Abuse Treatment for Adolescents, and Conflict Resolution from the Inside Out, as well as non-
clinical supplemental groups. All groups are led by clinical staff. A review of group sign-in sheets
and Weekly Progress Note forms found the program provides group therapy at least four days a
week, along with individual and family therapy. At the time of the annual compliance review, the
groups being provided at the program included Seeking Safety, Girls in Real Life Situations,
open process groups, and DBT Skills Manual for Adolescents. Individual, group, and family
counseling, if applicable, are provided to each youth as part of their individualized treatment
plan. Clinical staff are on-site seven days a week with therapeutic activities being provided daily.
Youth with co-occurring substance abuse disorders receive substance abuse services, with a
substance abuse group being held one time a week by qualified clinical staff. The program has
a valid Chapter 397 license, allowing non-licensed staff under the direct supervision of a
qualified professional to provide substance abuse services. A licensed professional is on-site at
least five days a week, with clinical staff who are qualified to provide substance abuse services
being on-site daily. A review of group sign-in sheets found mental health groups were limited to
ten or fewer youth and substance abuse groups were limited to fifteen or fewer youth.
Counselor caseloads are limited to no more than twelve youth, with the average caseload being
ten youth. Five youth were interviewed, and each youth indicated they are participating in
individual or family therapy. Five interviewed staff confirmed direct care staff do not facilitate
mental health or substance abuse groups. During an interview, the designated mental health
clinician authority (DMHCA) confirmed mental health and substance abuse services are
available on-site through the provision of MHOS and SAOS. The DMHCA indicated all mental
health and substance abuse services provided at the program are provided under the
supervision of a licensed professional and specialized mental health services include a
minimum of one thirty-minute individual therapy session bi-weekly, one monthly sixty-minute
family therapy session, supportive counseling, as needed, and group therapy sessions for forty-
five to sixty minutes four times a week. The DMHCA confirmed the groups being provided at the
time of the annual compliance review and indicated the program has not had any youth
requiring SAOS. The facility administrator was interviewed and indicated the program provides
SAOS.
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3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
The program has a policy and procedures indicating psychiatric services, including psychiatric
evaluation, psychiatric consultation, medication management, and medical supportive
counseling, will be provided to youth with a diagnosed Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth receiving psychotropic
medication in the program. Psychiatric services in the program are provided by a psychiatrist
with a clear and active license, which expires on January 31, 2025. The program does not utilize
a psychiatric advanced practice registered nurse (APRN). The psychiatrist’s contract indicates
they will be available for emergency consultation twenty-four hours a day, seven days a week. A
review of treatment team meeting minutes found the psychiatrist briefed a representative of the
treatment team regarding the psychiatric status of each youth receiving psychiatric services who
was scheduled for a treatment team meeting. A review of individualized treatment plans found
the psychiatrist’s evaluation and recommendations for youth were incorporated into their
treatment plans. A review of sign-in/out logs found the psychiatrist was on-site at least once
every two weeks, as required. The program’s contract does not include tele-psychiatry;
however, tele-psychiatry was utilized one time during the annual compliance review period. The
Department’s Office of Health Services (OHS) approved the one instance of tele-psychiatry. A
review of treatment team meeting minutes and thirty-day medication reviews forms found the
psychiatrist actively participates in, manages, and supervises psychotropic medication services
in the program. A back-up psychiatrist was not utilized during the annual compliance review
period. During an interview, the psychiatrist indicated they are responsible for psychiatric
consultation, evaluation, and treatment in the program. The psychiatrist indicated they are on-
site one time a week and meet with the designated mental health clinician authority (DMHCA)
weekly. The psychiatrist indicated they have weekly clinical meetings with healthcare staff to
review important medical issues pertaining to youth at the program who receive psychiatric
services. The psychiatrist indicated they do not have any concerns with mental health or
substance abuse services at the program. The DMHCA was interviewed and confirmed they
meet with the psychiatrist weekly to discuss youth receiving psychiatric services.
Five youth mental health records were reviewed, and each youth was referred for a psychiatric
interview, as the program’s practice is to refer each youth. Two of the reviewed youth were
admitted with psychotropic medication, one was prescribed psychotropic medication during the
interview, one was prescribed psychotropic medication at a later date, and the remaining was
not prescribed psychotropic medications. All five youth received a diagnostic interview,
documented on the appropriate form which clearly identified it as an Initial Diagnostic
Psychiatric Interview, within fourteen days of admission. Each youth’s psychiatric interview
included the youth’s history, a Mental Status Examination, documentation of DSM-5 diagnosis,
treatment recommendations, and initial treatment goals. Each youth’s diagnosis was consistent
with their treatment plan. The initial interviews also included the prescribed medications,
explanation of the need for psychotropic medication related to the youth’s diagnosis, target
symptoms, potential side effects, risks and benefits of taking the medication, and frequency of
medication monitoring/management for the three applicable youth. The initial psychiatric
interview resulted in the prescription of psychotropic medications or changes to the youth’s
psychotropic medication regimen for each of the three applicable youth and page three of the
Department’s Clinical Psychotropic Progress Note (CPPN) was completed for each. A review of
thirty-day medication reviews found all four youth who received psychotropic medications at the
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program confirmed they were seen for medication reviews by the psychiatrist at least every
thirty days. Each thirty-day medical review included documentation of identifying data,
diagnosis, target symptoms of each medication, evaluation and description of effect of
prescribed medications on target symptoms, prescribed psychotropic medication names,
dosage and quantity, normal dosage range, ordered dosage, frequency and route of
administration, reason for changes in medication and/or dosage, side effects, adherence to the
medication regimen, height, weight, blood pressure, most recent serum levels or laboratory
findings, as appropriate, if there was telephone contact with the parent/guardian to discuss
medication, the psychiatrist’s signature, the date, and monitoring for Tardive Dyskinesia. One
reviewed youth received tele-psychiatry while at the program and the standard of care was the
same as rendered in-person. Documentation each youth agreed to participate in the tele-
psychiatry session and the parent/guardian provided consent was located in each youth’s
record.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a Suicide Prevention Plan they utilize to ensure they safely assess and protect
youth with an elevated risk of suicide in the least restrictive means possible. The program’s
Suicide Prevention Plan includes the identification and assessment of youth at risk of suicide,
staff training, suicide precautions, levels of supervision, referral, communication, notification,
documentation, immediate staff response, and the review process. The program’s review
process for suicide attempts and mortality review includes the circumstances surrounding the
event, the facility procedures relevant to the incident, all relevant training received by involved
staff, pertinent medical and mental health services involving the victim, possible precipitating
factors, and recommendations, if any, for changes in policy, training, physical plant, medical or
mental health services, and/or operational procedures. The program’s Suicide Prevention Plan
was reviewed by the designated mental health authority (DMHCA) on May 15, 2023.
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 has a policy and procedures to ensure any youth exhibiting suicide risk behaviors
is placed on suicide precautions and a minimum of constant supervision. Five youth records
were reviewed, and one youth was applicable for suicide precautions, so two additional records
were requested. Two reviewed youth were determined to be at risk because of staff observation
and one was a self-report. Each youth was placed on precautionary observation (PO) and
referred for an Assessment of Suicide Risk (ASR) upon being determined as at risk. Two youth
were placed on constant supervision and the remaining youth was placed on one-to-one
supervision upon being determined at risk. Each youth’s PO status was documented in the
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program’s logbook and each youth was allowed to participate in select activities with other youth
in designated safe areas of the facility while on PO. A suicide alert was initiated in the
Department’s Juvenile Justice Information System (JJIS) for each youth. Each youth had an
ASR completed by a licensed mental health professional on the Department’s ASR form within
twenty-four hours of being determined at risk. Each ASR included documentation of each
youth’s parent/guardian and juvenile probation officer (JPO) being notified of the potential
suicide risk. Upon completion of an ASR, PO was continued for each youth; two youth remained
on constant supervision and the remaining youth was stepped down to constant supervision
from one-to-one supervision. Mental health staff provided supportive services for each reviewed
youth. Each reviewed youth had a Follow-Up ASR completed on the Department’s Follow-Up
ASR form prior to their removal from PO. Two reviewed youth’s Follow-Up ASRs indicated
suicide precautions could be discontinued, and both youth were stepped down to close
supervision prior to the transition to standard supervision. The remaining youth had an
additional Follow-Up ASR completed prior to suicide precautions being discontinued and this
youth was stepped down to close supervision prior to the transition to standard supervision.
Each youth was maintained on close supervision until it was determined no longer necessary by
a licensed mental health professional. The discontinuation of close supervision was
documented by mental health staff in each youth’s record. A conference was held by the facility
administrator and licensed mental health staff before reducing the level of supervision for each
youth and the discontinuation of close supervision was documented in accordance with the
program’s Suicide Prevention Plan for each youth. Each youth’s discontinuation from PO was
documented in the program’s logbook and each youth’s suicide alert was accurately closed in
JJIS following the recommendation from the Follow-Up ASR. The program had two instances of
youth being placed on PO which were applicable for video review. Video review confirmed
proper supervision was maintained for both. None of the reviewed youth were determined to be
in crisis. The program has not utilized secure observation since the contract was initiated. Five
staff interviews were conducted, and each staff was able to explain what to do if a youth
expresses suicidal thoughts, including notifying mental health, notifying the supervision, placing
the youth on constant supervision, searching the youth’s room for sharp objects, and
maintaining documentation.
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 has a policy and procedures ensuring any youth placed on suicide precautions is
maintained on one-to-one or constant supervision. Staff shall provide the appropriate level of
supervision and record observations of the youth’s behaviors at a minimum of every thirty
minutes. Five youth records were reviewed, and one youth was applicable for suicide
precautions, so two additional records were requested. Suicide Precaution Observation Logs
were maintained for the duration each youth was on suicide precautions and the appropriate
level of supervision and observations of the youth’s behavior were documented in real time, not
exceeding thirty-minute intervals, for each youth. Notification to the facility administrator was
documented on each youth’s Suicide Precaution Observation Log when warning signs were
observed. Each youth’s Suicide Precaution Observation Log was reviewed by mental health
clinical staff and signed by mental health clinical staff and each shift supervisor. Safe housing
requirements were documented on each log.
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3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
A total of ten staff training records were reviewed for completion of the required six hours of
annual suicide prevention and implementation of suicide precautions training. Training included
suicide drills, which were held no less than quarterly on each shift. The program was able to
complete suicide drills in the three quarters since the execution of the contract. Quarterly suicide
drills were completed on all three shifts for the duration of the annual compliance review period.
All mock mental health drills were in response to a simulated suicide attempt or serious self-
inflicted injury. The drills addressed the use of cardiopulmonary resuscitation (CPR) as required.
Youth were not used in drill simulations. The facility administrator interview confirmed suicide
drills are conducted monthly and all staff participate in a drill at least quarterly. Five interviewed
staff were asked what they are responsible for if a youth expresses suicidal thoughts. All five
staff said they would notify mental health staff and place the youth on sight and sound
supervision. Four staff also indicated they would search the youth's room and notify the
supervisor. Two staff indicated they would document the supervision provided to the youth.
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 Crisis Intervention Plan which includes notification and the alert
system, means of referral, including youth self-referral, communication, supervision,
documentation, 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.
None of the five mental health and substance abuse records reviewed were applicable for a
Crisis Assessment. Three examples of Crisis Assessments were requested; however, the
program did not have any since the last annual compliance review. The program utilizes the
Department’s Crisis Assessment form to document reasons for assessing a youth
demonstrating acute psychological distress.
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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 an Emergency Mental Health and Substance Abuse Plan which
includes immediate staff response, notifications, communication, supervision, authorization to
transport for emergency mental health or substance abuse services, transport for Baker Act,
transport for 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 Act 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 has an on-going safety planning process for each youth, which is designed to
identify stimuli which have both positive and negative effects on the youth. Five youth mental
health records were reviewed, and each youth had a Safety Plan which included warning signs,
baseline behaviors, crisis recognition, jointly development coping strategies, intervention
strategies preferred by each youth, and the debriefing process. Each youth’s Safety Plan was
completed on the day of admission and was prepared jointly by the youth, parent/guardian, and
clinical staff. Each youth’s Safety Plan incorporated recommendations from clinical
assessments and screening instruments and incorporated trauma responsive practices. Each
youth’s safety plan was reviewed and updated at least every thirty days and as necessary
following any significant behavior or mental health events identified by each youth’s treatment
team. Each youth’s Safety Plan is maintained in master control and available for staff to review.
Five interviewed youth indicated they contributed to their Safety Plan. Five staff were
interviewed, and each indicated Safety Plans are kept in master control. Four staff were able to
explain the process for reviewing Safety Plans. The remaining staff misunderstood the Safety
Plan for precautionary observation. The facility administrator was interviewed and indicated
Safety Plans are reviewed every thirty days.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a policy and procedures requiring the designated health authority (DHA) to be
clinically responsible for the medical care of all youth in the program. The DHA is a
licensed physician specializing in internal medicine with experience in adolescent health. The
license is active and clear, with an expiration date of January 31, 2025. The DHA has no
disciplinary cases or public complaints on record. The program does not use a physician’s
assistant or advanced practice registered nurse. Sign-in/out logs during the annual compliance
review period confirmed the DHA was on-site at least once a week for two hours, with a week
defined as the seven-day period beginning on Sunday and ending on Saturday, as required by
contract. In the event the DHA is on vacation or has scheduled leave, the program has a back-
up physician who holds a clear and active license with an expiration date of January 31, 2024.
The back-up DHA was not utilized during the annual compliance review period. The DHA was
interviewed and advised they see youth for initial intake, periodic evaluations, sick calls, and
referral to a specialist as needed. The DHA confirmed they are on-site every Wednesday for a
minimum of two hours, and communicates with program staff by telephone, email, or in person
while on-site. The DHA is available for emergency purposes and can be contacted by telephone
or answering service. The DHA further advised they perform clinical services while on-site and
review all off-site care for youth by reviewing youth Individual Healthcare Records. The DHA
meets with program staff every three months or more frequently as needed to review any new
medical changes with any youth assigned to the program.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a policy and procedures which require for daily clinical care to be performed
by licensed medical staff; either a registered nurse (RN) or licensed practical nurse (LPN)
according to developed and authorized protocols. The program has not used any LPNs during
the annual compliance review period. The program has one full-time health services
administrator (HSA) who is a RN, and two full-time RNs. The program also has two additional
RNs which they will use pro-re-nata (PRN), if needed. A review was conducted of nursing
licensure credentials, both full-time and PRN, which confirmed each of the nurse licenses were
clear and active. The HSA’s license expires on August 24, 2023, and the other two full-time
RN’s licenses expire on November 30, 2024. The contract requires for the HSA to work forty
hours weekly, and two RNs to be on-site for a total of eighty hours weekly. The HSA and two
additional RNs provide coverage from 7:00 a.m. to 7:00 p.m., seven days a week, with a
minimum of two RNs on duty at all times, which fulfills contractual requirements.
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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 a policy and procedures for all health-related procedures and protocols which
they use. The medical and respective treatment FOPs were signed by the designated health
authority (DHA) on August 20, 2023, by the facility administrator on August 31, 2023, and by the
psychiatrist on December 6, 2023. They were also signed by the health services administrator
(HSA) on August 31, 2023, and the two full-time registered nurses (RNs) on November 6, 2023.
The two full-time RNs were hired during the annual compliance review period. Documentation
was provided showing they both received a comprehensive clinical orientation to the
Department’s healthcare policies and procedures, given by the HSA. Approval of treatment
protocols or standing procedures were written and authorized by the DHA and were not
delegated to any other person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program maintains a policy and procedures which require the completion of an Authority for
Evaluation and Treatment (AET) for each youth, which authorizes specific treatment for youth in
the custody of the Department. Five youth Individual Healthcare Records (IHCRs) were
reviewed. Three IHCRs contained an AET form signed by the youth’s parent/guardian and a
Department representative. All three were not originals and were stamped with the word “copy”.
The other two youth were under the care of the Department of Children and Families (DCF) and
contained court orders which served as the AET and authorized all treatment and procedures.
None of the youth were over the age of eighteen; therefore, they did not have a documented
release of information. The nurse was interviewed and advised all projected intakes are
reviewed in the Department’s Juvenile Justice Information System (JJIS) to validate the AET.
New admissions are discussed with case management prior to youth arrival. If needed, the
juvenile probation officer (JPO) would be contacted through case management to obtain a new
AET. In the case of a youth who is over the age of eighteen, the youth will be allowed to give
their own consent but must first sign a release of information which will authorize verbal
consent.
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 policy and procedures requiring the program to inform the
parent/guardian of significant changes in the youth’s condition and to obtain consent when new
medications and treatments are prescribed. Five youth Individual Healthcare Records (IHCRs)
were reviewed, and all were applicable for parental/guardian notification and consent. All five
IHCRs contained documentation of parental/guardian notification and consent. New medication
was ordered for all five youth and documentation of attempted contact to the parent/guardian
was noted in each youth’s chronological progress notes. All written notifications were sent
utilizing the Department’s Parental Notification of Health-Related Care: General, Parental
Notification of Health Related Care: Medications, or the Acknowledgement of Receipt of the
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Clinical Psychotropic Progress Note (CPPN) form when documented on the CPPN. Four of the
five youth were applicable for taking psychotropic medications. Notes confirming staff witnessed
all telephone call attempts and conversations for psychotropic medications were documented in
each applicable youth’s chronological progress notes. Parent/guardian verbal consent was
documented on page three of the CPPN for each youth whenever a new psychotropic
medication was prescribed, discontinued, or the drug dosage was significantly changed. Two of
the five youth were in the care of the Department of Children and Families (DCF), and the court
authorized all treatment and procedures or indicated all treatments were approved by court
order. All five IHCRs were reviewed for vaccinations and each youth had their immunization
records verified on the day of admission through the Florida Shots website. The nurse was
interviewed and advised parents/guardians are notified within twenty-four hours with a written
parental/guardian notification whenever a youth goes off-site, sees a physician, or receives a
diagnostic team. Verbal consent is obtained as soon as possible, and after the order is written
by the physician. In the event of an emergency, attempts will be made to verbally contact the
parent/guardian before taking the youth to the emergency room and the program will contact the
parent/guardian upon returning to the program. Witnessed verbal consent is also obtained to
initiate a new medication.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures which require the program to ensure youth are
screened upon admission for healthcare concerns which may require a referral for further
assessment by healthcare staff. Five youth Individual Healthcare Records were reviewed, and
all contained a completed Facility Entry Physical Health Screening (FEPHS) form. The FEPHS
form was completed by a registered nurse on the date of admission for all youth. There were no
changes in physical custody for greater than twenty-four hours for any reviewed youth. The
nurse was interviewed and advised nursing assessments are completed immediately following
the initial search of each youth which is conducted in the health services department during
admission. Nursing staff use the admission notification process to become aware of when youth
are being admitted to the program. The admission screening is completed by a registered
nurse, and if there is a change in physical custody of a youth since their admission, a new
FEPHs form, along with a new body chart, are completed.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures requiring the orientation of all youth to the general
process of healthcare delivery services at the program. Five youth Individual Healthcare
Records (IHCRs) were reviewed, and each youth received a general care orientation on the day
of admission. The orientation included access to medical care, sick call, what constitutes an
emergency and when to notify staff, medication process to include side-effect monitoring, the
right to refuse care, what to do in the event of sexual assault or attempted sexual assault, the
non-disciplinary role of healthcare providers, and standard universal precautions. All of the
IHCRs contained a signed and dated Healthcare Services Orientation form acknowledging they
received orientation to healthcare services.
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4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures outlining the process of notifying the designated
health authority (DHA) when admitted youth require emergency care or routine notification in
accordance with Department requirements. The program notifies the DHA for all admissions.
Five youth Individual Healthcare Records (IHCRs) were reviewed. Three youth had a known or
suspected chronic condition upon admission. None of the youth were identified as being in-need
of an emergency response upon admission. Each IHCR contained a DHA
Notification of Admission form which verified the DHA was notified upon the youth’s admission
to the program. Two of the five youth reviewed were taking psychotropic medications upon
admission, and notes in each youth’s IHCR confirmed the psychiatrist was notified. The nurse
was interviewed and advised when youth are admitted with serious or chronic conditions, the
DHA is notified by telephone or verbally if on-site, regarding the youth history and any chronic
conditions, once the initial nursing assessments and record reviews are complete. This
notification is conducted by the nurse and noted on the DHA Admission Notification form.
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 policy and procedures requiring the use of the Department’s Health-
Related History (HRH) form for all youth admitted into the program. Five youth Individual
Healthcare Records (IHCRs) were reviewed, and all contained a new HRH form which was
completed on the day of admission. Each HRH form was completed prior to the Comprehensive
Physical Assessment (CPA), and all were reviewed by the designated health authority (DHA).
The nurse was interviewed and advised one of the nurses completes the HRH on all youth
during admission, before the CPA is completed.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures which require the program to use the standardized
Comprehensive Physical Assessment (CPA) form for all youth admitted into the physical
custody of a Department. Five youth Individual Healthcare Records (IHCRs) were reviewed, and
all contained a new CPA, which was completed within seven days of admission. None of the
reviewed youth had a current CPA on file at the time of admission. All of the CPAs were
completed by the designated health authority (DHA). Two youth were documented as a Medical
Grade one, one youth was a Medical Grade two, and two youth were a Medical Grade five. All
sections of each CPA were marked with an “O” or an “X”, as required, with sections marked with
an “X” containing further detail in the comment section to elaborate on the abnormality. No
youth refused any part of the exam. The DHA deferred part of the exam for all reviewed youth.
Each deferred area was documented as “deferred by clinician” written by the DHA, with an
explanation as to why it was deferred. The Department’s Problem List was updated for all five
youth. All youth had at least one verified Tuberculosis Skin Test (TST) completed within the last
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year, with the results of the TST documented on the CPA and the Infectious and Communicable
Disease form. The nurse was interviewed and advised the DHA completes a new CPA for each
youth annually. The nurse also advised TSTs are administered annually, after screenings are
complete for each youth.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures which require for all youth to be evaluated and
treated, if indicated, for sexually transmitted infections (STIs). Five youth Individual Healthcare
Records (IHCRs) were reviewed, and documentation confirmed each youth was screened and
evaluated for STIs during admission. Two of the five youth required further evaluation and were
referred to the designated health authority (DHA). These referrals were documented on the
appropriate form. Testing was ordered for four of the five youth, and was performed on three
youth, with one youth refusing. The testing, screening results, clinical evaluations, and
diagnoses were documented on the Infectious and Communicable Disease form and filed in the
lab section of the IHCR for the three youth who were tested. All five youth were offered
counseling, testing, and if indicated, treatment/referral for human immunodeficiency virus (HIV).
Three of the five youth received HIV testing and consent was documented for each. Each of the
results were filed in their IHCR in a sealed envelope marked “confidential”, as required. Each
sealed envelope was signed by the DHA, indicating their review. Documentation of pre and
post-test counseling was documented on the Health Education Record for each youth tested.
Each youth’s confidentiality was protected and results were not included on the program’s
internal alert system. The program’s policy and procedures reflect HIV test results are only
disclosed to the youth’s legally authorized representative, healthcare providers during the
course of diagnosis, consultation, or treatment of the youth, the Department of Health for
purposes of reporting and control of spread of disease, health facility staff committees
conducting program monitoring, evaluation, and service reviews, medical personnel who have
been subjected to significant exposure, and healthcare facility personnel or agents for the
healthcare provider who have a need to know in the course of patient care activities of
administrative operations. The program has a provider with a 500/501 certification by the
Department of Health who provides the HIV pre and post-test counseling services. Five youth
were interviewed, and all said they could request a HIV test whenever they needed to. The
nurse was interviewed and advised youth are screened for STIs during admission and when the
initial screening indicates. If screening indicates a need for further evaluation, the DHA is
immediately notified, and orders are received for the evaluation. STI screenings, evaluation, and
testing are documented in the youth IHCRs. Youth can be rescreened at any time, if requested.
HIV testing results are kept in a sealed confidential envelope in the youth IHCR. Youth are
asked if they want HIV testing during intake and it is documented on the HIV risk assessment. A
HIV log is maintained identifying youth who have requested testing and on-site testing is
provided monthly, if needed. Following consent, HIV testing is completed. The test results are
sealed, marked confidential and filed in the lab section the chart. Confidential results are given
to the youth upon discharge.
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4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures which allow all youth in the program to be able to
submit sick call requests and have complaints treated appropriately through the sick call
system. The program must respond in a timely manner and document all sick call encounters.
Five youth Individual Healthcare Records (IHCRs) were reviewed and none of the reviewed
youth presented with a similar sick call complaint three or more times within a two-week period.
A total of twenty-seven Sick Call Request forms were reviewed from the five youth IHCRs. All of
the sick call requests were completed by a registered nurse (RN). The review was documented
on the Sick Call Request form. Each completed the Sick Call Request form was filed in the
youth’s IHCR and documented on the Sick Call Index and on the program’s Sick Call Referral
Log. All dates listed on the Sick Call Index corresponded to the completed Sick Call Request
forms located in the IHCRs. A review of the daily schedule, posted schedule, and nurse
interview confirmed sick call was conducted daily, as required. Sick call is conducted at the
program daily, from 11:20 a.m. to 11:50 a.m. Sick call times were posted outside the medical
office, above the sick call box and in the housing units. Five staff were interviewed, and all said
RNs review and conduct sick call. Five youth were interviewed, three said they are seen for sick
call immediately, and two said they are seen within one day. The nurse was interviewed and
advised youth can submit a sick call at any time by placing the proper form in the sick call box.
The box is monitored by the nurses at regular intervals throughout the day, at least every two
hours and then prioritized at the scheduled time. Youth are assessed within twenty-four hours.
The nurse further stated sick call is conducted in the medical clinic by a nurse, and by the
designated health authority (DHA), if they are on-site. The nurse also said referrals are made if
the youth have the same complaint three times within fourteen days or if the protocol treatment
appears to be ineffective. The nurse confirmed the program does not have restrictive housing.
The nurse also advised the program has treatment protocols which were approved by the DHA.
A sick call encounter was observed during the annual compliance review week. The youth’s
verbal consent was obtained prior to observing the sick call. The youth was escorted to sick call
by direct care staff. The DHA identified themself and stated why the youth was there. The youth
was seen in a private area, with no other youth present to see or hear the examination, and was
examined by licensed staff. The direct care staff waited outside the exam room, with the door
closed, to maintain privacy of the youth during the sick call exam.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures which require them to have a comprehensive process
for the provision of episodic and first-aid care. Five youth Individual Healthcare Records
(IHCRs) were reviewed for episodic care and three were applicable for having on-site episodic
or first-aid care during the annual compliance review period. On-site care was provided by
licensed healthcare staff and documented each event in the required subjective, objective,
assessment, and plan format.
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The program has five first-aid kits, which are kept in master control, each of the two housing
units, and an additional two for transport which are also maintained in master control. First-aid
kits are checked weekly by nursing staff. The check consists of a visual observation of each
first-aid kit to ensure the security seal in intact. If not, a report is submitted to the facility
administrator, the kit is replenished, and resealed. The program has a policy in place to send
first-aid kits to medical if used, for replenishment and resealing. Nursing staff also conduct
thorough inspections on all first-aid kits monthly by breaking the seal, inspecting contents,
replenishing deteriorated or expired items, and resealing each kit. Three first-aid kits were
checked, the kit in master control, one transport kit, and one housing unit kit. Each seal was
broken, and all items compared with attached inventory list. All items were accounted for, with
current dates, and were properly sealed. All were fully stocked with designated health authority
(DHA) approved items. A review of First-Aid Kit Inspection forms during the annual compliance
review period was conducted and confirmed first-aid kits were inspected weekly by nursing staff.
The program has one automated external defibrillator (AED), located in the multi-purpose room.
Procedures are kept inside the AED case. Nursing staff check the AED monthly to ensure the
batteries and pads are operable. The batteries were last changed on May 2, 2023 and expire
June 2024. The pads expire on December 10, 2024. There was no note showing when they
were last changed. The green light was flashing on the AED indicating the AED was
operational.
A review of emergency drill documentation during the annual compliance review period
confirmed the program conducted monthly drills on each shift, which exceeds the quarterly
requirement. The emergency drills indicated cardiopulmonary resuscitation (CPR)/AED
demonstration was practiced at least annually, with at least one drill being conducted on each
shift with CPR and/or AED administration on a quarterly basis. Drills also simulate episodic care
events which call for immediate first-aid and/or administration of CPR techniques and the
initiation of the emergency procedures to follow when a life-threatening emergency occurs.
Announced and unannounced emergency medical drills are conducted at least quarterly on
each shift as well. The program maintains a list of emergency numbers, including the Poison
Information Control Center, in a cabinet in the medical office, which is inaccessible to youth.
Authorized direct care staff have been appropriately trained on the administration of the
epinephrine auto-injector by a registered nurse. Five in-service and five pre-service staff training
records were reviewed, and all staff were trained in episodic, first-aid, and emergency care, as
required. There were no episodic or first-aid events during the annual compliance review week;
therefore, no events were observed.
The program has a specific policy for the use, access, and inventory of Narcan. Narcan is to be
used only by trained staff in the event of an accidental overdose, for youth in the care of the
program. Narcan is stored in the locked medical supply cabinet and can only be accessed by
nursing staff and staff who have been trained to dispense Narcan, if needed. Each staff with
access to Narcan have been trained, with the most recent training having been conducted on
November 16, 2023. Narcan is inventoried weekly, along with all other over-the-counter
medications, controlled medications, sharps, and medical equipment. The nurse was
interviewed and advised nursing progress notes reflect episodic care. It is also notated on the
episodic log. Non-licensed staff can complete an appropriate form to notify nursing staff upon
their return to assess youth who received treatment after hours. The nurse confirmed the
number and location of the first-aid kits and the AED and advised the medical department tracks
youth who are sent off-site for emergency or episodic care on the episodic or sick-call log. The
nurse also confirmed the number of drills the program conducts and the frequency they are
conducted.
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4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures requiring the provision for timely referrals and
coordination of medical services to an off-site healthcare provider, and the proper
documentation of such services, as required by the Department. Five youth Individual
Healthcare Records (IHCRs) were reviewed for off-site first-aid or emergency care and three
were applicable for off-site care. In each of the three, the Summary of Off-Site Care
Consultation Report form was utilized and filed in their IHCRs. Each applicable IHCR included
documentation of parental/guardian notification efforts. Discharge documents and instructions
were also filed in all three IHCRs as well as documentation of the designated health authority’s
(DHA) review and signature/initials of all off-site findings, instructions, and information. One of
the three youth required follow-up testing, referrals, or appointments and documentation
indicating the referrals were tracked was included in the IHCR. The nurse was interviewed and
advised youth who are sent off-site for first-aid or emergency care are tracked on the episodic
log. The program ensures all hospital orders are followed by having the DHA review all off-site
paperwork and ensuring any orders are adhered to. The nurse ensures the DHA reviews all off-
site care findings, instructions, and information by flagging the documents in the youth's IHCR
for review. Follow-up testing, referrals, and appointments are placed on a calendar in medical,
as well as on an internal 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 has a policy and procedures requiring youth who have chronic conditions to
receive regularly scheduled evaluations and necessary follow-up. Five youth Individual
Healthcare Records (IHCR) were reviewed, and three were applicable for chronic conditions.
Each of the applicable youth were identified as having a chronic condition on the Facility Entry
Physical Health Screening (FEPHS) form. None of the reviewed youth had a communicable
disease. Two of the youth were taking prescribed medication on an on-going basis. All three
applicable youth had an identified chronic health condition. All youth were classified with the
correct Medical Grade and were placed on the program’s Chronic Illness List. Documentation
reflected two of the three applicable youth received periodic evaluations at least every ninety-
days. The third youth has not been in the program for ninety days; therefore, did not require a
ninety-day periodic evaluation. Progress notes were reviewed for documentation of each
completed periodic evaluation. On-site periodic evaluations were conducted prior to renewing
an expired prescription medication for all the reviewed youth. The Department’s Problem List
was updated in accordance with Florida Administrative Code for each youth. The facility
administrator was interviewed and said they meet daily with the nurse and quarterly with the
designated health authority (DHA) to review important youth healthcare issues. The DHA was
interviewed and stated periodic evaluations for youth with chronic conditions are conducted
every two months and the program uses a tracker to ensure evaluations are conducted as
required. The nurse was interviewed and confirmed all youth with chronic conditions are tracked
on the chronic condition roster and the internal tracker.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a policy and procedures which require for medication to 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. Five youth
Individual Healthcare Records (IHCRs) were reviewed, and three youth were taking prescribed
medication upon admission. The three applicable youth IHCRs included a Prescription
Medication Verification Checklist form, which indicated the prescriptions were verified. This
verification was also included in the chronological progress notes. The designated health
authority (DHA) and psychiatrist, when applicable, were contacted to obtain the order to resume
to specified medications prescribed prior to admission. All medications had a current, valid order
and were given pursuant to a current prescription. All five youth were applicable for over-the-
counter (OTC) medications not listed on the Authority for Evaluation and Treatment and all OTC
medications were administered in accordance with approved protocols. The Medication
Administration Record (MAR), which includes all information required by Florida Administrative
Code, was included in each youth IHCR. None of the youth reviewed had medication given to
them by non-licensed staff. Each of the MARs contained documentation reflecting staff initialed
each administered medication. Nursing staff documented weekly side-effect monitoring on each
of the youth MARs. One youth refused medication and the youth signed a Refusal of Treatment
form, which was filed in the youth’s IHCR. In addition, the refusal was clearly documented on
the MAR. All the MARs contained each youth’s name, Department identification number
(DJJID), date of birth, allergies, precautions, Medical Grade, and medical alerts. Two of the
youth were taking prescribed psychotropic medication upon admission, and the DHA and
psychiatrist were notified upon admission. Both youth received an initial diagnostic evaluation
within fourteen days of admission, and received a medication monitoring review every thirty
days, as required. During the annual compliance review week, an observation of medication
administration for two youth was conducted. Each youth was escorted to medical individually by
direct care staff. The nurse identified themself and stated why the youth was in medical. The
same nurse who administered the medication prepared it. The nurse verified each youth’s
allergy and alert status. The nurse and youth both initialed the MAR. The nurse observed the
youth while the youth took the medication to ensure the medication was swallowed. The Six
Rights of Medication Delivery/Administration were verified for each youth taking medication.
Five youth were interviewed and four said the nurse gives them medication and were able to
explain the process. The fifth youth said they do not take medication. Five staff were
interviewed, and all said medication is administered by nursing staff. Two of the five staff said
the supervisor can also administer medication, if needed. The nurse was interviewed and said
they use a medication reconciliation receipt and prescription verification form to verify a youth's
medication regimen when a youth is admitted with medication. The nurse also confirmed the
program uses a preprinted pharmacy MAR, which contains all the Department's requirements.
The nurse advised non-healthcare staff can provide medication in the event nursing staff is
unavailable; however, the staff must be trained by a nurse using the approved DHA curriculum.
The nurse also advised the program’s medications are procured through a local pharmacy, and
expired medication which needs to be disposed is stored and picked up by the pharmacy for
disposal.
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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 has a policy and procedures requiring any medical equipment classified as sharps,
as well as stock medications, to 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 keeps sharps in a locked cabinet in the medical office. A review of
sharps inventories during the annual compliance review period confirmed they are utilizing a
perpetual inventory with descending counts as each sharp is used and disposed. Medications
are kept in a locked medication cart, which is stored in medical. The medication cart clean and
organized with stock items separate from youth-specific medications. All controlled substances
had a perpetual inventory and were stored separately from other medications, in the locked
medication cart, behind two locks. Stock over-the-counter (OTC) medications are stored in a
locked cabined in the medical office. All medications are stored in a separate, secured area,
inaccessible to youth. The program does not have any youth requiring refrigerated medication.
They do have a refrigerator in the medical room, which would be emptied for use to store
refrigerated medication, should the need arise. Discontinued and expired medications which
needs to be disposed are stored in the secured medication cart and picked up by the pharmacy
for disposal. A review of medication inventories during the annual compliance review period
confirmed they are utilizing a perpetual inventory with descending counts as each medication is
issued. In addition, medical staff conduct a weekly count and documented this on each youth’s
Individualized Controlled Medication Inventory Record as required. In accordance with Board of
Pharmacy regulatory requirements, a shift-to-shift inventory count of all controlled substances
was documented on the youth’s Individualized Controlled Medication Inventory Record. Three
supervisory level, non-healthcare staff were trained by the nurse in the delivery and oversight of
medication self-administration in the event medication needs to be administered when nursing
staff are not on-site. Three controlled medications, three OTC medications, and three sharps
were reviewed and counted. All the counts listed on the inventories matched the observed
counts, with no discrepancies. The nurse was interviewed and confirmed the pharmacy
disposes of all expired and discontinued medications, and all controlled substances are locked
in the medication cart, which is behind a locked door, and the key for the controlled substance
portion of the medicine cart is in a locked box.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a policy and procedures which require the implementation of a infection
control procedures which include prevention, containment, treatment, and reporting
requirements related to infectious diseases, in accordance with Occupational Safety and Health
Administration (OSHA) federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The 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
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time of intake and subsequently when the need is identified. The program’s infection control
procedures and exposure control plan were signed by the designated health authority and
facility administrator (FA) on July 7, 2023, and by the chief compliance officer on July 1, 2023.
The program’s infection control procedures include 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 cause by any other infectious agent,
whether spread directly or indirectly, outbreaks of pediculosis and/or scabies, Methicillin-
Resistant Staphylococcus Aureus (MRSA) and other emerging antibiotic-resistant micro-
organisms, food-borne illnesses such as those caused by E. Coli, bio-terrorist agents, and
chemical exposures in the workplace. Hepatitis B immunizations are available for all staff and all
staff have access to personal protective equipment. There were no instances in which the
Department of Health and the Department’s Central Communications Center (CCC) should
have been notified of an infectious disease during the annual compliance review period. The
exposure control plan was written in accordance with OSHA standards and is available to all
staff. This plan was last reviewed and signed by the administration of the program on July 1,
2023. The program’s process for needle stick post-exposure evaluation includes routes of
exposure and how exposure occurred, obtaining consent, testing the source individual's blood
to determine HIV and Human Papillomavirus (HPV) infectivity, documenting results, obtaining
consent, testing the exposed staff’s blood, and providing the exposed staff a written copy of the
healthcare professional's opinion. There were no instances involving the quarantining or
hospitalization of at least ten percent of the total population of youth or staff, or six individuals
during the annual compliance review period, which would have required a CCC report. The FA
was interviewed and advised a copy of the exposure control plan is kept in master control, and it
is reviewed with the staff at hire and on an annual basis. The nurse was interviewed and
confirmed the exposure control plan is located with the facility operating procedures, and
training is conducted by a registered nurse. Infection control training is also provided to youth
every six months.
4.19 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
The program has a policy and procedures requiring they provide access to prenatal care for all
pregnant youth. In addition, health education shall be provided to both youth and staff. Five
youth Individual Healthcare Records (IHCRs) were reviewed, and none of the youth were
pregnant at the time of the annual compliance review. The program advised they have not had
any pregnant youth during the annual compliance review period. A review was conducted of
training sign-in sheets which confirmed non-healthcare staff receive in-service education on
girl’s healthcare annually. This training is provided by a registered nurse. The training curriculum
included observation and monitoring of emergency care needs/symptoms of possible
miscarriages. The program has nursing protocols and treatment plans for pregnant youth.
The nurse was interviewed and advised they have provisions for services to pregnant youth, in
the event they receive a youth who is pregnant. The nurse also advised youth are tested for
pregnancy during admission. In addition, youth are provided with the required health education
topics. These educational classes are provided by licensed nursing staff.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures stating how they will maintain active supervision of
youth at all times. Observations of staff during the annual compliance review week found staff
supervising youth appropriately during all observed activities. According to the policy and
procedures provided to the annual compliance review team, staff-to-youth ratios are one staff to
six youth during awake hours, one staff to eight youth during sleep hours, and one staff to five
youth for off-site activities. Observed activities made during the annual compliance review week
included youth during school hours, in the multi-purpose room, and youth movement through
the facility. The daily schedules were posted in the dorms and cafeteria. At no time during the
annual compliance review week were youth observed wandering freely about the program.
Each of the five interviewed staff confirmed their understanding of the procedures when there is
a discrepancy with the count. All the staff indicated the count is reconducted until the count is
reconciled and all movement is stopped. Observations found the counts were conducted at
scheduled and unscheduled times and the shift supervisor was able to give an accurate count
when asked. Informal interviews with five staff found they were aware of the number of youth
under their supervision immediately without having to stop and count.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program has a policy and procedures addressing the behavior management system (BMS)
which the program refers to as the positive performance system. The policy and procedures
include protocols regarding feedback given to staff regarding their implementation of the BMS.
There is an agreement between the program and the school related to the BMS reflecting a joint
plan for the BMS during school, and all appropriate parties including education were involved in
the development, implementation, and on-going maintenance of the BMS. Reviewed
documentation revealed the program’s facility administrator (FA) and assistant facility
administrator provided training to the education staff in the jointly combined BMS plan to include
use of the BMS during school. A review of five youth case management records confirmed each
youth orientation included a review of the program’s BMS and the BMS documented in the
youth handbook included the rules governing conduct and positive and negative consequences.
Five staff position descriptions were reviewed whose job functions included implementation of
the program’s BMS, and five reviewed pre-service training records reflected each staff was
trained in the program’s BMS. The BMS was posted in the program’s living areas, accessible to
youth, which included the rules governing conduct and positive and negative consequences.
The program’s BMS included all required elements and did not include increased length of stay,
denial of basic rights or services, group punishment, punishment of youth by other youth, or
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disciplinary confinement. The program’s BMS was not changed or in the process of being
changed since the last annual compliance review. The program’s BMS includes a process for
staff to explain youth the reasons for any sanctions imposed and the youth are given an
opportunity to explain their behavior. The negative consequences are in direct relation to the
severity or seriousness of inappropriate behavior exhibited. The BMS provides an opportunity
for staff and youth to discuss the impact of the behavior on others, reasonable reparations for
harm caused to others, and alternate acceptable behaviors. Positive interactions and consistent
application of the BMS by the program staff were observed during the week of the annual
compliance review. The program has a variety of rewards/incentives to include but not limited to
games, music, movie night, and prizes. The FA was interviewed and indicated the program
utilizes a positive performance system which places an emphasis on rewards and positive
reinforcement. The youth are able to earn points daily and they have to earn positive days to
move up to the next level. Consequences can be a loss of points or a treatment team referral.
Five youth were interviewed, and each youth was familiar and able to explain the BMS level
system. Each youth stated youth are never allowed to punish other youth. Three youth indicated
all staff use the rewards the same and the remaining two indicated all staff do not use the
rewards the same. Two youth believed the BMS system is very good, one youth said good, and
remaining two youth said poor. Each youth was able to provide examples of consequences.
Four youth was able to provide examples of rewards and the remaining youth did not provide
examples of any rewards. A follow-up informal interview was conducted with the FA and the FA
indicated all staff receive training and feedback regarding BMS and rewards are provided
consistently. The FA indicated there are variety of rewards and the program’s BMS is effective.
Five staff were interviewed. Four staff said they received training on BMS. The remaining staff
said the staff is new and is still learning but the staff always talks about BMS and indicated the
BMS is effective. Each staff was familiar regarding the BMS. Four staff provided examples of
rewards and the remaining staff indicated the staff does not have much interaction with youth as
the staff is a transportation staff. Each staff indicated things cannot be taken away from youth as
a consequence. Four staff were able to explain the consequences given to youth and stated
youth are able to explain their behavior. The remaining staff indicated the staff does not have
much interaction with youth as the staff is a transportation staff. Four staff were able to explain
how they receive feedback regarding the implementation of the BMS and the remaining staff
indicated the staff does not fill out point cards as the staff is a transportation staff.
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, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures requiring them to 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. The policy also requires staff to
conduct the observations in a manner to ensure the safety and security of each youth and to
document real time observations manually or electronically. The program has thirty-eight
cameras to provide video surveillance throughout the facility. At the time of the annual
compliance review, all cameras were operational. Video recordings are stored for thirty days on
the program’s camera recording system. A sample of security tapes and corresponding logs
was reviewed from both housing units on three separate dates to verify ten-minute checks. All of
the checks were conducted within the ten-minute requirement, with most checks being
conducted every eight-minutes. Staff who completed the checks initialed the check sheet. Staff
conducting checks did so in a manner which appeared they were making thorough observations
of youth, as opposed to just walking by each room without pausing. A review was conducted of
check sheets for the annual compliance review period, six days each month, which confirmed
the program staff are conducting the checks as required. Five staff were interviewed, and all
said they conduct checks every eight minutes when youth are in their rooms.
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 maintains a policy and procedures which address population census, counts, and
tracking of youth. 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 has
adapted to counts being completed formally and informally every thirty-minutes, at the beginning
and end of each shift, and at every movement. The program utilizes the master control logbook
to document youth counts and movements. Logbooks were reviewed from May 2023 to
November 2023. The logbook is utilized to maintain a chronological record of events as they
occur. The program headcounts are conducted by the shift supervisor at the beginning of each
shift to verify accuracy and document the count in the program’s logbook. Counts are conducted
at beginning of shift, after outdoor activities, and emergency situations. The logbook also tracks
youth intakes, releases, and movements outside of the facility. The program utilizes alert boards
to track the daily count of all youth in and out of the program. Staff were observed conducting
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youth counts during youth line movements during the annual compliance review week. Staff
were aware of all youth whereabouts and were able to provide the proper counts to the annual
compliance review team members during the review week. Five staff were interviewed, and
each was aware of count procedures, as required by program policy, including what to do in the
case of an unsuccessful count.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures which require them to maintain a chronological record
of events, incidents, and activities in a central logbook maintained at master control. The
program ensures direct care staff, including each supervisor, are briefed when coming on-duty.
Logbooks were reviewed for the annual compliance review period including three days from
each month. All the logbooks were bound with numbered pages, and all entries were made in
ink with no erasures or white-out areas. None of the pages had been removed or destroyed.
There were minimal errors found, and all were struck through with a single line and initialed by
the staff making the correction. A review of the activity schedule and logbooks documented
minimal interference of educational instruction and indicated education classes were conducted,
as scheduled, and showed youth arriving and departing school on time. The logbook review
also verified recreation was conducted, as scheduled. The program does not maintain shift
reports. A review of the logbooks confirmed the program documented events such as
emergency situations, incidents including the use of mechanical restraints, special instructions
for supervision and monitoring of youth, population counts and the beginning and end of each
shift, any other population counts conducted during a shift, perimeter security checks and other
security checks conducted by direct care staff, transports away from the facility, including the
names of staff, youth involved, and destination, removal of any youth from the mainstream
population, and time of anticipated arrival or departure and mode of transportation. The logbook
review documented all internal incidents were reported to the Florida Abuse Hotline and/or the
Department’s Central Communications Center.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures to address key control. The policy and procedures
addressed distribution, tracking, storage, and overall control and security of keys. A review of
the inventory confirmed it matched the key rings in use. The keys are kept in a secure lock box
within master control, which is not accessible to youth. Each set of keys has an assigned key
hook. Keys are assigned to staff according to their department. Restricted keys, temporary
keys, and visitor keys are all kept separate from each other.. A sampling of five key rings was
conducted. All key rings with the exception of one had the correct number of keys when
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compared to the inventory and key log. One key ring was missing a key, which was discovered
to be a broken desk key, which had been reported as broken. This key was obsolete, and
removed from the inventory during the annual compliance review week. There were no incidents
of lost keys, which was verified by the review of internal incident reports and Department’s
Central Communications Center (CCC) reports. A random check of three staff key rings
confirmed the keys matched the inventory. The physical plant manager is responsible for
replacing broken or damaged keys. Informal interviews with staff confirmed staff’s knowledge of
the key rings and assigned keys. All observations during the annual compliance review week
found personal keys were secured and staff were aware of program keys in their possession.
Key control logs documented the issuance and return of keys on a consistent basis. All five
interviewed staff confirmed they had knowledge of the implementation of key control policies
and procedures. Additionally, staff reported if keys were damaged, they would notify their
supervisor and submit a maintenance request. An informal interview with the shift supervisor
indicated assigned keys are only assigned by the facility administrator, assistant facility
administrator, and maintenance. Restricted keys are kept apart from non-restricted keys and
only assigned staff can access restricted keys. Master control tracks keys as they are signed
out and back in by staff prior to receiving their personal keys.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures which address illegal contraband and prohibited
items. The policy delineates items and materials considered contraband when found in the
possession of youth. The program provides youth with the list of contraband items and materials
and informs the youth of the consequences if they are found with contraband. The program has
a system in place to prevent contraband from entering the facility which includes defining items
considered to be contraband, providing youth a list of items considered contraband and
informing youth of the consequences if they are found with contraband, and searching of the
physical plant, grounds, youth, and mail. The policy also addresses any staff who is found in
possession of contraband in a program will be subject to disciplinary action up to and including
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dismissal, and requires for law enforcement to be contacted if any found item would be
considered illegal as defined in Florida Statutes, or if there is evidence of any type of unlawful
activity. During the annual compliance review period, there were no instances of any illegal
contraband found which was turned over to law enforcement. A review of logbooks confirmed
the program documents the confiscation and disposition of contraband, to include the disposal
of non-illegal contraband. The logbooks also document the frequency of searches and the
results of searches. The facility administrator (FA) was interviewed and advised once an
unauthorized/contraband item or material is found, such item or material shall be removed from
the possession of the person and disposed of in the prescribed manner. In all instances
involving the confiscation of contraband which is illegal, the confiscated items will be tagged.
Stamps, checks, and stamped envelopes shall be returned to the sender by regular mail. All
other unauthorized items shall be either discarded, returned to its original owner, mailed to the
youth’s home, or stored and returned to the youth upon their release. All contraband, illegal
drugs other than alcohol, weapons, or other illegal contraband items or materials will be turned
over initially to the FA, who will document the custody trail and preserve it in an evidence bag
with a facility statement, detailing the date, time, and location of the item. The contraband items
will then be turned over to local law enforcement authorities and a criminal report filed. All
contraband will be stored in the locked evidence cabinet in the FA’s office until it is turned over
to law enforcement or properly disposed of.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures which require them to perform searches to ensure no
contraband is being introduced into the facility. During the annual compliance review week,
searches of youth were observed after all internal movements. There were no admissions,
transports, visits, off-campus activities, or issuance of tools involving youth during the annual
compliance review week. During the searches which were observed, youth were treated with
dignity and respect to minimize stress and embarrassment, searches were conducted by staff of
the same gender, searches were thorough, and staff were heard giving instructions to youth. All
observed searches were conducted as required. Five staff were interviewed, and all were aware
of when and how youth searches are conducted, which is after every movement. Five youth
were interviewed and asked when they were searched. All youth said they are searched after
every movement. Two youth said they are also searched after outdoor activities, after meals,
and one said they are also searched after visitation.
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 maintains a policy and procedures addressing vehicles and maintenance. The
program utilizes two vehicles for youth transports. Both vans had up-to-date inspections. The
vehicles are also inspected weekly by the plant manager. Results of weekly inspections are
documented and stored in the program’s vehicle maintenance log/binder. A member of the
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annual compliance review team inspected the vehicles, and all required equipment was
observed, which included a seatbelt cutter, window punch, and fire extinguisher. The first-aid
kits are not stored in the van to preserve the items inside of the kit. Staff check out a first-aid kit
prior to a transport and return the kit to the program upon return. All seatbelts in the van were in
proper working condition. The vehicle also had a safety screen separating the youth from the
driver. A random check of personal vehicles and the vans was conducted during the annual
compliance review week and all were found to be locked. There were no transports to observe
during the annual compliance review week. All five staff were able to identify how youth are
secured during transports.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a policy and procedures addressing transportation of youth, outlining the
staff to youth ratio during transports as one to five; however, if there are five or less youth, a
minimum of two staff are needed to perform all transports. The program’s transport vehicles
were inspected by an annual compliance review team member and the vehicles were found to
be in working order. The transport vehicles are equipped with a safety screen separating the
driver from the passenger’s compartment. The program has an approved transport list which is
updated monthly to ensure staff driver’s licenses are valid. This approved driver’s list is located
in the administrative area. An annual compliance review team member observed the facility
transporter conduct a routine check of all personal vehicles in the parking lot including the
program’s transport vehicle. All vehicles were found to be locked and secured. The annual
compliance review team was not able to observe a transport during the annual compliance
review week. Staff interviews confirmed they are issued a cellular telephone before transport
and staff do not conduct transports in personal vehicles. Vehicles are checked before and after
transports. All five staff were able to accurately describe what safety equipment is required for
all transports. All five staff were able to describe the process required in case of an emergency.
All five staff knew the ratio of staff to youth during a transport. All five youth stated they had not
seen staff place contraband inside the vehicle. All five youth stated they feel safe during
transports.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The policy and procedures designate the assistant facility administrator (AFA) as the person
responsible for conducting the weekly safety and security audits. The weekly safety audits are
kept in a binder, which is reviewed weekly during the safety committee meeting held on Fridays.
This committee consists of the facility administrator, assistant facility administrator, the physical
plant manager, and another member of the management team. Findings are discussed and a
corrective action plan is implemented to fix any deficiency noted. During the annual compliance
review period, there were no inspections missing. The forms documented safety and
maintenance repairs needed and the date and time the repairs were completed, or due to be
completed. All forms were reviewed and signed by the facility administrator. The forms cover
radios, cameras, keys, telephones, mechanical restraints, the generator, flashlights, fire safety
equipment, alarms, ensuring no anchor points, youth rooms, recreation area, grounds,
correction action needed, and corrective action completed. The interview with the facility
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administrator confirmed the weekly safety audits are conducted in accordance with program
policy and procedures.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures to address tool inventory and management.
The policy addresses the issuance, inventory, and control of equipment and tools. The policy
also states all Class A tools are maintained off-site at Tampa Residential Facility. Youth only
have access to Class B tools which are brooms, mops, and scrub brushes. The program has
identified their plant manager as the program’s tool control manager. The policy classifies tools
into two categories as Class A tools and Class B tools. Class A tools are hazardous with sharp
edges or points and 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. The plant manager stated there
were no tools which were damaged or out of use at the time of the 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 maintains a policy and procedures addressing youth tool handling and
supervision. The policy outlines proper procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries to youth and staff. The policy also states Class A
tools are maintained at Tampa Residential Facility and the youth at Hillsborough Girls Academy
do not have access to tools, except Class B tools which consist of a broom, mop, and scrub
brush. The program completes risk assessments which determine youth risk to self and others
are completed. Youth case management records were reviewed, and all records indicated youth
have been trained on the proper usage of Class B tools during their orientation process. Youth
signed an acknowledgement of tool training during the orientation process. The signed
acknowledgement form is filed in each youth’s record. Youth interviews confirmed youth are
only allowed to use a scrub brush, mop, and broom. One youth stated they do not use tools.
Staff interviews revealed youth are allowed to use Class B tools.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a policy and procedures which address outside contractors. The
program has established guidelines for outside contractors which include information regarding
tool control and restrictions. The program has a form to be signed by outside contractors which
addresses how tools will be checked upon arrival to and departure from the program,
restrictions of youth access in the work area, immediate reporting of missing tools, restriction of
personal cellular telephones, and/or equipment capable of taking pictures and/or recording
audio/video in secure areas. The form also requires contractors to list each tool brought into the
facility. This list is reviewed by the plant manager or designee before the contractor has access
to a secure area. This list is again reviewed before the contractor exits the program. The
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contractor’s failure to sign this form prohibits access to work within the program. Outside
contractors are escorted and supervised by the plant manager or designee any time they are
within the facility. The annual compliance review team was not able to observe this process
during the annual compliance review. Program invoices were cross checked to ensure outside
contractor agreements were signed on the date of service. All invoices and contractor
agreements matched and there were no discrepancies found.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a policy and procedures requiring them to 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’s Continuity of Operations Plan (COOP)
requires monthly fire drills on each shift, in addition to monthly drills on a rotating basis on each
shift covering different types of emergencies. A review of the program’s drill binder revealed the
program conducted monthly fire drills on each shift during the annual compliance review period.
The program also conducted monthly emergency drills on each shift, with different types of
emergency scenarios, to include riot, hostage, lightning strike/severe weather, chemical spill,
flooding, chemical used as a weapon, and gang disturbance. Documentation for all of the drills
contained the type of drill, date and time of drill commencement and ending, participants, brief
scenario of the emergency, findings, and recommendations. Fire evacuation routes are posted
throughout the facility, outlining primary and secondary evacuation routes. The program has
twelve fire extinguishers throughout the facility, and all have been serviced within the past year.
Five staff were interviewed, and all said they participate in monthly fire drills. In addition, staff
also said they have participated in severe weather, hostage, riot/disturbance, and chemical spill
drills during the annual compliance review period. Five youth were interviewed, and three said
they participate in fire drills, while two said they have not participated in fire drills. The facility
administrator was interviewed and said COOP drills are conducted monthly and include
chemical, severe weather, and riots/disturbances. Medical and fire drills are conducted monthly
on all three 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 policy and procedure addressing the Continuity of Operations Plan (COOP).
Policy states the COOP is located in master control, facility administrator, and assistant facility
administrators’ office. The plan addresses alternative housing plans approved by the applicable
Department regional director/designee. The COOP was last approved on January 26, 2023. The
COOP addresses fire prevention and evacuation, severe weather, disturbances or riots, bomb
threats, hostage situations, chemical spills, flooding, terrorist threats or acts, staff roles and
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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 program conducts COOP drills on each shift.
The drill documentation included the type of drill, date and time of the drill, participants, brief
scenario and findings/recommendations, and pictures. The drills included escape, missing tools,
fire, evacuation due to severe weather, lightning, riot, active gunman, and chemical. The
program has food and necessary supplies readily available in case of emergency evacuation
being maintained at Tampa Residential Facility. The program maintains an administrative hard
copy on youth in case of emergency with all required information which are located in the case
management office and master control. The facility administrator reported the COOP is located
in master control, facility administrator, and assistant facility administrators’ offices.
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 maintains a policy and procedures addressing storage and inventory of flammable,
poisonous, and toxic items and materials. The program’s flammable, poisonous, and toxic
materials are stored in a flame-resistant cabinet. Policy also states all flammable, poisonous,
and toxic items are maintained at Tampa Residential Facility. Only cleaning chemicals are
maintained on-site at Hillsborough Girls Academy. The program maintains proper inventory of
these items. The program’s plant manager is the only individual authorized to handle flammable,
poisonous, and toxic items. A binder is stored in the cleaning supplies closet containing the
Safety Data Sheets (SDSs) for the items located in the cabinet as well as cleaning supplies. The
cleaning supplies closet is locked at all times and can only be accessed by the plant manager,
supervisors, and facility management. Staff sign these items in and out with each use.
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 maintains a policy and procedures addressing youth handling and supervision of
flammable, poisonous, and toxic materials. The policy prohibits youth using those items and
materials. Flammable, poisonous, and toxic materials are stored in a storage locker located at
Tampa Residential Facility. Youth do not have access to these items and are supervised by
staff during daily cleaning. Although youth were not observed participating in facility clean-up
during the week of the annual compliance review, four youth interviews indicated they are
prohibited from using chemicals/cleaning products, one youth said laundry soap, window
cleaner, and toilet cleaner. Staff spray chemicals and youth wipe the area.
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Office of Accountability and Program Support Page 65 of 68 (Revised September 2022)
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 maintains a policy and procedures addressing disposal of all 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’s plant manager is the only individual authorized to handle flammable, poisonous, and
toxic items. 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 waste disposal
company. The plant manager further stated the program has not needed to dispose of any
chemicals since the last annual compliance review. An interview with the facility administrator
validated this practice. The kitchen is not in use at Hillsborough Girls Academy.
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 68 (Revised September 2022)
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 visitation and communication for youth while
in the program. The visitation procedures are posted at the front door and on the wall in the
lobby. The visitation and communication procedures are covered in the resident handbook,
parent/guardian handbook, and addressed on the orientation checklist. The program utilizes
staff translators or the interpreter line with live translators to be utilized if necessary. Five youth
interviews indicated they can make weekly calls to their parents/guardians. Four youth stated
they had no knowledge of the interpreter services and one said they have staff translate. The
visitation schedule was posted in the lobby and at the front door. Visitation documentation
indicated visitation is being offered on the weekends as required by policy. The visitation,
telephone, and correspondence logs were reviewed. The logs showed youth have contact with
only approved persons. Incoming and outgoing mail is searched and recorded in the
correspondence logs, then given to the youth’s case manager who delivers the mail to the youth
and has them open the mail in front of them. There were no youth applicable for a history of
human trafficking, therefore, the program has not been required to request clarification from the
youth’s juvenile probation officer (JPO) about any parent/guardian past or current human
trafficking investigation involvement.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a policy and procedure stating recreation activities shall be provided for a
minimum of one hour a day. The policy states a schedule shall be made with a selection of
activities for the youth to choose from. The youth have a variety of recreation and leisure
activities. The program’s schedule has structured indoor and outdoor recreation and leisure
activities which include large muscle activity for a minimum of one hour each day. A review of
the logbook for the annual compliance review period indicated recreation was conducted as
scheduled. The program’s contract requires a recreation therapist. At the time of the annual
compliance review this position was vacant. A review of five youth records confirmed each
youth record contained a wellness plan. Five interviewed youth stated the program allows the
opportunity to exercise, yoga, play outside, read a book, play a board game, arts and crafts,
sports, or physical fitness activities. Five youth also stated physical activities are provided for at
least one hour. Five interviewed staff confirmed recreation was occurring and included activities
such as football, basketball, weightlifting, tug of war, board games, and playing video games.
5.24 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy and procedures address their practice for the search and inspection of
controlled observation rooms. An observation of the program’s controlled observation rooms
confirmed all requirements were met. A review of documentation for three youth who were
placed on controlled observation was completed. Reviewed documentation confirmed each
room, and each youth were searched prior being placed in the room. Each youth was searched
by two staff of the same gender. The program utilizes a controlled observation checklist which
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 68 (Revised September 2022)
documents both the room and youth search. All three controlled observation checklists were
completed as required.
5.25 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
A review of documentation for three youth who were placed on controlled observation was
completed. None of the three youth exhibited behaviors indicative of a mental health crisis.
Each of the three controlled observation placements were authorized by a supervisor. Each
controlled observation was authorized due to at least one qualifying criteria. The staff discussed
with each youth the reasons for their placement and the expected behavior for removal from
placement. A health status checklist was completed for all three youth reviewed with none of the
three youth having any complaints or injuries. All three youth were in controlled observation for
less than two hours.
5.26 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
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 and procedures address controlled observation safety checks and release
procedures. A review of documentation for three youth who were placed on controlled
observation was completed. The first page of the controlled observation report was completed
and submitted to a supervisor for review for each of the three youth reviewed. Safety checks
were completed and documented on the Controlled Observation Safety Checks form at least
every fifteen minutes for each of the three youth. A program supervisor, with delegated
authority, approved each of the three youth’s release from controlled observation, which was
based on behavior and whether the youth was no longer an imminent threat to themself or
others. None of the three youth required an internal alert upon placement and release from
controlled observation. The Controlled Observation Report, Health Status Checklist, and
Controlled Observation Safety Checks forms were maintained in an administrative file for each
of the three youth; however, is not maintained in each youth’s individual management record.
The facility administrator reviewed and approved the controlled observation report for all three
youth within twenty-four hours of each of the three youth’s releases from controlled observation,
which is within the required fourteen days. None of the three youth required an internal alert
upon release from controlled observation. The program’s policy and procedures address staff
designations for controlled observation. Five youth were interviewed and all five said they had
not been sent to their rooms for getting in trouble.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 68 (Revised September 2022)

report_type: QI Residential