summary: QI Residential - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Daytona Juvenile Residential Facility
Rite of Passage, Inc.
(Contract Provider)
1386 Indian Lake Orad
Daytona Beach, Florida 32124
Review Date(s): October 31, 2023- November 3, 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:
Heather Molinario, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Rob Aguis, Office of Education, Career and Technical Education Deputy Director (Standard 1)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Patrick Brock, Office of Education, North Education Coordinator (Standard 2)
LeAnn Gruentzel, Office of Accountability and Program Support, Deputy Regional Supervisor
(Standard 4)
Cindy Jones, Office of Education, West Central Education Coordinator (Standard 2)
Tamara Mahl-Adkins, Office of Accountability and Program Support, Regional Monitor
(Standard 1)
Gustavo Mazorra, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Program Name: Daytona Juvenile Residential Faciltiy MQI Program Code: 1226
Provider Name: Rite of Passage, Inc. Contract Number: 10693
Location: Volusia County / Circuit 7 Number of Beds: 33
Review Date(s): October 31, 2023 - November 3, 2023 Lead Reviewer Code: 197
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 63 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
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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 * Non-Applicable
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Non-Applicable
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* 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 63 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
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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 63 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
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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 63 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
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Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 63 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
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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 Non-Applicable
5.25 Controlled Observation Non-Applicable
5.26 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 63 (Revised September 2022)
Program Overview
Daytona Juvenile Residential Facility is a thirty-three bed program, for thirteen to eighteen year
old males, located in Daytona Beach, Florida. The program is operated by Rite of Passage, Inc.,
through a contract with the Department. The program provides juvenile sexual offender
treatment services through Pathways: A Guided Workbook for Youth Beginning Treatment,
Roadmap to Recovery, or Footprints: Steps to a Healthy Life. The program has offered
additional services to include Anger Management for Substance Abuse and Mental Health
Clients, Conflict Resolution from the Inside Out, Transforming Anger to Personal Power, Social
Skills Lessons and Activities for grades seven through twelve, Stress Management for
Adolescents, 100 Interactive Activities for Mental Health/Substance Abuse Recovery, Creative
Therapy, and The Council for Boys and Young Men. Additional treatment services provided
include family and individual therapy, group therapy, and recreation therapy. Program
administration is comprised of a program director, human resources coordinator, designated
mental health clinician authority, health services administrator (HSA), and three shift
supervisors. Case management services are provided by a transitional service manager and a
transitional manager. Mental health staff at the program includes a psychiatrist, a licensed
designated mental health authority, and two master’s-level therapists; the remaining master’s
level therapist position has been vacant since March of 2023. Medical services are offered
seven days a week, 7:00 a.m. to 5:00 p.m., and are provided by the HSA, who serves as the
supervisor over a part-time registered nurse (RN), and the designated health authority (DHA).
The remaining RN position is vacant. Educational services are provided by the Volusia County
School Board. The layout of the program includes two primary buildings including an
administrative and education portable, and a brick building which houses the youth dormitories,
medical office, cafeteria, multi-purpose room, and staff offices.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 63 (Revised September 2022)
Strengths and Innovative Approaches
• The lead teacher was recognized as the Department’s 2023 Teacher of the Year.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 63 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures to ensure initial background screenings are
conducted, and this policy also ensures all volunteers, mentors, and interns, who interact with
youth on an intermittent basis and less than ten hours a month, are always present with a staff
who has had a completed background screening. The Annual Affidavit of Compliance with Level
2 Screening Standards was completed and sent to the Department’s Background Screening
Unit (BSU) on January 12, 2023, by the required January 31 deadline. An annual screening was
completed on January 12, 2023, for the school board teachers. Seventeen new staff were hired,
or participated in the hiring process, since the last annual compliance review. Fifteen of
seventeen staff had a background screening and criminal history report completed by the
program prior to contact with youth and confidential records, one was terminated prior to
receiving the background screening, and the remaining staff was previously hired by the
provider and had cleared both screenings prior to transferring to this program. Two of seventeen
new staff required an exemption, both of which are still pending and neither staff has contact
with youth or youth records; the remaining fifteen staff were not applicable. Two of seventeen
staff had a break in service noted in the Staff Verification System (SVS) and a new background
screening was conducted for both staff; the remaining fifteen staff were not applicable. Sixteen
of seventeen new staff were employed as direct care staff, and each had a pre-employment
assessment tool maintained in their personnel record; the remaining staff was not applicable. All
sixteen of the applicable staff received a passing score on the pre-employment assessment
tool. Fourteen of sixteen applicable staff were added to the Clearinghouse roster; the remaining
two staff were separated from the program and were not employed long enough to be entered
on the clearinghouse roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures to ensure five-year background rescreenings are
conducted. The program did not have any applicable staff for this indicator during the annual
compliance review period.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 63 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
 The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
 All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
 Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
 The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
 A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to ensure all allegations of abuse are investigated
and handled appropriately. The policy outlines all required elements of reporting. The program
did not have any allegations during this annual compliance review period. The code of conduct,
which all staff sign, was observed with each staff signature within each of the five reviewed staff
training records. The program had the Department’s Central Communications Center (CCC)
and Florida Abuse Hotline numbers posted throughout the facility, accessible to youth and staff.
The Trauma Responsive and Caring Environment (TRACE) self-assessment for the program
was completed on June 28, 2023. Five youth interviews were conducted. One of five youth
indicated they were never stopped from calling the Florida Abuse Hotline; the remaining four
youth reported they have never needed to call. All five youth stated they can find the reporting
numbers throughout the facility; one youth additionally stated the staff can be asked for the
number. All five youth reported the staff are respectful to them and other youth. Four of five
youth stated the staff do not use curse words when speaking to youth; the remaining youth
stated on occasion staff will use curse words in conversation, but not at the youth. Five staff
were interviewed, and each was able to explain the basic process to handle a youth’s request to
use the reporting numbers to include the youth’s unimpeded access to the reporting numbers
and notification of administration. None of the interviewed staff have observed a coworker
impeding a youth’s ability to report abuse. All five staff were able to confirm the Florida Abuse
Hotline and the CCC numbers are posted throughout the facility. The program director was
interviewed and was able to provide information regarding the code of conduct and
administrative actions taken should staff act in a prohibited manner. The program has trauma
responsive practices, which include an advisory board and completion of TRACE assessments.
The program director outlined the program’s response process to allegations of abuse, and how
the program ensures staff and youth have access to the Florida Abuse Hotline and the CCC
numbers. The date and completion of the most recent TRACE assessment was confirmed in the
program director’s interview.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 63 (Revised September 2022)
1.04 Management Response to Allegations (Critical) Non-Applicable
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 had no incidents of physical, psychological, or emotional abuse during the annual
compliance review period; therefore, this indicator is rated non-applicable.
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 for notification to the Department’s Central
Communications Center (CCC) of reportable incidents. The program had a total of seven
reportable incidents in this annual compliance review period; the required minimum sample of
five incidents was reviewed. Each of the five reviewed incidents were reported within the
required two hours from the time the reporter became aware, and each incident was
documented in the logbook as required. There were no additional reportable internal incident or
grievances located during the annual compliance review. The program had four CCC incidents
in the prior annual compliance review period; an increase of three incidents was documented
this annual compliance period. The program director was interviewed and was able to provide
information regarding the code of conduct and administrative actions taken should staff act in a
prohibited manner. The program director outlined the program’s response process to allegations
of abuse, and how the program ensures staff and youth have access to the Florida Abuse
Hotline and the CCC numbers.
1.06 Protective Action Response (PAR) and Physical
Non-Applicable
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
There have been no Protective Action Response Right Interactions model (PAR/RI) incidents
during the annual compliance review period; therefore, this indicator is rated non-applicable.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
Five newly hired staff training records were reviewed, and all five staff were still in the first 180
days of hire. Four of five reviewed training records had documentation of completion of all
required trainings for youth contact in the Department’s Learning Management System
(SkillPro); the remaining record indicated the staff was completing the final training, Protective
Action Response (PAR)/Right Interactions (RI) and has not had youth contact during the annual
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 63 (Revised September 2022)
compliance review period. All five had completed cardiopulmonary resuscitation (CPR), first-aid,
automated external defibrillator (AED), professionalism and ethics, suicide awareness and
prevention, emergency procedures, child abuse reporting, and Prison Rape Elimination Act
(PREA). Each reviewed training record confirmed the staff have completed over the required
120 hours; however, each was missing several required Department and contractual trainings,
and have a training schedule to have the outstanding trainings completed within their first 180
days. The contractually required trainings, beyond what is required by Florida Administrative
Code, for staff are gender-responsive, positive reinforcement techniques and strategies, Right
of Passage (ROP) New Hire Training, and ROP On the Job Training. A review of PAR/RI, CPR,
and first-aid instructor certifications indicated all had the required training. The training plan
included course names, descriptions, objectives, and training hours for any instructor-led
training of the required topics. The program’s contract states, and second contractual
amendment affirms, coach counselors/night coach counselors, and shift supervisors are the
only staff considered for 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 previous annual compliance review, which ended February 24, 2023, reviewed 2022 in-
service staff training records. Five different staff training records, including three supervisory
staff, were reviewed for in-service training. All five reviewed training records indicated the staff
completed in 2022, or are current as of the annual compliance review week, with all required
trainings to have youth contact, which include Protective Action Response (PAR)/Right
Interactions (RI) update, cardiopulmonary resuscitation (CPR), first-aid, automated external
defibrillator (AED), professionalism and ethics, six hours of suicide prevention, active shooter,
emergency procedures, program operating procedures, and Prison Rape Elimination Act
(PREA), as well as juvenile sex offender treatment training. Three of five staff training records
were completed and documented in the Department’s Learning Management System (SkillPro).
The remaining two staff were missing some required trainings; one staff was missing five and
one staff was missing three; however, both staff are current with all required trainings. The three
supervisory records contained documentation all met, or exceeded, the required eight hours of
additional training for the current training period.
A review of PAR/RI, CPR, and first-aid instructor certifications indicated all had the required
training. The program submitted the in-service training plan, in writing, to the Department’s
Office of Talent, Leadership, and Culture on January 11, 2022, and January 13, 2023. The
program is aware the Department’s deadline for submission is December 1st of the year
proceeding implementation. The training plan included course names, descriptions, objectives,
and training hours for any instructor-led training of the required topics. The program had an in-
service training calendar, which is updated when changes occur.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 63 (Revised September 2022)
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures to address the training requirements for the grievance
process, as well as documenting the three phases. The process from start to finish shall take no
longer than seventy-two hours, from the informal, to the formal, and then the appeal phase.
The program utilizes a “Request to Speak” form for informal grievances. The youth complete the
top portion of the form to state what they request to address; and the staff then documents the
outcome of the meeting/conversation; both youth and staff sign the form. The program
maintains a grievance binder with copies for at least twelve months, as required. The program’s
grievance binder contained a total of eight informal grievances since February 25, 2023, the
start of the annual compliance review period. Five grievances were reviewed. Each grievance
was resolved in the informal phase, and the documentation conformed the program’s
procedures. There were no formal grievances submitted this annual compliance review period.
Five youth were interviewed. Each youth confirmed they know how to make a grievance and
where to find information, the handbook and postings, about the program’s grievance process.
All five youth stated they can ask for assistance, if needed. Five staff were interviewed, and
each was able to describe the grievance procedures, as well as the different levels or types of
grievances. The program director’s interview also confirmed the program’s grievance
procedures.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program has trained eight staff to facilitate non-primary groups during this annual
compliance review period. All clinical groups are facilitated by a master’s-level therapist. Each
staff had the required education and work experience to provide groups, which is information
the program reviewed when considering the staff for group facilitation. A review of group sign-in
sheets, program schedules, and contract services tables was conducted, and found groups
were provided accordingly. The program had an executed amendment to the service table
effective August 24, 2023, and the review found the transition in services provided has
occurred. The program’s reviewed activity schedule confirmed the program is providing
planned, structured activities to the youth for at least sixty percent of the awake hours. The
program director was able to provide a list of staff who facilitated groups during the annual
compliance review period. The program utilizes interventions which are evidence-based,
promising practices, and practices with demonstrated effectiveness. The designated mental
health clinician authority (DMHCA) formal and informal interviews confirmed appropriately
trained staff are facilitating groups, and the program provides interventions to youth based on
needs identified in their individualized mental health and substance abuse treatment plans.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 63 (Revised September 2022)
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures for providing services through groups of ten or fewer
youth, individual sessions, and family sessions. The life skill interventions utilized by the
program are all either evidence-based, a promising practice, or a practice with demonstrated
effectiveness as identified by the Department. Communication, interpersonal relationships and
interactions, non-violent conflict resolution, anger management, and critical thinking are all
provided through the program’s multiple targeted gender groups and services. The program
also included interpersonal, hygiene, and interpersonal reflection into the provided life skill
interventions. The program uses cognitive behavioral therapy (CBT), trauma-focused CBT, and
social recovery therapy (SRT) disciplines. A review of group sign-in sheets, fidelity observation
checks, program schedules, and the contract services tables was conducted, and found groups
were provided accordingly. The program had an executed amendment to the service table
effective August 24, 2023, and the review found the transition in services provided has
occurred. Five youth were interviewed, and each was able to identify life skills groups/activities
which they participate in, as well as how they can use the learned skills at the program. Four of
five youth stated they have participated in gender-specific services; the remaining youth stated
he did not. The non-affirming youth was new to the program and had not participated in the
Council for Boys and Young Men. The designated mental health clinician authority (DMHCA)
confirmed the services provided, frequency, and who facilitates the services at the program. The
list was inclusive of all contractual services, and the amended services since August 24, 2023.
The DMHCA stated youth are offered the opportunity to practice skills daily during staff and peer
interactions and can also practice skills during interactions when youth communicate daily by
telephone calls or visitation. The program director was interviewed and he stated the program
utilized the Council for Boys and Young Men as a gender specific group through October 10,
2023, and are currently utilizing Living the Legacy.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program provides restorative justice awareness to youth through Impact of Crime (IOC), a
promising practice primary service, and through LifeSkills Training, an evidence-based service.
Restorative justice groups/activities are provided twice a week, in accordance with the program
schedule, and are designed to assist youth in accepting responsibility for harm caused and
impact of their offense, expose the youth to victims’ perspectives, and provide opportunities to
participate in restoration activities. A review of group/activity sign-in sheets and video was
conducted to confirm the services provided. The youth perform community service throughout
the year in a variety of opportunities, and youth were observed to be engaged in these services.
Four of five interviewed youth were able to confirm their group participation; the remaining youth
was newly admitted to the program and required assistance in identifying restorative justice
services received. Each youth was also able to identify learned skills which are practiced while
in the program. The program director confirmed community service projects are utilized by the
program to teach youth about restorative justice.
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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 for an internal alert system. When risk factors or
special needs are identified during or following the classification process, the program staff
update the Department’s Juvenile Justice Information System (JJIS), the internal alert board,
and the logbook, if applicable. The alert board includes the name, Department identification
number (DJJID), a photograph of the youth, and a color-coded dot system for all program
related alerts. Shift supervisors are responsible for providing alert information during shift
briefings. Five youth case management records were reviewed and were found to have all the
appropriate alerts entered into JJIS, recorded on the alert board, and in the logbook where
applicable. The all alerts contained in the five reviewed records were observed to be properly
entered, maintained/updated, and closed, if applicable, by appropriate staff. Five staff were
interviewed, and each staff was able to identify where youth alerts are located for review. The
program director’s interview confirmed the program’s policy and procedures regarding alert
practices, including identification of staff responsible for alert maintenance and dissemination of
information. The nursing staff interview confirmed the health services administrator (HSA) is
responsible for documentation and updating medical related alerts.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program separates each youth record into an Individual Healthcare Record and an
individual case management record. All five case management records had a file tab with the
youth’s name, the Department’s identification number (DJJID), date of birth, county of
residence, and committing offense, as well as being labeled confidential. All five records
contained sections categorized as legal information, demographic and chronological
information, correspondence, case management and treatment activities, and miscellaneous. All
youth records are stored in locked file cabinets labelled confidential and are located within
locked rooms.
1.15 Advisory Board Satisfactory Compliance
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The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a community advisory board which meets at least every ninety to 120 days.
The formal meetings were held in March, June, and September of 2023, and the next scheduled
meeting is December 14, 2023. A review of advisory board meetings, agendas, notification
emails, and letters since the last annual compliance review indicated the program conducts
formal meetings once every ninety days. A review of documentation indicated the program
director solicited active involvement from law enforcement representatives, the judiciary,
business community, school board, faith-based and other community partners, as well as trying
to recruit victim advocates and a parent/guardian of previously involved youth in the juvenile
justice system. All meetings were held in-person; no scheduled meetings were cancelled or
rescheduled. A board member interview was conducted, and they indicated youth are typically
present during the advisory board meetings. The meetings discuss program needs/changes,
and members work to assist with the needs by donation and community involvement. The
advisory board members created a non-profit in the spring of 2023 to meet the needs of the
youth within the program. This committee is comprised of at least forty local business owners
and stakeholders. The board member reported they have held a multitude of informal meetings
since the start of the non-profit. The program director’s interview response confirmed the
frequency, invited members, and activities of the advisory board, to include the highly involved
and active status of the board.
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 addressing staff performance evaluations. A review
of five job descriptions indicated each staff’s performance standards were clearly identified. A
review of five personnel records indicated each performance evaluation was completed at least
annually on established performance standards matching the job description. The program has
the contractually required key positions filled including the program director, health services
administrator, designated mental health clinician authority (DMHCA), psychiatrist, licensed
mental health staff, recreational therapist, and transition services manager. The program is
utilizing ROP staff from another program to cover the vacant full-time nurse and therapist
positions. Five staff were interviewed. Three of five stated the communication at the program is
good; one staff identified communication at the program was very good; and the remaining staff
stated it is fair. All five staff confirmed they received at least annual performance reviews. The
program director stated the program has a morale committee to address the needs of the staff
and has been able to maintain a solid core group of staff. The program director also stated staff
participate in pro-social activities off-campus as well as staff appreciation activities during all
campus meetings.
1.17 Special Contract Conditions Satisfactory Compliance
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The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
A review of the program’s contract and recent amendment was completed. The second contract
amendment was effective August 24, 2023. The program is transitioning to the new or altered
contractual changes as a result. The program has a student council, and a Ram level youth is
the president. The first Wednesday of each month each department of the program recognizes
specific youth who achieves a high standard the previous month. The program assists eligible
youth in the dual enrollment program through a local college; however, no youth were eligible
this annual compliance review period. The program had eight youth achieve their high school
equivalency diploma (GED) and were eligible for online courses through an online learning
resource, and a career and technical education course at the program. Quarterly workshops are
held with post-secondary youth to educate them on how to complete scholarship applications
and financial aid forms. All teachers at the program completed behavior management system
training in May of 2023. Staff-to-youth ratio can only use direct care staff and supervisors for the
ratio count. The contract and second amendment both contained discrepancies regarding the
changes to the nursing staff; clarification was obtained from residential headquarters making the
new nursing staff requirements one and a one half registered nurses for sixty hours and one
health services administrator for forty hours, totaling 100 hours. The program is in compliance
with these specified requirements, changes, and/or updates. The program director was
interviewed and stated the program’s transitional case manager works with the teaching staff to
create study plans for youth preparing to take post-secondary education exams, the youth have
opportunities for vocational and employability skill building, including résumé writing and mock
interviews. Three of five interviewed youth were able to state at least one vocational and
employability skill building class or activities they participated in; the remaining two youth were
not yet in transition, where the program offers these items. The applicable youth provided
examples like business classes, vocational rehabilitation, cardiopulmonary resuscitation
certification, and a state-based employment skills online program.
1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
The program’s contract requires the provision of career and technical education (CTE) services
by the provider or by Volusia County Schools. The school district, in conjunction with the
program, offer Entrepreneurship and Small Business and Microsoft Office Suite (MOS). The
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program is offering Occupational Safety and Health Administration (OSHA) 10, and Florida
Ready to Work Levels 1-3 and Soft Skills. Four youth are working on the soft skills certification.
The program will need to include all youth in the soft skills component moving forward. The
program is successfully offering, and youth are earning certifications in cardiopulmonary
resuscitation (CPR) and first-aid training as the CTE services. Youth certifications were
reviewed, and the program is successfully offering one certification from the Master Credential
List, Entrepreneurship and Small Business, and as reported rapid credentials such as CPR/first-
aid training, OSHA 10, and Florida Ready to Work Workplace Essentials and Soft Skills to
youth. Several other services are available to youth, such as Forklift, ServSafe, Horticulture/4H,
and National Retail. Fifteen youth have participated in OSHA 10 with three earning
certifications, seventeen youth participated in CPR/first-aid and five earned certifications,
twenty-seven youth participated in MOS and Entrepreneurship and Small Business with five
earning certifications, twenty-nine youth participated in Florida Ready to Work Levels 1 through
3 with ten youth earning certifications, and no youth have particioated in Forklift, ServSafe, and
Horticulture/4H. Youth have elected not to take several of the CTE services offered. The
program does not have a designated time for CTE built into the education schedule Monday
through Friday. CTE offerings are age appropriate, appropriate for the abilities and goals, 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 were
interviewed and one reported participation in these services; the remaining four had not
participated. The youth who stated no participation were not in transition when the services
were offered or were too young to participate. The program director confirmed the certifications
and vocational services outlined in the contract are provided.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a practice to gather and share data trend analysis. Surveys of staff are taken
quarterly, and youth, parent/guardian, and stakeholder surveys are taken regularly. The
program uses both formal interview style, in-person surveys, and informal surveys. The program
also utilizes the data gathered through the Department systems, and human resources
information through the provider to analyze as well. This information is shared with
stakeholders, youth, and families through a variety of platforms, including management
meetings, advisory board, youth town hall meeting, and student council, through a computer
presentation. Program staff and administration review data trends monthly and the stakeholders
review the information quarterly. The presentation, survey results, and advisory board minutes
were reviewed, and found the described practices are occurring. The data and information
collected are used by the program to reduce negative incidents, support staff, and assist the
youth with treatment goals and feelings of safety.
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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 each 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 the youth’s admission. 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, or prior to, each youth’s admission. Five youth case management records were
reviewed, and all contained documentation verifying the 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, an orientation was not observed. Five interviewed youth said orientation began within
twenty-four hours of admission, and the orientation to the program included program rules,
procedures, and schedules. 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
or mental health screenings, assessments, or treatment. One of the five reviewed youth was
over the age of eighteen; the remaining four youth records were not applicable. A review of the
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one applicable youth and two additional applicable youth case management records found
signed documentation from the youth was included 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 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, 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. The procedure
requires all admitted youth to 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 program’s
classification form includes physical characteristics of the youth, age and maturity level,
identified special needs, history of violence, gang affiliation, criminal behavior, sexual
aggression or vulnerability to victimization, 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 assignment 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 identified during, or subsequent to, the classification process immediately had the
appropriate alert entered into the program’s internal alert system and JJIS. The five reviewed
youth records all 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. No youth at the program participate in off-campus activities. The program director 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.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
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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. There were no additional youth case management records of youth with gang
involvement to review.
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 were no additional youth case
management records of youth with gang involvement to review. The program has the Gang
Resistance and Drug Education (GRADE) packet to be used as the intervention tool if needed.
The program director interview indicated youth who wish to disaffiliate with a street gang will
have the opportunity to do so.
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 each youth’s case. Five
youth case management records were reviewed, and all had a RAY completed within thirty days
of admission. The initial assessments were all maintained in the youth case management
records, as well as in the Department’s Juvenile Justice Information System. Four of the five
youth were applicable for reassessments. One youth had not been in the program for ninety
days at of the time of the annual compliance review. All four applicable youth for reassessments
had all reassessments completed within ninety days from the time the last reassessment was
completed. All reassessments were maintained in the youth’s case management records.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
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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 a 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
being developed within thirty days of each youth’s admission. All performance plans were
developed following the 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 each Individualized Performance Plan, as indicated by their signature on the
plan. One of the five youth was under the care of the Department of Children and Families
(DCF), and the assigned caseworkers participated in the development of the performance plan.
One youth was over the age of eighteen, therefore, their parent/guardian did not participate 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 case
management record. All five reviewed youth records had a performance plan, which included
the individualized goals and were based upon the prioritized needs reflecting the risk and
protective factors identified during the initial assessment process, the youth’s three top
criminogenic needs, delinquency interventions based on RAY results, with measurable
outcomes which are intended to decrease the youth’s criminogenic risk factors, and promote
strengths and 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
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last sixty days of the youth’s stay, youth and program staff responsibilities to accomplish and
complete goals, and target dates for completion. All five reviewed youth case management
records contained a transmittal letter and confirmation a copy of the performance plan was sent
to the committing court and the JPO within ten days of completing the plan. Three of five youth
had a copy of their performance plan mailed to their parent/guardian within ten days of
completing the plan; one youth was over the age of eighteen, therefore, a copy of the plan was
not mailed to the parent/guardian, as they did not participate in the development of the plan.
The remaining youth had a copy of the performance plan mailed to the DCF caseworker 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, four were applicable and contained documentation showing the performance plans
were reviewed every thirty days during the youth’s formal treatment team review. One youth
was not applicable for revisions to the Individualized Performance Plan due to not being in the
program for ninety days or more. Three of the applicable records contained revisions due to
newly acquired/revealed information which warranted revisions; the remaining applicable record
did not have newly acquired information. All four applicable youth case management records
contained revisions which were a result of the youth demonstrating progress towards
completing a goal.
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 each 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 three of
five contained documentation confirming Performance Summaries are being completed within
the required time frame. One of five youth was not applicable due to not being in the program
for ninety days and the remaining youth had a Performance Summary completed and sent to all
required parties twelve days late. All Performance Summaries included the youth’s status on
performance plan goals, the youth’s overall treatment progress, the 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
five records indicated each youth was allowed to read and add comments to the Performance
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Summary prior to signing, and verified the 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
program director or designee, and the youth. A copy of the summaries were sent to the court,
the juvenile probation officer (JPO), and the parent/guardian within ten working days for three of
five youth. One youth who was under the age of eighteen and in the care of the Department of
Children and Family Services (DCF) had a copy of the summary sent to the DCF caseworker
within ten days. The remaining youth was not applicable due to not being in the program for
ninety days. Three closed youth case management 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, and were sent
with the 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 the youth’s case
management record. The court did not object to the youth’s release in any of the three closed
youth case management records reviewed. The program provided written notification to each
youth’s parent/guardian and completed a Residential Assessment for Youth after each PRN
was approved. Three closed youth case management records indicated the program provided
the JPO with the Sexually Violent Predator Program eligibility form/notification checklist which
was located in each of the records. This form and supporting documentation are required to be
sent 240 days prior to each youth’s anticipated date of release. All three closed youth case
management records were applicable for victim notifications, and all had a copy of the mailed
Victim Notification of Release letter to the victim at least ten days prior to the youth’s release.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a 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
were no treatment team meetings to be observed during the annual compliance review week.
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
program director 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. The
remaining youth was over the age of eighteen and did not involve their parent/guardian in their
case management.
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 each youth’s performance plan
references or incorporates their 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
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additional plans for each youth. Each youth has a separate treatment plan, such as medical,
mental health, and/or substance abuse. One of five youth was applicable and under the
supervision of the Department of Children and Families (DCF) and their case plans through
DCF were coordinated with youth’s performance plan.
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 procedure requires treatment teams to meet biweekly, 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 youth had formal reviews conducted at least every thirty
days. The documentation for formal treatment team meetings included the 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 each youth biweekly each month, alternating with the formal treatment team
meetings, which results in each youth having an informal or formal treatment team meeting
every two weeks. The informal treatment team meetings documented the 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. During
all formal and informal treatment team meetings each youth was provided an opportunity to
demonstrate skills acquired in the program. Each 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. Treatment team meetings were observed by
video review since they occurred the week prior to the annual compliance review for two youth.
All required staff were present for both observed meetings, 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 were
also asked if they were given an opportunity during treatment team meetings to demonstrate
any skills they have learned in the program, and all five said yes.
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
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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 each youth’s successful transition to the community upon release from the
program. Three closed youth case management 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 the youth,
treatment team leader, program director or designee, the youth’s juvenile probation officer
(JPO), the parent/guardian, and education staff. During the transition conference, the
participants reviewed the 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 had all attendees
sign and date indicating they attended. A copy of each 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.
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 the assembly of an exit portfolio for each
youth to assist them once released back into the community. Three closed youth case
management records were reviewed, and all contained an exit portfolio which had been
discussed and initiated for each youth during the transition conference. Each exit portfolio
contained a copy of the transition plan, a calendar with dates, times, and locations of upcoming
community appointments, and a copy of the youth’s Social Security card. Two of three case
management records also had the youth’s birth certificate; the remaining one was requested but
never received. One youth record contained a copy of the youth's state of Florida identification
card (ID), one record contained documentation of the ID card being requested, and one youth
record had no documentation of the request being sent due to the youth being over eighteen
years of age. Each exit portfolio also contained educational and vocational certificates,
educational records, a résumé, and sample completed employment applications. All exit
portfolios were verified during the youth’s exit conference, and the documentation indicated the
exit portfolio was completed and given to the youth upon release, with the exit portfolio
information forwarded to the juvenile probation officer.
2.17 Exit Conference Satisfactory Compliance
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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, in
addition to 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 case management
records were reviewed, and all had an exit conference which was conducted at least fourteen
days prior to the youth’s release, and each included documentation 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.
The youth’s date of admission and date of termination documented in each case management
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 the youth. Each 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 Speak Out forms, grievance forms, town hall meetings, and the youth advisory board to
allow youth to provide input. Youth advisory board meeting agendas, minutes, and notes, Speak
Out 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
or youth advisory board leader, using Speak Out forms, the grievance process, or talking to
staff. The program director was interviewed and advised youth input is obtained during the
monthly youth advisory board meetings, during daily housing meetings, surveys which are
completed by youth, and during 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 based on the age and
appropriateness for the educational abilities of youth in the program. The program provides type
three career education development. The interview with the lead educator indicated this
includes business entrepreneurship with certifications provided. An interview with the program
director indicated the program provides career education in entrepreneurship and business
ownership. Three closed youth case management records were reviewed. All three records
included a completed employment application, a résumé, and appropriate documents essential
to obtaining employment, along with documented appointments with a Career Source Center.
Documentation indicating the youth's parent/guardian and juvenile probation officer (JPO) were
aware of the vocational plan was present for each youth. Two of three youth case management
records reviewed did not have a State of Florida identification card (ID) and contained
documentation of requesting the ID from the parent/guardian; the remaining record did include a
state ID.
2.20 Educational Access (Critical) Satisfactory Compliance
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The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide educational access. The program provides
education services based on the approved 250-day school calendar. The education services are
distributed over twelve months and includes ten days for teacher training and planning. A review
of the daily school schedule revealed the program provided six fifty-three-minute class periods
with a thirty-minute lunch daily; this satisfies the Department’s weekly requirement of twenty-five
hours of instructional time. The interview with the lead educator indicated the school schedule is
adhered to. Five youth were interviewed and all reported there is little to no interruption to the
school day. A review of six randomly selected logbook entries, including three dates within the
last thirty days, showed the youth were attending school according to the daily bell schedule.
The video review of three days within the last thirty days verified the logbook entries to be
accurate, and in compliance with the program’s school schedule.
2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program maintains a policy and procedures requiring an Education Transition Plan to be
developed for each youth upon admission. Three closed youth case management records were
reviewed. Each youth record included the specified Education Transition Plan and an exit plan
indicating the case manager, parent/guardian, and youth were all aware of the plan. Each
record contained an Electronic Educational Exit Plan (EEEP), which identified the next
educational placement information and input from the post-release school district
representative. All five interviewed youth reported they were not sure they participated in the
development of their Education Transition Plan. All five youth reported the program was
preparing them very well or well to achieve their educational goals for the completion of high
school, high school equivalency diploma (GED), vocational school, college, and/or employment.
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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 requiring they have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA). The
program has a licensed mental health counselor (LMHC) who serves as the DMHCA and has a
clear and active license in the State of Florida, with an expiration date of March 31, 2025. The
program did not use any other DMHCAs during the annual compliance review period. The
DMHCA is a full-time staff of the program and is on-site at the program forty hours each week,
Monday through Friday. The DMHCA is also on call twenty-four hours a day, seven days a
week for clinical emergencies. The regional clinical director serves as the back-up DMHCA and
is also a LMHC with a clear and active license in the State of Florida, with an expiration date of
March 31, 2025. The DMHCA was interviewed, and said their role is to provide oversight of
mental health and substance abuse services to ensure these services are provided in
accordance with each youth's individualized mental health and substance abuse treatment plan.
The DMHCA also provides clinical supervision for unlicensed therapists. Clinical services
provided include crisis services, group, individual, and family therapy sessions. The DMHCA
communicates with the clinical team daily in person, electronically, and by telephone. Formal
staffing occurs during weekly clinical supervision meetings and the DMHCA has an open-door
policy to communicate with and support the clinical staff.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program’s contract does not require any other licensed clinical staff other than the individual
serving as the designated mental health clinician authority (DMHCA). The licensed mental
health and substance abuse clinical staffing is in accordance with the current contract. Copies of
the DMHCA’s license and the Chapter 397 license were available on-site.
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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 which require mental health and substance abuse
services be provided by individuals with appropriate qualifications. The designated mental
health clinician authority (DMHCA) must ensure clinical staff working under their supervision are
performing services the staff are qualified to provide based on education, training, and
experience. An informal interview with the DMHCA confirmed these procedures were being
followed. Documentation was reviewed which verified each non-licensed mental health clinical
staff working under the direct supervision of the DMHCA received a minimum of one hour a
week of on-site, face-to-face direct supervision, by a licensed mental health professional, for the
purpose of overseeing and directing the mental health services provided in the program during
the annual compliance review period. This direct supervision was documented on the
Department’s Licensed Mental Health Professionals and Licensed/Certified Substance Abuse
Professionals Direct Supervision Log form. The program has an active and valid Chapter 397
license, which expires on March 24, 2024. This license is posted in the administrative hallway,
and the large group room. The program employs a recreational therapist, which is required by
contract. The recreational therapist has the required education and experience and provides all
the required recreational activities to each youth. The program has three non-licensed therapist
positions. One of the non-licensed therapist positions has been vacant since May 2023. This
has not affected delivery of services, as the clinical supervisor and two non-licensed therapists
each have a caseload of less than ten youth, as required by contract. A review of credentials for
the non-licensed therapists verified they both hold a master’s-level degree from an accredited
university or college in the field of counseling. The non-licensed substance abuse clinical staff
provide substance abuse services in the program, which is licensed under Chapter 397, working
under the direct supervision of a qualified professional. Both non-licensed clinical staff
conducted Assessments of Suicide Risk (ASRs), and have completed twenty hours of training
and supervised experience in assessing suicide risk, mental health crisis intervention, and
emergency mental health services. The training included administration of five ASRs conducted
on-site in the physical presence of a licensed mental health professional. This training was
documented on the Department’s Non-Licensed Mental Health Clinical Staff Person’s Training
in Assessment of Suicide Risk form.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a policy and procedures to ensure the mental health and substance abuse
needs of youth are identified through a comprehensive screening process requiring referrals to
be made when youth have identified mental health and/or substance abuse needs or are
identified as a possible suicide risk. The program screens all youth upon intake by administering
the Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) in the Department’s
Juvenile Justice Information System (JJIS). Five youth mental health records were reviewed,
and all had a MAYSI-2 completed in full. The MAYSI-2 results for all five youth indicated further
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assessment was required, and referrals were made for further evaluation for all five youth. The
program’s practice is to conduct further evaluation on each youth admitted regardless of the
MAYSI-2 results. The program ensures an Assessment of Suicide Risk (ASR), and a
comprehensive mental health and substance abuse evaluation are conducted on all youth. The
program director (PD) developed written facility operating procedures for the implementation of
a standardized admission/intake mental health and substance abuse screening process. The
policy addresses the standardized screening process which includes review of commitment
packet information, reports and records, administration of the MAYSI-2 in JJIS, staff training in
mental health and substance abuse issues, and a standardized process for referral of youth
identified as in need of further mental health and/or substance abuse evaluation to a proper
professional or, when immediate attention is needed, to a hospital or Baker Act or Marchman
Act receiving facility. The policy was approved by the PD on January 10, 2023, the regional
clinical director on January 5, 2023, and the designated mental health clinician authority on
February 13, 2023. The PD was interviewed and confirmed the program uses comprehensive
evaluations, MASYI-2s, and ASRs to identify youth at risk for mental health and substance
abuse problems and suicide.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a policy and procedures which require they conduct comprehensive mental
health and substance abuse evaluations on all youth admitted to the program. Five youth
records were reviewed, and all received a mental health and substance abuse evaluation upon
admission. The five youth received an in-depth assessment within thirty days of admission. All
five assessments contained identifying information of the youth, reason for evaluation, relevant
background information, behavioral observations, Mental Status Examination, interview or
procedures administered, discussion of findings, diagnostic impression, and recommendations.
All five records had signed consents for substance abuse treatment. Four of five mental health
and substance abuse assessments were completed by a non-licensed clinical staff, and each
was reviewed and signed by a licensed mental health professional within ten calendar days; the
remaining assessment was completed by a licensed mental health professional.
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 in place requiring an Initial or Individualized Mental
Health or Substance Abuse Treatment Plan (ITP) for youth determined to have a serious mental
disorder or substance abuse impairment and are receiving mental health or substance abuse
treatment in a program. Five youth mental health and substance abuse records were reviewed,
and all had an initial ITP developed within seven days of initiation of treatment. The initial ITP
was documented on a program form which included all required elements. The initial ITP was
signed by the mental health clinical, or substance abuse clinical staff completing the form. Four
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of five initial ITPs were signed by all members of the treatment team who participated in the
development of the plan, except for the parent/guardian who participated on the telephone, and
this was noted on the initial ITP. The remaining youth was eighteen years of age and did not
have the parent/guardian participate. Four of five ITPs were completed by a non-licensed
mental health clinical staff, and each was signed by the licensed clinical supervisor within ten
days of completion; the remaining initial ITP was completed by the licensed clinical supervisor.
Three of five initial ITPs included the youth’s psychiatric needs, including medication and
frequency of monitoring by the psychiatrist; the remaining two were not applicable. All five youth
had ITPs developed within thirty days of admission. The ITPs were developed on a form which
contained all required elements. All ITPs were signed by the mental health or substance abuse
clinical staff completing the plan. A comparison of video to the logbooks and sign-in sheets was
conducted, which verified groups were conducted as required, to include time and length of
each group.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program has a policy and procedures which govern treatment and discharge planning.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans. The policy
also requires, for all youth who received mental health and substance abuse treatment while in
a program, to have a discharge summary completed documenting the focus and course of the
youth's treatment and recommendations for mental health and substance abuse services upon
each youth's release from the program. Five youth records were reviewed, and all youth were
assigned to a treatment team upon arrival to the program. Each treatment team was comprised
of the youth, program administration, residential living unit staff, education staff, medical staff,
mental health and substance abuse staff, and the parent/guardian, if applicable. Three closed
youth records were reviewed for discharge plans. All three closed records contained the
Department’s Mental Health and Substance Abuse Treatment Discharge Summary form, and
each received individual, group, and family counseling; which was provided by a licensed
professional or a non-licensed substance abuse clinical staff, who is a staff of a service provider
licensed under Chapter 397, and who works under the direct supervision of a qualified
professional as defined in Florida Administrative Code, in accordance with the youth’s Initial or
Individualized Substance Abuse Treatment Plan. One of the three youth had a properly
executed Authority for Evaluation and Treatment form; the remaining two youth were over
eighteen years of age and did not require one. All three youth provided consent through a
signed Youth Consent for Substance Abuse Treatment form. All treatment notes were
documented on a form which contains all required information. All three closed youth records
documented the mental health and substance abuse group therapy included individual
psychotherapy or counseling, psychosocial skills training, and progress notes showing each
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youth received services as stipulated on the treatment plan. Each closed record had a
discharge plan documented on the Department’s Mental Health/Substance Abuse
Treatment Discharge Summary form. None of the youth reviewed were released while on
suicide alert/precautions. The Treatment Discharge Summary documented the services needed
for daily maintenance of the positive improvement in behavioral, emotional, and social skills
made by the youth during treatment for all three youth. Each closed youth record contained
documentation which reflected the discharge plan was discussed with the youth,
parent/guardian, if applicable, and the juvenile probation officer (JPO) during the exit
conference. Documentation in each closed record confirmed a copy of the discharge summary
was provided to each youth, JPO, and parent/guardian, if applicable.
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 has a policy and procedures which require specialized treatment services to be
provided to youth. The policy was approved by the program director on January 10, 2023, the
regional clinical director on January 5, 2023, and the designated mental health clinician
authority (DMHCA) on February 13, 2023.The program’s required clinical groups according to
the contract are Pathways: A Guided Workbook for Youth Beginning Treatment and Footprints:
Steps to a Healthy Life (supplemental as needed). Aggression Replacement Therapy, Cannabis
Youth Treatment, and Sexual Education/Healthy Relationships and Health Boundaries were
discontinued by an approved Request to Change Services document signed by the Department
on October 11, 2023. Five youth were interviewed, and all said they participate in individual
counseling once a week. Four youth said they participate in family counseling. One youth said
family counseling is weekly, one youth said family counseling is monthly, two youth said family
counseling is every two weeks, and the remaining youth did not participate in family counseling
because he is over the age of eighteen. Five staff were interviewed, three staff said they do not
facilitate mental health or substance abuse groups; the remaining two staff, who are therapists,
said yes. The DMHCA was interviewed and advised the program provides group, individual, and
family therapy services to youth and their families. The DMHCA meets with the psychiatrist
every two weeks to discuss youth receiving psychiatric services. The program provides sex
offender services to youth, which includes sex offender and mental health and substance abuse
evaluations, sex offender treatment planning and therapy, crisis interventions, and therapeutic
activities, to include skill training and relapse prevention. Staffing at the program consists of a
full-time juvenile sex offender therapist on-site five days a week, forty hours a week; a licensed
psychiatrist to provide psychiatric evaluation and medication management and participate in
treatment planning; and three counselors ensure the caseloads are limited to a staff to youth
ratio of one to ten. One of three non-licensed therapist positions has been vacant since May
2023; however, this has not affected delivery of services, as the clinical supervisor and two non-
licensed therapists each have a caseload of less than ten youth, as required by contract. The
DMHCA provided documentation which verified the qualifications of being a juvenile sex
offender therapist, based on having completed the required continuing education course. This
documentation was submitted to the Department’s Office of Health Services, who confirmed the
qualifications.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
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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 governing psychiatric services. The psychiatric services include
psychiatric evaluation, psychiatric consultation, medication management, and medical
supportive counseling provided to youth with a diagnosed mental disorder and each youth
receiving psychotropic medication in the program. The policy was approved by the program
director, designated mental health clinician authority (DMHCA), and psychiatrist on March 31,
2023. The program employs a psychiatrist through an independent contractor agreement. The
psychiatrist is scheduled to be on-site every two weeks, for a minimum of two hours, and on call
for emergencies during the evening and on weekends and holidays. The psychiatrist has a clear
and active license which expires on January 31, 2025. The psychiatrist briefs a representative of
the treatment team regarding the psychiatric status of each youth receiving psychiatric services
who is scheduled for a treatment team review. The psychiatrist’s evaluation and
recommendations for each youth are also incorporated into the mental health clinical staff’s
evaluations of the youth and the youth’s Individualized Mental Health or Substance Abuse
Treatment Plan. The program does not use a psychiatric advanced practice registered nurse. A
review was conducted of the sign-in/out logs for the psychiatrist’s biweekly visits, which
confirmed the psychiatrist was at the program as required by the agreement with the program
and the contract with the Department. A review of five youth records confirmed the psychiatrist
actively participates in the managing and supervision of psychotropic medications at the
program, when applicable. The program does not conduct tele-psychiatry, and it is not included
in the contract. The psychiatrist was interviewed and advised he meets with the DMHCA every
two weeks to discuss youth regarding psychiatric services. The DMHCA was interviewed and
confirmed they meet with the psychiatrist every two weeks and more frequently, if necessary, to
discuss youth regarding psychiatric services. Three of five youth entered the program on
psychotropic medication. The program conducts a diagnostic interview for all youth within
fourteen days of admission. The Initial Diagnostic Psychiatric Interviews include history of the
youth, Mental Status Examination, diagnoses and ensuring each diagnosis is consistent with the
treatment plan, treatment recommendations, prescribed medications, explanation of the need
for psychotropic medication, target symptoms, initial treatment goals, potential side effects, risks
and benefits of taking the medication, and frequency of medication monitoring. The initial
psychiatric evaluations were completed on a form developed by the program which contains all
required elements of the Department’s Clinical Psychotropic Progress Note (CPPN). The form
was clearly identified as an initial psychiatric interview. The three applicable youth records for
medication confirmed each youth received the prescribed psychotropic medications and
included documentation of face-to-face medication monitoring reviews being conducted every
thirty days. The psychiatric evaluations were documented on a form developed by the program
which contained all the required elements within the CPPN. The reviews were completed,
signed, and dated by the psychiatrist; and included identifying youth information, diagnosis,
target symptoms of each medication, evaluation, description of effects of prescribed medication
on target symptoms, the name, dosage, and quantity of the medication, side effects, youth’s
adherence to the medication regimen, height, weight, blood pressure, and most recent serum
drug levels or laboratory findings. The three youth records with prescribed psychotropic
medications each required monthly monitoring of Tardive Dyskinesia; and reviewed
documentation supported the monitoring was conducted monthly.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
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The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a policy and procedures requiring they follow a Suicide Prevention Plan to
safely assess and protect youth with elevated risk of suicide in the least restrictive means
possible. This written plan includes identification and assessment of youth at risk of suicide,
staff training, suicide precautions, levels of supervision, referrals, communication, notification,
documentation, immediate staff response, and a review process. The review process for suicide
attempts and mortality reviews includes circumstances surrounding the event, 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. The Suicide Prevention Plan was last reviewed by the program director and
the designated mental health clinician authority 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 govern suicide prevention services. This policy
defines suicide precautions as methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. It further requires for any youth exhibiting suicide risk behaviors to be
placed on suicide precautions, either precautionary observation or secure observation, and a
minimum of constant supervision. The policy was approved by the program director (PD) and
designated mental health clinician authority (DMHCA) on February 13, 2023. Any 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 (ASR). A review of five youth mental health and substance abuse records was
conducted, and only two were applicable for having been determined to be at risk. The program
advised no other youth at the program were determined to be at risk and required suicide
prevention services during the annual compliance review period. The two applicable youth were
determined to be at risk during the admission screening process. Each applicable youth was
placed on precautionary observation and had an ASR completed on the same day. Each
applicable youth was placed on constant one-to-one supervision; and each ASR contained
documentation showing the youth’s parent/guardian was notified of the potential suicide risk.
Mental health staff provided supportive services and completed a Follow-Up ASR prior to
removing each applicable youth from precautionary observation. Each Follow-Up ASR was
documented on the Department’s Follow-Up Assessment of Suicide Risk form; and each
applicable youth was maintained on constant one-to-one supervision until a follow-up ASR
indicated suicide precautions could be discontinued and the youth could be stepped down to
close supervision prior to transition to standard supervision. Youth remained on close
supervision until it was determined no longer necessary by the DMHCA, or licensed mental
health professional. Discontinuation of close supervision was documented in each youth record
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by clinical staff. Both records contained documentation of a conference held by the PD and
DMHCA to reduce the level of supervision, and this was documented in accordance with the
program’s Suicide Prevention Plan. A suicide alert was initiated in the Department’s Juvenile
Justice Information System (JJIS) for each occurrence. The JJIS suicide risk alert was properly
closed by clinical staff, based on the recommendation of the ASR. The program’s logbooks
were reviewed and revealed appropriate documentation indicating administration or supervisory
staff provided instructions related to the suicide risk assessment findings and suicide precaution
decisions. Youth who were placed on precautionary observation were allowed to participate in
select activities with other youth. The ASRs were completed within twenty-four hours of
screening by a licensed staff or appropriately trained non-licensed staff. Both ASRs showed the
discontinuation of precautions were documented by non-licensed staff and both were reviewed
and signed by licensed staff. The PD documented the discontinuation of supervision in the
logbook. A review of video footage while each youth was placed on precautionary observation
was unable to be completed due to video footage being maintained a maximum of thirty days;
however, all documentation verified appropriate supervision was maintained. Five staff were
interviewed, and all were able recite the steps to take if a youth expresses suicidal thoughts,
which included notifying mental health, searching the youth for sharp objects, placing the youth
in a locked room, documenting supervision, and notifying the shift supervisor.
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’s Suicide Prevention Plan requires staff to maintain one-to-one or constant
supervision of youth placed on suicide precautions. Five youth mental health and substance
abuse records were reviewed, and two were applicable for youth who were placed on
precautionary observation (PO). The program had no other youth placed on PO since the last
annual compliance review. The two applicable youth records contained the Suicide Precaution
Observation Log form which documented the appropriate level of supervision and observations
of the youth’s behavior in real time, not exceeding thirty-minute intervals. The observed warning
signs were communicated to the program director and mental health clinical staff and
documented on the Suicide Precaution Observation Log. Suicide Precaution Observation Logs
were reviewed and signed by each shift supervisor and mental health clinical staff and had
documented safe housing requirements.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a policy and procedures addressing suicide prevention training for staff. A
review of five pre-service and five in-service training records was conducted and confirmed
each staff completed the required training for suicide prevention, which consists of two hours of
suicide prevention training in the Department’s Learning Management System (SkillPro) and
four hours of instructor-led training. The program has one suicide response kit which is stored in
master control. The suicide response kit is co-located with one of the first-aid kits. A review was
conducted of the program’s mock suicide drills which confirmed the program exceeded the
required quarterly drill on each shift. All mock mental health drills in response to a suicide
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attempt and/or incident of serious self-injury were simulated. The program provides semi-annual
training on emergency response procedures which include mock training in emergency
response to a suicide attempt or incident of serious self-inflicted injury and include the use of
cardiopulmonary resuscitation (CPR), suicide response kits, or an automated external
defibrillator (AED). A review of training records confirmed each staff participated in at least one
drill which included the use and demonstration of CPR, to include the AED annually. Staff who
were not present during a quarterly drill can review each drill scenario and procedures in an
effort to understand the process and receive the necessary training to respond to an incident of
a suicide attempt or serious self-inflicted injury. The program director was interviewed and
advised suicide prevention training is provided to all staff monthly. Five staff were interviewed
and all said the knife-for-life was kept in master control. One of five staff said an additional one
was kept in medical. Four staff said medical and suicide drills are conducted monthly, and the
remaining staff said they are conducted weekly.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a policy and procedures which require a response 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 must be able to differentiate a youth who has an
acute emotional problem or serious psychological distress from one who requires emergency
services. The program has a written crisis intervention plan which includes notifications and an
alert system, means of referral, youth self-referral, communication, supervision, documentation,
and review. The crisis intervention plan was reviewed and approved by the program director
and the designated mental health clinician authority on February 13, 2023.
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.
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The program has a policy and procedures governing Crisis Assessments which was reviewed
and approved by the program director and the designated mental health clinician authority on
May 15, 2023. The program has not had any Crisis Assessments during the annual compliance
review period.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a policy and procedures requiring emergency care for youth determined to be
an imminent danger to themselves or others due to mental health or substance abuse
emergencies occurring in the program. The program has a written emergency mental health and
substance abuse plan which was reviewed and approved by the program director and the
designated mental health clinician authority on May 15, 2023. This plan includes immediate staff
response, notifications, communication, supervision, authorization to transport for emergency
mental health or substance abuse services, transport for emergency mental health evaluation
and treatment under Florida Administrative Code, transport for emergency substance abuse
assessment and treatment under Florida Administrative Code, 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 a policy and procedures requiring an on-going safety planning process for
each youth. The safety plan shall be designed to identify stimuli which have both positive and
negative effects on the youth. Five youth mental health and substance abuse records were
reviewed, and all contained safety plans. All five safety plans included warning signs, youth
baseline behavior, crisis recognition, jointly developed coping strategies, intervention strategies
preferred by the youth, and a debriefing process. Each safety plan was completed within
fourteen days of admission, and was jointly created by the youth, parent/guardian, clinical staff,
and case manager. The five reviewed safety plans incorporated recommendations from
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previous and current clinical assessments and were updated every thirty days after the creation
of the initial safety plan. All youth safety plans are maintained in a centralized binder in the
administration break room. Five youth were interviewed, and all said they contribute to their
safety plan. Five staff were interviewed; three staff said safety plans are in the administrative
building, one staff said they are in the briefing room, and the remaining staff said they are in
master control. Two staff said they review safety plans as needed, one staff said the therapist
completes the plans monthly, one staff said they are reviewed at the start of shift, and the
remaining staff did not know. The program director was advised of the results, and as a result
the program will review this information with all staff. Two staff said they review safety plans
monthly, one staff said they last reviewed them a few months ago, one staff said yesterday, and
the remaining said today. The program director was interviewed and advised youth safety plans
are updated monthly, and more frequently as needed.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program’s designated health authority (DHA) is a licensed physician who holds an
unrestricted license, meeting all requirements for independent and unsupervised practice in
Florida. The DHA license expires on March 31, 2024. The DHA’s specialty training is in internal
medicine with experience in adolescent health. The DHA does not have any disciplinary cases
or public health complaints on record. According to the contract, the DHA is required to be on-
site a minimum of two hours a week. A review of the sign-in sheets for the annual compliance
review period indicated the DHA was on-site, as required. If the DHA has a scheduled absence,
the program has an agreement with another licensed physician to provide medical care to the
youth. The DHA does not use an advanced practice registered nurse and has not needed to
utilize the back-up DHA during the annual compliance review period. The back-up licensed
physician holds a clear and active unrestricted license, which expires on January 31, 2024, and
meets all requirements for independent and unsupervised practice in the State of Florida. There
was no inclusion of telemedicine in the program’s contract. The interviewed DHA confirmed
responsibilities included conducting Comprehensive Physical Assessments, periodic
evaluations, sick call if needed, continuity of care for youth with chronic conditions every ninety
days or sooner if needed, being on call twenty-four hours, seven days a week, and policy and
procedure development. The DHA attested to being on-site two hours minimum every week,
meeting with staff to review all forms located in the youth records, as well as by telephone if not
on-site, and meeting with youth when on-site.
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 one full-time registered nurse (RN), one part-time RN, and utilizes one RN
from another program to cover required hours. One RN serves as the health services
administrator (HSA). Reviewed license credentials reflected each RN has a clear and active
license in the State of Florida. Two of three licenses are valid through April 30, 2024, and the
remaining one is valid through April 30, 2025. In addition, reviewed documentation confirmed
each of the RNs have current cardiopulmonary resuscitation (CPR) certifications. The required
on-site hours according to the contract are forty hours for the HSA and sixty hours for the two
RNs, for a total of 120 hours through August 24, 2023. The contract was amended on August
24, 2023, for forty hours for the HSA and sixty hours for one-and one-half RNs, for a total of 100
hours. There is one vacancy; however, the nursing staff are in compliance with the contractual
requirements with the RN covering from another program. The program has placed
advertisements for the vacancy and should be completing interviews soon.
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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 protocols utilized at the program.
The designated health authority (DHA), program director (PD), and psychiatrist signed and
dated all treatment policies and protocols on January 11, 2023. The nursing protocols were
signed by all nursing staff this year. Two policies received changes during the annual
compliance review period and were signed by all required parties on March 2, 2023, and June
30, 2023. An annual review of all policies and procedures were signed by the respective
individuals from each discipline on July 18, 2023, signifying their understanding of any new
health-related Department policies. All newly hired medical staff receive a comprehensive
clinical orientation to the Department’s healthcare policies and procedures conducted by the
registered nurse (RN). The DHA wrote and authorized approval of treatment protocols and
standing procedures which were not delegated to any other person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
Five reviewed youth Individual Healthcare Records (IHCRs) were applicable for the Authority for
Evaluation and Treatment (AET) forms at admission. Each IHCR contained a signed AET form
by all required parties with the word “Copy” legibly stamped on it. Each AET is valid for as long
as the youth is in the program or until the youth’s eighteenth birthday. One youth turned
eighteen while at the program and signed a release of information form. One of five youth was
in the care of the Department of Children and Families, and a court order was located in the
IHCR. An interview with the registered nurse (RN) confirmed if the youth’s AET is not
documented in the Department’s Juvenile Justice Information System (JJIS), within the
Electronic Commitment Packet, the youth’s juvenile probation officer (JPO) would be contacted
to obtain a new or current AET.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for parental/guardian
notification or consent. Two IHCRs were applicable for parental/guardian notifications for over-
the-counter (OTC) medications beyond those covered by the Authority for Evaluation and
Treatment (AET). Both records contained the notification. The remaining three youth did not
require OTC medications beyond those covered by the AET. Three of five applicable IHCRs
included documentation of attempted contact to the parent/guardian in the progress notes when
a new medication was ordered. All five IHCRs contained written notifications documented on the
Department’s Parental Notification of Health-Related Care: General or Parental Notification of
Health-Related Care: Medications forms; however, two were notifications to update on progress
and medications were still not prescribed. Three of five youth were taking prescribed
psychotropic medications and documentation noted staff witnessed all telephone call
conversations or attempts; the remaining two youth were not applicable. Three of five youth
were applicable for a new psychotropic medication, change in dosage, or discontinuation of
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medication which was documented on page three of the Department’s Clinical Psychotropic
Progress Note (CPPN) form. One of five youth were in the care of the Department of Children
and Families (DCF). All five IHCRs contained documentation each youth’s vaccinations were
verified within thirty days of admission. None of the youth needed vaccinations while in the
program. An interview with the registered nurse (RN) confirmed parental/guardian notifications
are completed when new medication is prescribed, health related care, chronic, mental health,
or physical health conditions, medical complaints three or more times during a two-week period,
a youth is taken off-site for healthcare except when statutorily protected from disclosure to the
parent/guardian, and when youth are taken off-site. Telephone communications are attempted,
as well as mailed notification, to the parent/guardian are completed when necessary and is
noted in the progress notes. When any youth’s illness or injury requires emergency medical
services or is life threatening the designated health authority is contacted for orders, which are
relayed to the program director, shift supervisor, parent/guardian, and the Department’s Central
Communications Center, if required. Every effort shall be made to contact the parent/guardian
of youth under the age of eighteen years of age prior to the initiating of the new psychotropic
medication. This notification must be mailed. Notification for discontinuing or making medication
adjustments may be made by mail. The program is not allowed to start or stop a medication
without parental/guardian consent. Vaccination records are obtained either through the
commitment packet or the Florida Department of Health website, which is reviewed prior to or
the day of admission, when the nurse is required to meet with the youth for screenings. An
appointment is made at the county health department if a youth needs any required
vaccinations.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for a Facility Entry Physical
Health Screening (FEPHS) form. All five FEPHS forms were completed by the registered nurse
(RN) on the date of the youth’s admission. One youth was applicable for being out of the
physical custody of the Department. The RN completed a new FEPHS rescreening when the
youth returned. The interview with the RN confirmed nursing staff receives email notification the
day before a youth is admitted and completes screening during admission. The nurse usually
completes the screening; however, if direct care staff complete the admission screening, a
nursing staff will document a review on the screening form. A health care admission rescreening
will be completed each time the physical custody of the youth changes and subsequently
returns.
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.
A review of five youth Individual Healthcare Records (IHCRs) confirmed all youth were provided
a general care orientation upon admission to the program. The covered topics included access
to medical care, sick call, what constitutes an “emergency,” medication process, right to refuse
care, what to do in the case of a sexual assault or attempted sexual assault, the role of non-
disciplinary healthcare providers, and standard universal precautions, as evidenced by each
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youth’s signature documented on the Health Education form in the IHCR. The program also
utilizes an education binder to ensure all required orientation topics are reviewed.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to notify the designated health authority (DHA) or
designee, by telephone or verbally, of each youth’s arrival at the program and provide
immediate notification when any youth admitted to the program requires emergency care. The
program’s practice is to notify the DHA of all youth admissions including youth with chronic
conditions, medical concerns, or any youth admitted on psychotropic medications. Five youth
Individual Healthcare Records (IHCRs) were reviewed, and two of five youth were admitted with
a known or suspected chronic condition or required a referral to the DHA. One additional IHCR
for a youth with a chronic condition was reviewed. Each IHCR had documentation the DHA was
notified within twelve hours of admission. None of the youth were identified as in need of an
emergency response upon admission. All records documented the DHA notification in the
youth’s Chronological Progress Notes and the Chronic Conditions Log was updated after each
notification. Two youth were applicable for taking psychotropic medication upon admission and
the records documented notification to the psychiatrist. An interview with the registered nurse
(RN) confirmed the DHA is notified by medical staff on the day of admission and it is
documented on the program’s admission progress note.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
A review of five youth Individual Healthcare Records (IHCRs) found all had a Health-Related
History (HRH) form completed on the day of the admission. Each IHCR indicated the HRH form
was completed prior to the Comprehensive Physical Assessment (CPA) evidenced by the
signatures and date. All five IHCRs documented the designated health authority (DHA)
reviewed the HRH form as evidenced by a checkbox on the CPA and a focused note in the
admission documentation. An interview with the registered nurse (RN) confirmed medical
completes the HRH form on the day of admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
Five reviewed Individual Healthcare Records (IHCRs) confirmed the program utilized the
Department’s Comprehensive Physical Assessment (CPA) form. All CPAs were completed by
the designated health authority (DHA) within seven days of the youth’s admission to the
program. All seven CPAs documented the youth’s Medical Grade. The program completes a
new CPA for all youth, no prior CPAs were utilized. All sections of the CPAs were completed in
full utilizing required markings. All five youth refused part of the exam which was documented
on each CPA as well as the refusal form. The Department’s Problem List was updated for each
youth, when applicable. Each CPA included documentation of the most recent verified
Tuberculosis Skin Test (TST) which was administered within the last year. The results of the
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TST were documented on each youth’s CPA and matched the documentation on the
Department’s Infectious and Communicable Disease (ICD) forms. An interview with the
registered nurse (RN) relayed a CPA is completed within seven days of admission by the DHA
and completed every year thereafter. A TST not completed within the last year is administered
within seventy-two hours of admission and documented in the youth's IHCR.
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.
A review of five Individual Healthcare Records (IHCRs) found all youth were clinically screened
and evaluated for sexually transmitted infections (STIs) on the date of admission. All five of the
IHCRs were applicable for further evaluation, were referred to the designated health authority
(DHA), and were all documented on the Department’s Sexually Transmitted Infections form. The
DHA determines, based on the youth’s risk factors, screening tool, and evaluation, whether to
order testing for STIs. All testing, screening, clinical evaluations, and diagnoses were
documented on the Department’s Infectious and Communicable Diseases (ICD) forms,
excluding the human immunodeficiency virus (HIV) results, and were filed in the lab section of
the IHCR. None of the youth were referred for further testing and none were out of the
Department’s physical custody; therefore, a rescreening was not applicable. All five youth were
offered pre/post-test counseling, testing, and referral for treatment for HIV, and each refused the
testing. The program’s policy ensures a youth’s HIV test results are only disclosed to the youth,
the youth’s legally authorized representative, healthcare providers during treatment, the
Department of Health for purposes of reporting, health facility staff committees conducting
program monitoring, medical personnel who have been subject to significant exposure, and
healthcare facility personnel or agents for healthcare providers who have a need to know during
patient care. Pre and post-test counseling services are provided by the DHA. Five interviewed
youth stated they can request testing for HIV. The registered nurse (RN) was interviewed and
reported youth are screened for STIs utilizing the ICD form. The nurse will notify the DHA when
further evaluation is needed. Rescreening is required when a youth returns to the program and
when the physical custody of a youth changes. Youth can request HIV counseling and testing
services and HIV test results are sealed in the youth's IHCR. The DHA conducts the HIV pre-
counseling, testing, and post-counseling and the process is documented in the education record
and on the ICD form.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for the program’s sick call
process. None of the youth presented with a similar sick call complaint three or more times
within a two-week period. All five IHCRs documented a Sick Call Request form was completed
by the youth and by the registered nurse (RN). None of the youth were in restricted housing of
any kind. Each Sick Call Request form and progress notes were documented as required,
including vital signs, treatment, education, and follow-up plans. Each sick call event was
documented on the Sick Call Index and on the program’s Sick Call Referral Log. All the dates
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listed on the Sick Call Index corresponded to the completed Sick Call Request forms located in
the youth IHCRs. Sick call occurs twice a day, seven days a week, and hours are posted
throughout the facility with the daily activity schedule. Sick call hours are posted on the medical
office door and in the dormitory. Sick call forms are located on the dormitory, in the education
area, and the common room. A nurse conducts all sick calls; however, the program does have
procedures for a shift supervisor to review sick calls if a licensed nurse is not on-site. An exam
table and equipment are used to perform sick call. Five interviewed staff advised the nurse
reviews and conducts sick call; and three staff mentioned the supervisor can as well if needed.
Five interviewed youth stated they are usually seen within a day of making a sick call request.
The interviewed RN relayed the process for requesting to see medical for health complaints is
by completing and submitting a sick call request, which is provided to the nurse within two
hours. The RN conducts all sick calls, unless the DHA is on-site, in the clinic. A youth is referred
to the DHA if they present with similar complaints in a short time frame or is not progressing with
the recommended treatment. Treatment protocols have been approved by the DHA. A youth is
assessed twice a day if in restricted housing and/or confinement. During the annual compliance
review week, a sick call was observed when a youth requested to be seen by medical staff.
Observations validated the program’s practice when conducting a sick call request. Direct care
staff were observed escorting the youth to the medical office. The direct care staff positioned
themselves outside the doorway in order to maintain youth confidentiality. The RN facilitated the
sick call, after identifying themselves, examining the youth in a private area with no other youth
present in the room.
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.
A review of five youth Individual Healthcare Records (IHCRs) found three youth required on-site
episodic care. On-site care was provided by a licensed healthcare staff and documented in the
problem-oriented charting for each youth. The programs episodic and emergency care
procedures were reviewed. There is a total of eight first-aid kits located in designated areas
throughout the program and one kit used for transportation. The kits are in the administration
kitchen, master control, case management, dormitory kitchen, administration, education,
maintenance, and medical. One additional first-aid kit is reserved for the program’s vehicle. The
program has a process for ensuring contents of the first-aid kits are maintained and stored in
accordance with guidelines to prevent expiration or deterioration. An observation of three first-
aid kits confirmed the kits were fully stocked with designated health authority (DHA) approved
contents. The nurse monitors the first-aid kits monthly and checks for expired contents, which is
documented on the first-aid kit logs. The program has two automated external defibrillators
(AEDs) located in master control and the administration kitchen. The AED procedures are
located with the AEDs. The AED batteries and pads are checked by the registered nurse (RN)
once a month. Documentation confirmed the RN monitored the AEDs as required. The nurse
conducted a self-test of the AEDs in front of the regional monitor with no issues noted. The
batteries of the AEDs were last changed in February and April 2023 and expire in February and
April 2027. The AED pads were changed in February and May 2023 and expire in March and
June 2025.
A review of the emergency drills confirmed the program conducted an emergency drill to include
cardiopulmonary resuscitation (CPR)/AED annually. The emergency medical drills simulated an
episodic care event which called for immediate first-aid, and/or administration of CPR
techniques, and the initiation of emergency procedures to follow when a life-threatening
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emergency does occur. Direct care staff have the opportunity to participate in at least one
emergency “man down” drill annually. Unannounced and announced emergency drills are
conducted at least quarterly on each shift. The program had a list of emergency numbers which
were inaccessible to youth. The emergency numbers are posted in medical and master control.
A review of ten training records confirmed all staff were trained in episodic, first-aid, and
emergency care, and the administration of the epinephrine auto-injector. An episodic care event
was observed during the annual compliance review week. The staff was not present during the
exam.
The program has a policy and procedures regarding Naloxone Nasal Spray (NARCAN), which is
a prescription strength medicine for the emergency treatment of a known or suspected opioid
overdose emergency with signs of breathing problems and severe sleepiness or not being able
to respond. The program maintains at least one prescribed stock NARCAN for emergency
purposes of accidental overdose. NARCAN should not be ordered for each individual youth,
must be maintained in a designated area, and locked at all times, but still accessible to both
nurses and supervisory staff trained to assist in the delivery of medications when the emergency
arises. A perpetual/daily inventory of medication utilization must be maintained. Shift
supervisors may administer NARCAN. Nursing staff and supervisory staff shall be trained on
administration of NARCAN. The youth must go out by emergency medical service (EMS) if there
is use of NARCAN. At the discretion of the designated health authority (DHA), NARCAN may be
signed out from the medication cart during transport. NARCAN is stored in the staff locker room,
master control, emergency box, medication cart, and medication overstock. Medical staff,
administration, and supervisors have access to the NARCAN in the medication cart, overstock,
and emergency box. NARCAN is stored in a breakable box in both master control and the staff
locker room. All staff are trained on the use of NARCAN. Five interviewed staff confirmed they
are able to call EMS. All five interviewed youth reported they can see a doctor or dentist if
needed. The interviewed RN was able to relay the locations and inventories, with expiration
dates, of the first-aid kits and two AEDs. The nurse explained the process for documenting on-
site episodic care on the episodic care log. The nurse tracks off-site emergency care episodes
through the episodic log as well as an outlook calendar. Emergency drills are completed
monthly for each shift, which include CPR procedures at least quarterly.
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.
A review of five Individual Healthcare Records (IHCRs) found two were applicable for off-site
care. An additional IHCR was reviewed. Each of the three applicable IHCRs indicated the youth
required off-site first-aid or emergency care. The Department’s Summary of Off-Site Care
Consultation Report form was utilized and the off-site care was documented on the appropriate
log. All three IHCRs had documentation of the parent/guardian notification efforts. Each IHCR
had the applicable discharge documentation filed. The designated health authority (DHA)
reviewed and signed all off-site care findings, instructions, and information for all three off-site
incidents. One youth required follow-up testing, referrals, or appointments; the remaining two
were not applicable. There was evidence indicating the referral was tracked and youth received
appropriate follow-up care as documented in the IHCR. The registered nurse reported off-site
emergency care episodes and any follow-up appointments are tracked through the episodic log
as well as an outlook calendar. Once a youth returns, the hospital orders are forwarded to the
DHA, who will review and meet with the youth the next time they are on-site.
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4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
A review of five youth Individual Healthcare Records (IHCRs) found two were identified on the
Department’s Facility Entry Physical Health Screening (FEPHS) form with a current chronic
condition at admission; therefore, an additional record was reviewed. None of the youth were
identified as having a communicable disease. Two youth were taking prescribed medication on
an on-going basis; the remaining youth was not. All three youth were undergoing treatment for a
physical health condition, classified with a Medical Grade of two to four, and placed on the
program’s Chronic Illness List. Reviewed progress note documentation verified each youth
received periodic evaluations at least every ninety days. Two applicable youth received a
periodic evaluation prior to renewal of prescriptions which had expired. None of the youth were
applicable for taking anti-tuberculosis medications. One IHCR documented an evaluation was
conducted off-site and the evaluation was documented on the Department’s Summary of Off-
Site Care form, which was signed by the designated health authority (DHA). There was no
evidence of any lapses in care or missed periodic evaluations. The Department’s Problem List
was updated for each youth. The interviewed program director confirmed they meet with
medical staff daily to discuss all medical issues pertaining to youth. An interview with the DHA
confirmed periodic evaluations are completed every at least every ninety days and tracked
through the chronic roster as well as maintained in a calendar. The registered nurse was
interviewed and stated the program monitors youth with chronic conditions through the chronic
alert roster.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
A review of five youth Facility Entry Physical Health Screening (FEPHS) forms found three
youth were taking medication at the time of admission; the remaining two were not applicable.
Each of the youth medications were verified prior to the youth being admitted into the program
with the prescription verification being documented in each Chronological Progress Notes. The
designated health authority (DHA), and when applicable, the psychiatrist were contacted to
obtain an order to resume the specified medications prescribed prior to each admission. The
two youth who were admitted on psychotropic medication received an Initial Diagnostic
Psychiatric Interview within fourteen days. All three Individual Healthcare Records (IHCRs)
included a current practitioner order form indicating the DHA or psychiatrist continued
prescription for the youth. None of the youth were in restricted housing of any kind. Two youth
were applicable for over-the-counter (OTC) medications not listed on the Authority for
Evaluation and Treatment (AET), which were administered according to approved protocols.
The Department’s Medication Administration Record (MAR) was used to document all
medications and treatments for all five reviewed IHCRs. The MAR clearly indicated medication
start and stop dates of each youth’s medications. Non-healthcare staff only assisted in the
delivery of medications when licensed healthcare staff were not on-site. The staff initialed each
administered medication entry. There were no undocumented explanations for lapses or errors
in medication administration for any of the reviewed IHCRs. The registered nurse (RN)
documented side-effects monitoring weekly on the MAR for all three applicable reviewed MARs.
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Two applicable youth only received OTC medications and were not applicable for weekly side-
effect monitoring. None of the youth refused medication. Each MAR contained all required
elements. All five youth initialed each provided medication entry. None of the youth required
parental/guardian notifications. There were no indications of lapses or errors in medication
administration, or youth refusals. The two applicable youth who were prescribed psychotropic
medication subsequent to admission received medication monitoring every thirty days as
required. There were no standing orders for psychotropic medications, emergency treatment
orders for psychotropic medication, or any pro-re-nata (PRN) orders for psychotropic
medications.
Two medication passes were observed. The RN administering medication’s sole responsibility
was to conduct medication pass and not conduct other activities or supervise youth. Both youth
were escorted by a direct care staff and approached the RN individually. The RN identified
themself and confirmed the reason youth was present. The RN prepared the medication and
verified the youth’s allergies and alert status. Both the RN and youth initialed each MAR, and
the RN observed to ensure the medication was swallowed. The Six Rights of Medication
Delivery/Administration were maintained in each of the youth records. Five interviewed staff
stated the nurse dispenses medication; however, any trained staff are able to provide
medication if needed. Five youth were interviewed and four youth stated the nurse provides
medication, with one youth stating they do not take medication. The interviewed RN confirmed a
youth's medication regime when admitted with medication is verified though the review of
commitment packet as well as completing the Department's Prescription Medication Verification
Checklist form. The program uses the Pharmacy Alternative MAR and the Department's MAR
for PRN medications. Any approved non-licensed healthcare staff who provide medications are
trained by the RN through the health services authority curriculum with the list of trained staff
kept in the front of the MAR binder. Medication pass is conducted twice daily with an additional
afternoon time, if needed. A psychiatrist is on-site every other week complete initial
assessments and for medication management.
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.
A review of the medical equipment classified as sharps confirmed the items were securely
stored and inventoried utilizing a routine perpetual inventory descending count as each was
used and disposed. All medications were identified and secured in a locked medication cart
designated for storage of medications. The medication cart was secured, clean, and organized
with stock items separate from youth-specific medications, as well as different types of
medication, injectables, topical, drops, and liquids, which were secured separately. All
medications were stored in a separate, secured area, inaccessible to the youth. All controlled
medications had a perpetual inventory and were stored separately from other medications
behind double locks. Narcotics are also stored behind two locks. Refrigerated medications were
stored in a secured refrigerator only used for medication. The program’s process for the
destruction and disposal of expired or discontinued medications is using the drug buster liquid.
Controlled substances are disposed of monthly when the pharmacist is on-site. A review of
documentation confirmed the program conducts a perpetual and weekly inventory of all sharps
and stock over-the-counter (OTC) medications, with no discrepancies found. The nursing staff
maintained a shift-to-shift inventory of all controlled substances on each youth’s Individualized
Controlled Medication Inventory Record. The number of pills, tablets, or dosages remaining
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were documented on the youth’s Individualized Controlled Medication Inventory Record after
each administered dosage.
Five supervisory-level staff were trained by the registered nurse (RN) in the delivery and
oversight of medication self-administration. Observations conducted of inventory counts of three
controlled medications, three OTC medications, and three sharps found no discrepancies. The
interviewed RN reported if there is a discrepancy in any count of inventory, first a recount is
conducted, if there is still a discrepancy, then they determine if the add/remove sheet was used
and the item was not taken out of inventory; if it still does not match they contact staff on the
shift the discrepancy was noted for and contact regional staff. The RN also confirmed
medication is disposed using the drug buster and controlled substances are counted and locked
in the medication cart under two different locks. The consultant pharmacist, whose license is
posted in medical, is on-site once a month and reviews the medication and expiration dates, as
agreed upon.
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 combined Exposure Control and Infection Control Plan, which is reviewed
and signed annually, is available to all staff, and is located in the medical and maintenance
offices. The designated health authority (DHA) and program director (PD) signed the plan on
July 5, 2023, and the psychiatrist signed on July 18, 2023. The program’s infection control
procedures included prevention, containment, treatment, and reporting requirements related to
infectious diseases, as according to the Occupational Safety and Health Administration (OSHA)
federal regulations and the Centers for Disease Control and Prevention (CDC) guidelines. The
plan addresses common childhood infectious, self-limiting, episodic contagious illnesses, viral
and bacterial infectious diseases, tuberculosis, Hepatitis A, B, and C, human immunodeficiency
virus (HIV), infectious diseases caused by blood-borne pathogens, other outbreaks or
epidemics caused by any other infectious agent, outbreaks of lice or scabies, Methicillin-
Resistant Staphylococcus Aureus (MRSA) and other antibiotic resistant micro-organisms, food-
borne illnesses, bio-terrorist agents, and chemical exposures. Staff have access to personal
protective equipment and the program offers Hepatitis B immunizations to all staff. The program
has a comprehensive process for needle stick post-exposure evaluation. The program has a
separate file to contain documents of any youth or staff who experience a facility or occupational
exposure, which has not happened during the annual compliance review period. The
interviewed PD verified the Exposure Control and Infection Control Plan is maintained in
medical and maintenance offices and reviewed annually. The registered nurse (RN) verified
during an interview the Exposure Control and Infection Control Plan is maintained in the medical
and maintenance offices. A RN conducts infection control training for both staff and youth
yearly, as well as conducts training to staff yearly on exposure control.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
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This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures outlining how youth are to be supervised in the
program. During interviews with five staff, staff reported youth are locked down, movements are
stopped, a search of the facility is conducted, and a head count of all youth is done when there
is a discrepancy in the youth count. During the annual compliance review week, observations of
youth and staff interactions were conducted during meals, education, movements, medication
pass, cleaning, and recreation. Youth and staff engaged in positive interactions during
observations. The staff to youth ratio is one to eight during daytime activities and one to twelve
during sleeping times. Three randomly chosen staff were asked if they knew how many youth
they were currently supervising, and each was able to immediately provide the information.
During the facility tour, the daily schedule was observed to be posted and available to youth in
the dormitory and day room/dining room. A review of ten-minute checks confirmed staff
observed youth while they were in their sleeping rooms.
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 for the behavior management system (BMS) which is
designed to maintain order and security, foster compliance with the program rules, and teach
youth alternative pro-social methods of dealing with problems using both rewards and a system
of progressive discipline. The program uses the Measurable Achievement Plan (MAP) as their
BMS. The BMS was last updated in February 2023. The program has an agreement between
the program and the school board in regard to the BMS and a review of five job descriptions
confirmed each included the implementation of the BMS. All staff, including education staff,
were trained on the use of the BMS. Each of the five reviewed youth records included
documentation the BMS was reviewed during their orientation. Five staff training records
confirmed they received training in the implementation of the BMS. The program’s policy and
procedures include a process where staff are able to provide feedback in regard to the BMS.
The program provided documentation appropriate parties were involved in the development,
implementation, and on-going maintenance of the BMS. During the initial tour, the BMS was not
posted; however, there was a posting of each youth’s level status, so staff and youth are aware
of each youth’s level at any time. The youth handbook includes rules and positive and negative
consequences. The BMS includes all the required elements and does not include increase of
length of stay, denial of youth’s basic rights or services, promotion of group discipline,
punishment of youth by other youth, or disciplinary confinement. Observations revealed staff
provide expectations throughout the day, address unacceptable behavior, and encourage youth
when displaying positive behavior. During interviews with five youth, it was revealed they
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understand the program’s consequences and the process of receiving consequences. In
addition, the youth were able to provide examples of rewards they can earn while in the
program. Four the of the five youth reported staff are fair with giving out rewards; and one stated
no, it depends on the staff. Each of the five youth were able to explain the level advancement
process. None of the youth reported being able to punish another youth. Three of the five youth
reported the BMS is good and the remaining two reported it as being fair. The program director
(PD) reported their BMS is called MAP. The recreational therapist is to ensure rewards are
provided on a consistent basis and track all consequences daily to ensure fair treatment. In
addition, the BMS/MAP is monitored by the treatment team and PD on a monthly/quarterly
basis. Staff are evaluated annually on administering the BMS/MAP fairly and consistently. Five
staff were interviewed and reported supervisors provide feedback on the utilization of the BMS
during meetings, through emails, and individually.
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.
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 indicating ten-minute checks should be conducted
when youth are in their sleeping rooms. The program has fifty-eight cameras, and all are
operational. The program maintains thirty days of stored video recordings. During the interview
with the program director, it was confirmed the program has fifty-eight cameras and all are
operational. A review of three days of video recordings on each shift and check logs confirmed
checks are completed within the ten-minute requirement. Staff initialed the Ten-Minute Check
Log at least every eight minutes for each of the Ten-Minute Check Logs reviewed during the
annual compliance review week. During interviews with five staff, they confirmed staff conduct
ten-minute checks every eight minutes when a youth is placed in their rooms for sleeping or
non-punishment reasons.
5.05 Census, Counts, and Tracking Satisfactory Compliance
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The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program has a policy and procedures outlining the process for accounting for youth through
physical counting of youth at various times throughout the day. During the annual compliance
review week, staff were observed conducting counts at every movement, reporting counts on
the radios, and documenting counts/tracking in the logbook. A review of randomly selected
dates since the last annual compliance review, with three days being reviewed each month, was
conducted. Staff documented counts at the beginning of each shift, every hour, and at the end
of each shift. When applicable, releases, transportation, and admissions were documented in
the master control logbook, the program does not use living unit logbooks. During interviews
with five staff, it was reported head count counts are conducted every thirty minutes. Emergency
counts are done after drills, when there are missing youth, power outages, and after emergency
situations. When asked, each staff was aware of the current census.
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 outlining the expectation of documenting in the facility
logbook, which includes the shift report review. Logbooks since the last annual compliance
review were reviewed and are used as the shift report. The program maintains a bound logbook
with numbered pages for each month. Errors were typically struck through with a single line,
dated, and initialed by the staff correcting the error. Reviewed documentation of randomly
selected days within the logbooks reflected each entry included the date and time of the event,
the name of the staff and youth involved, as well as a brief description, the name, and signature
of the staff making the entry. Logbooks included entries for emergency situations, population
counts, law enforcement access to youth, perimeter checks, and youth movement. In addition,
admissions and releases were documented as well as transports away from the program.
Supervisors and direct care staff document in the logbook a review of previous shifts in order to
be updated on any situations which may have occurred since their last shift. The program
currently has two shifts, each shift debriefing occurs before and after the time the annual
compliance review team was on-site. The reviewed logbooks confirmed internal incidents
reported to the Florida Abuse Hotline and/or the Department’s Central Communications Center
were documented.
5.07 Key Control (CRITCAL) Satisfactory Compliance
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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 outlining the key control process. The programs
policy and procedures include key assignment and usage, inventory and tracking of keys,
secure storage of keys not in use, process of addressing missing or lost keys, and reporting and
replacement of damaged keys. Since the last annual compliance review, the program did not
have any incidents reported to the Department’s Central Communications Center (CCC)
regarding keys. The program director, maintenance, human resources, and the clinical director
have permanent keys. Observations of the distribution of keys was not conducted; however, an
informal interview with the supervisor confirmed the process of daily key control and what
occurs when a key is damaged. A review of the sign-in and out key log confirmed staff sign
when receiving a key and turning them back in. The key inventory was reviewed, one supervisor
key had one extra key on the key ring; however, on the inventory list the supervisor key is to
have six keys instead of seven. The program corrected this discrepancy within twenty-four
hours of identification. Three random staff were asked if they were aware of the use of each key
on their key ring, and they were able to explain the use of each key. In addition, each staff knew
how many keys were on their key rings. All keys are stored in master control in a key box which
is secured with a lock only accessible to staff and not accessible to youth. Random observations
of the key box revealed the key box was secured. During interviews with five staff, it was
reported by each, youth do not have access to facility keys, they were able to explain the key
control process for visitors and staff in detail, and the process of what to do when a key is lost or
damaged.
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
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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 outlining contraband procedures for staff, youth, and
visitors. The program has a system in place to prevent contraband entering the facility which
includes all the required elements. Contraband lists are given to youth, staff, and visitors
through handbooks and the orientation process. The policy and procedures address any staff
who is found in possession of contraband in a program will be subject to disciplinary action and,
if applicable, notification to law enforcement will be made. Since the last annual compliance
review, the program did not have any contraband incidents which required the program to report
to the Department’s Central Communications Center (CCC). The program documents weekly
room searches and documents any items found in rooms in which youth are not allowed to
have, such as extra clothes or snacks. During the interview with the program director, it was
reported contraband items will be confiscated and delivered to the supervisor for proper locking,
storage, and/or elimination. Visitors in possession of contraband will be asked to lock the items
in their vehicle and/or leave the facility. If appropriate, the information will be reported to law
enforcement and shared with the placement agency. Illegal contraband shall be quarantined
until law enforcement is called and arrives on-site to investigate. During interviews with five
staff, it was reported by four of the five staff room searches are conducted twice a week. The
remaining staff reported searches are not part of their job duties.
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 outlining the process of searches and full body visual
searches. During the annual compliance review, observations of movements from various
locations confirmed staff were searching youth each time before movements. Youth were
treated with dignity and respect during searches. Searches were conducted according to the
Right Interactions (RI) training manual and by the appropriate number of staff and gender.
There were no admissions, transports, visitation, youth tool usage, or youth returning from off-
site activities during the annual compliance review week. During interviews with five staff, it was
reported by each youth are searched after every movement by male staff. During interviews with
five youth, it was reported searches are conducted when returning from off campus, outdoor
activities, when items are missing, after visitation, meals, or after work details.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a policy and procedures outlining vehicle maintenance. At the time of the
annual compliance review, the program’s only transportation vehicle was at the auto shop being
repaired. The program was able to provide documentation showing the vehicle had its annual
inspection, which did identify minor deficiencies which were corrected. During interviews with
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five youth, it was reported by each, they are placed in handcuffs, shackles, and seatbelts and
staff sit next to them when being transported. During interviews with five staff, it was reported by
four of the five, youth are placed in shackles, handcuffs, and seatbelts. The remaining staff
reported not doing transportation.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures ensuring the compliance of requirements related to
the transportation of youth and driver eligibility. During interviews with five staff, each reported
staff are to carry the facility cellular telephone and walkie talkie and the vehicle is searched prior
to and after transport. Four of the five staff reported safety equipment such as a fire extinguisher
and first-aid kit are located in the vehicle. Staff reported during emergencies, they are to call a
supervisor to report the incident. Each of the five staff reported staff are not allowed to transport
youth in personal vehicles. The program director reported the vehicle does have a safety
screen. The program conducts driver’s license checks quarterly for all staff who transport youth.
During interviews with five youth, it was reported by each never observing contraband being
placed in the vehicle and feeling safe during transport.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures outlining the process of weekly safety and security
audits which include all required elements. Weekly safety and security audits were completed
every week during the annual compliance review period. The Preventive Maintenance Checklist
is reviewed by the program director to ensure repairs are being completed. The program
director reported the process for identifying and tracking safety and security deficiencies are
weekly safety and security audits and perimeter checks.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures regarding tool inventory and management which
includes issuance, inventory, and control of equipment and tools. The program inventories all
tools prior to being used for work. Daily and monthly inventories are completed for sharp-edged
and pointed tools, except on days not used. The program prohibits machetes, bowie knives, or
other long blade knives. Random tool inventory checks were conducted, and each tool was
labeled with an identification number and the tools were placed on the shadow board; however,
the inventory list did not include the tool number, which did not allow a comparison of tool
number to the number on the tool.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
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There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures on youth tool handling and supervision. The
program’s policy and procedures included all required elements. During interviews with five
staff, four of the five reported youth are allowed to use scrub brushes, mops, and brooms. The
remaining staff reported youth do not use tools. During interviews with five youth, each reported
using brooms and mops. During the annual compliance review, youth were observed using
class B tools, and a one to five ratio was met during the cleaning time. A review of five youth
records confirmed all youth are trained on class B tools and risk assessments are completed
prior to tool usage.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures outlining the process of outside contractors. A
maintenance staff is assigned to each contractor to ensure the work is being competed and all
tools are accounted for after the work is completed. When contractors are on-site, youth are not
allowed in the vicinity of the work area. Sign-in sheets and/or instruction sheets were reviewed
for three outside contractors. The sheets included all required elements to ensure tools and
contractors are supervised and inventoried upon arrival and departure of the facility. The
guidelines for repairman/external worker tools include all required elements. A review of the
contractor’s sign-in sheet along with the corresponding work invoices verified the contractors
were on-site on the same date the documents were signed.
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’s Continuity of Operations Plan (COOP) addresses fire, safety, and evacuation
emergency processes and the frequency of conducting drills at random times, and under varied
conditions. Drills are documented on the program’s facility drill form which indicates the type of
drill, date and time of the drill, participants, a brief scenario, and recommendations. Fire drills
are to be conducted monthly on each shift and COOP drills are required to be conducted
quarterly. During interviews with five staff, it was reported they participated in medical drills,
suicide drills, escape, weather, major disturbance, bomb, hostage, chemical, and flood drills
since the last annual compliance review. A review of the program’s facility drill forms since the
last annual compliance review verified drills were performed on both shifts and included all staff
on duty. The forms included debriefing documentation and feedback on how the drills were
performed. Observations of the program during the annual compliance review week indicated
there were seventeen up-to-date fire extinguishers and egress plans posted throughout the
facility. During interviews with five youth, it was reported by each they were made aware of what
to do in case of a fire and participated in fire drills. The program director reported the staff
participate in monthly medical, fire, and COOP drills on all shifts.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
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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 Department approved Continuity of Operations Plan (COOP) available for all
staff to review. The COOP was submitted January 23, 2023, and approved by the Department
on February 15, 2023. The COOP provides for basic care and custody of youth in the event of
an emergency or disaster. The COOP addresses phases of a disaster plan as well as
emergency management including preparedness, response, and recovery. The COOP
addresses emergencies including fire prevention, bomb threats, evacuations, chemical spills,
severe weather, and terrorist attacks. A review of the plan indicated alternative housing has
been identified should the program require evacuation due to an emergency or disaster. The
program also has provisions of equipment and supplies maintained at another contractor
program to ensure a continuous operation of services during emergency or disaster situations.
The program maintains identifying information on each youth in the program. In the event the
program has to evacuate, each youth record accompanies the youth to the temporary location.
A review of five youth records indicated each has the youth’s name, Department identification
number (DJJID), admission date, gender, race, contact information, emergency contact, juvenile
probation officer (JPO), committing judge, victim information, physical description, health status,
and a photograph. The program director reported the COOP is located in master control,
administration, day room, and case management.
5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program has a policy and procedures regarding the storage and inventory of flammable,
poisonous, and toxic items and materials. All chemicals are stored in the locked maintenance
building and only accessible to maintenance personnel. Randomly chosen chemicals were
reviewed to ensure inventory matched actual number of items in the maintenance building, no
discrepancies were found. A Safety Data Sheet (SDS) binder is located inside the storage area
with a picture of each material and a number corresponding to the SDS. A perpetual chemical
inventory list is maintained and the chemicals are checked daily. An inventory sheet is
maintained and documents the daily use. A review of the inventory list verified this practice. The
program also has a chemical daily usage log used to track all toxic items when in use by
authorized staff. The form identifies the chemical number, description, amount used, amount
remaining, date chemical was used, and initial of staff for each chemical.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
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The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures prohibiting youth from handling any flammable,
poisonous, and/or toxic items or materials. Youth are not to clean, handle, or dispose of any
toxic, bio-hazardous bodily fluids, or human waste. Youth are strictly prohibited from the
maintenance area where toxic items and chemicals are stored. An observation of the youth
cleaning in the bathroom, confirmed the youth did not use any chemicals while cleaning. During
the interviews with five youth, it was reported by each youth, they do not use chemicals.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a policy and procedures to ensure all flammable, toxic, caustic, and poisonous
items are disposed appropriately. All unused hazardous materials are kept in the locked storage
shed located outside the facility and are disposed of according to the Safety Data Sheet (SDS).
In addition, the policy and procedures include required elements for chemical spills to be
cleaned up. The program does not have a fully functioning kitchen; therefore, does not have a
need to dispose of kitchen grease and waste. The program does not have any chemicals in
need of disposal, they have cleaning chemicals which they use and throw away the container
when emptied. The program director reported the program uses a hazardous waste facility to
dispose of toxic chemicals. All chemicals needing disposal have to be reported to the
maintenance manager at which time they will store the chemical in a safe place and contract the
company to come out and dispose the chemicals.
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
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Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a written policy and procedures for youth to have visitation and
communication with family members. Youth are informed of visitation upon admission during the
orientation process. The program encourages visitation from the parents/guardians by
forwarding a welcome letter upon the youth’s admission, notifying of the days and time of
visitation, who is allowed to visit, and the corresponding rules of visitation. A list of authorized
visitors and correspondence is maintained in the youth’s case management records and
updated, as needed. A review of five youth case management records verified each record
contained an approved correspondence, visitation, and telephone log. Visitation is held in the
administration area on Sundays from 1:00 p.m. to 3:00 p.m. Special visitations are also provided
for those parents/guardians who are unable to participate in the regularly scheduled visitation
day. Youth can have unimpeded access with the courts, attorneys, their juvenile probation
officer (JPO), and/or the Department of Children and Families (DCF) case worker. Incoming and
outgoing mail is reviewed by staff in front of the youth. This information is documented on the
mail log to which the youth and staff initial acknowledging receipt and review of mail. During
interviews with five youth, each youth reported being able to receive telephone calls and mail
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while in the program. During interviews with five staff, it was reported by two staff they do not
use a translator system, two staff reported they did not know, and the remaining staff reported
they get a translator if needed. The program director reported the program has an agreement
with third party language service entities.
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 procedures outlining recreation and leisure activities. The
program provides a variety of indoor and outside recreational and leisure activities to include
basic physical fitness, team and individual sports, art, leadership, and teambuilding activities.
Activities promote social and cognitive skill development, creativity, teamwork, healthy
competition, mental stimulation, and physical fitness. The program has a posted activity
schedule. Youth are encouraged by staff to participate in recreation with a choice of activity
options to explore their interests. Youth were observed to be engaged in constructive use of
leisure time during the annual compliance review week. A review of the recreational therapist
credentials reflected holding a required degree. During interviews with both five youth and five
staff, it was reported the youth participate in basketball, football, field days, four square, and
weights and they have recreation for an hour.
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.26 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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report_type: QI Residential