summary: QI Residential - FY24-25

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Crestview Youth Academy
Youth Opportunity Investments, LLC
(Contract Provider)
4449 Straightline Road
Crestview, Florida 32539
Review Date(s): November 5 - 8, 2024
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Ken Phillips, Office of Accountability and Program Support, Lead Reviewer (Standard 1 and
Interviews)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Co-Lead,
Standard 1 and Interviews)
Rebecca Smith, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Bradley Taylor, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Devon Whitten, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Program Name: Crestview Youth Academy
MQI Program Code: 1440/1441
Provider Name: Youth Opportunity Investments, LLC. Contract Number: 10210
Location: Okaloosa County / Circuit 1 Number of Beds: 56
Review Date(s): November 5-8, 2024 Lead Reviewer Code: 145
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
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 63 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) 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
* 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
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* 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 * Non-Applicable
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
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 63 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Satisfactory
5.24 Controlled Observation Satisfactory
5.25 Controlled Observation Safety Checks and Release Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 63 (Revised September 2022)
Program Overview
The Crestview Youth Academy is a fifty-six bed program separated into a secure side with
thirty-two beds, and a moderate side with twenty-four beds for thirteen to eighteen year old
males, located in Crestview, Florida. The program is operated by Youth Opportunity
Investments, LLC., through a contract with the Department. The program provides Substance
Abuse Treatment Overlay Services (SAOS) with delinquency programming and treatment
services. The program also provides Borderline Developmental Disability (BDD) services for the
moderate youth component. In addition, the program fosters each youth by providing
delinquency interventions including Skillstreaming the Adolescent, Impact of Crime, and Seven
Challenges. Program administration is comprised of a facility administrator and two assistant
facility administrators. Case management services are provided by a case management
director, two case managers, and a transition services manager. Mental health staff at the
program includes one clinical director who operates as the designated mental health clinical
authority (DMHCA), an assistant clinical director, and five therapists. Medical services are
provided by one full-time registered nurse (RN) and two full-time licensed practical nurses
(LPN). The program has a contract with a licensed psychiatrist who provides services bi-weekly.
The program also has a contract with a medical doctor who serves as the designated health
authority (DHA). The DHA is available by telephone twenty-four hours a day, seven days a
week, and is on-site for a minimum of one time a week for two hours. Education services are
provided by the Florida Scholars Academy. The facility structure consists of one main building
which has two separated living modules for youth. The living modules both consist of
bathrooms, dayrooms, and educational classrooms. The administration area is located in the
front of the main building. During the annual compliance review week, the vacant positions
included seven safety and security specialists, one shift supervisor, three master control
workers, and one unit manager. In addition, the facility administrator position is vacant as of
September 1, 2024. The former facility administrator is still employed with the provider, and
continues to assist the program during the transition time while seeking out a replacement for
this position.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 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 written policy and procedures in place which address initial background
screenings for all newly hired staff, volunteers, interns, and mentors prior to hire. A review of the
program’s employment roster found twenty-one newly hired staff applicable for an initial
background screening during the annual compliance review period. All twenty-one staff had an
initial background screening completed prior to contact with youth and confidential youth
records. Screenings included a review of criminal history. None of the reviewed staff had a
break in service as indicated in the Department’s Staff Verification System (SVS). Twenty staff
were applicable for completion of a pre-employment assessment tool and all those staff
received a passing score, which was documented in each staff’s personnel record. The
remaining staff was not going to be working directly with youth; therefore, they did not need a
pre-employment assessment. All twenty-one staff were added to the Clearinghouse employee
roster. A background screening was completed on two applicable staff hired from another
provider. All reviewed staff had a signed contraband attestation form in their personnel record.
The program did not have interns, volunteers, or mentors on-site for more than ten hours a
week, who required an initial screening. An Annual Affidavit of Compliance with Level 2
Screening Standards was completed and sent to the Department’s Background Screening Unit
(BSU) on December 14, 2023, for the program.
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.)
A review of the program’s employment roster found two staff applicable for a five-year
background rescreening. Two reviewed staff received a five-year rescreening completed as
required. All renewal requests were submitted to the Department’s Background Screening Unit
at least ten business days prior to the five-year anniversary.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 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’s written policy and procedures indicate the program shall promote an
environment of physical, psychological, and emotional safety. The youth shall have unhindered
access to report alleged abuse. Staff shall provide telephone access to report allegations of
abuse and at no time will a youth be prevented from self-reporting or making an abuse call.
Youth in controlled observation shall not be denied from making an abuse call; however, the call
may be delayed until the youth demonstrates calm and compliant behavior. The staff shall
immediately notify the shift supervisor, who will then notify the facility administrator. The staff will
assist in making the call, dialing the telephone number, recording date and time the of call,
obtaining the operator’s name and number, and documenting this information on the internal
incident report. The staff will also maintain sight and sound supervision of the youth. Any youth
refusal to make an abuse call shall be documented in the facility logbook and on the internal
incident report. Program administration is also responsible to ensure the Department’s Central
Communications Center (CCC) is notified of any calls made.
The program had a total of three incidents related to physical, psychological, or emotional abuse
during the annual compliance review period. All three incidents were found unsubstantiated.
None of the incidents involved potential human trafficking victims, child sexual exploitation, or
labor trafficking. Seven staff personnel records were reviewed indicating a signed a code of
conduct. The Florida Abuse Hotline and CCC numbers were observed to be posted throughout
the program. The program completed a Trauma Responsive and Caring Environment (TRACE)
self-assessment on June 25, 2024. Seven youth were interviewed and reported they felt safe in
the program. None of the youth have been stopped from reporting abuse and all stated the
Florida Abuse Hotline number is in the program. Six youth reported they have never exchanged
emails, telephone numbers, or social media contact information with staff. One youth stated
they planned on getting a staff’s contact information when they left to stay in touch. The facility
administrator (FA) stated a few of the staff have business cards and are mentors to the youth
once they leave the program. The FA stated they like to stay in the youth’s life for any positive
impacts they can have. Seven staff were interviewed about the process for staff and youth
calling the Florida Abuse Hotline or CCC for suspected abuse. All seven staff reported they
notify the supervisor or program director. All interviewed staff were able to summarize the steps
for calling suspected abuse to the Florida Abuse Hotline or CCC. When asked if they had heard
staff use profanity when speaking with youth, three staff reported never, and four staff stated
occasionally. In following up with the interview question, each of the four staff reported when
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 63 (Revised September 2022)
staff used profanity, it was done more to repeat what a youth may have said or in general
conversation, and not used in a threatening manner. The FA was interviewed and reported the
staff are trained in trauma-responsive practices and child abuse reporting upon hire with
refresher training being conducted yearly. The program ensures the staff and youth are
knowledgeable about contacting the Florida Abuse Hotline or CCC through daily morning
meetings, weekly town hall meetings, and monthly staff meetings. The FA also summarized the
program’s incident reporting process.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had three incidents related to physical, psychological, and emotional abuse since
the last annual compliance review. There was evidence within all three of these incidents where
management took immediate action to address the incident. For all incidents, the staff were
immediately placed on no youth contact. In two applicable incidents, the Department of Children
and Families (DCF) investigation found the allegations to be unsubstantiated. The third incident
only involved notifying the Department’s Central Communication Center (CCC). The facility
administrator was interviewed and reported there have been no substantiated incidents
regarding physical, psychological, or emotional abuse and no staff have received disciplinary
actions due to allegations of abuse towards a youth since the last annual compliance review.
Staff were removed from youth contact until the investigations were complete. All staff are
mandated reporters to call the Florida Abuse Hotline and the CCC. The program has these
numbers located throughout the program. The youth are also oriented during their intake and
this information is included in the youth handbook.
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.
A review of the Department’s Juvenile Justice Information System (JJIS) found the program had
a total of thirteen incidents reported to the Department’s Central Communications Center (CCC)
during the annual compliance review period. Five incidents in total were reviewed. All five
incidents were reported to the CCC within the required two-hour time frame. All five incidents
were documented in the master logbook. There were no additional internal incidents or
grievances discovered which needed to be reported during the annual compliance review week.
The program experienced a decrease in the number of reportable incidents during the last
annual compliance review period, as there were eighteen incidents reported last year and
thirteen reported this year.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 63 (Revised September 2022)
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program has a Right Interactions (RI) plan which was updated on November 16, 2023, and
was approved by the Department on November 28, 2023. The program had a total of twenty-
one RI incidents during the annual compliance review period. Five of the twenty-one incidents
were reviewed. Four of the five incidents had the required reports completed by the end of the
workday. One incident report had a typographical error where staff wrote the date of September
13, 2023, on the report instead of the actual report date of September 23, 2023. The facility
administrator acknowledged this error and will ensure staff are more cognizant of dates written
on reports. All reports included statements from all staff involved. None of the incidents included
the use of mechanical restraints. None of the incidents resulted in injury to youth or staff and
none included allegations of abuse. All five incident reports were reviewed by a supervisor and
a RI instructor. None of the incidents required a medical review. All five incident reports were
reviewed by an administrator within seventy-two hours of the incidents. All five RI Reports were
reviewed and maintained in the program’s centralized records. The program submitted all
monthly summaries as required during the annual compliance review period. The program’s RI
rate during the previous quarter was 0.86, which is below the statewide Residential RI rate of
1.81. The facility administrator was interviewed and reported RI and use of force incidents are
monitored through all-staff monthly meetings, shift briefings, and as needed. Youth who are
continuously involved in RI incidents are encouraged to provide feedback to administration. The
treatment team makes all attempts to help youth with tools on how to be compliant in the
program as it relates to treatment. Seven staff were interviewed and six were able to
appropriately summarize the program’s procedures for the use of RI. The remaining staff stated
they have not used RI.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program submitted a pre-service training plan/calendar prior to implementation. The training
plan/calendar was approved by all required parties, to include the assistant secretary for
residential services, and the director of the Department’s Office of Talent, Leadership, and
Culture. All instructors were qualified to deliver the trainings provided. Seven staff were
reviewed for pre-service requirements. All staff had trainings completed and documented within
the Department’s Learning Management System (SkillPro). Three of the seven staff were still
within their initial 180 days of employment. Two of these three staff had not completed the
minimum of 120 hours of pre-service training. All seven staff completed the required essential
skills training needed prior to having any youth contact. Trainings included child abuse
recognition, reporting, and prevention, cardiopulmonary resuscitation (CPR), first-aid,
automated external defibrillator (AED) training, emergency procedures, facility operating
procedures, Prison Rape Elimination Act (PREA), professionalism and ethics, Right Interactions
(RI) training, suicide awareness and prevention, active shooter preparedness, balanced
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Office of Accountability and Program Support Page 13 of 63 (Revised September 2022)
approach to restorative justice, the Department’s Central Communications Center (CCC)
incident reporting, civil rights, communication, Confidentiality and Health Insurance Portability
and Accountability Act (HIPAA), Department of Juvenile Justice History, equal employment
opportunity, gang awareness, human trafficking intervention, infection control/bloodborne
pathogens, information security awareness, Department’s Juvenile Justice Information Systems
(JJIS), mental health and substance abuse, quality report writing, safety, security, and
supervision of youth, sexual harassment, effective and respectful treatment of youth, and
trauma responsive practices. Six of seven reviewed staff completed Motivational Interviewing
(MI) training. The facility administrator stated the remaining staff missed the initial training
scheduled; however, has been rescheduled to take the training in November of this year. A
review of six applicable staff showed all completed the Vulnerability to Victimization and
Sexually Aggressive Behavior (VSAB) training. The remaining staff was not applicable for
having VSAB training completed. All seven reviewed staff also completed the Massachusetts
Youth Screening Instrument, Second Version (MAYSI-2) training, Intro to Youth Opportunity
Investments (YOI) (Mission Philosophy and Treatment Model), incident reporting, mental health
and substance abuse specialty services, Seven Challenges (YOI specific training), human
immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) education, iChoose
System, tool management, active youth supervision, transportation of youth, grievance process,
infection control, exposure control plan, behavior management system, and intended and safe
use of tools. There were no staff requiring additional job specific training.
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.
Seven staff were reviewed for in-service training requirements. All in-service trainings were
documented in the Department’s Learning Management System (SkillPro). Three of the seven
staff were supervisors. All seven staff completed more than the required twenty-four hours of
annual training. All seven staff completed active shooter preparedness, cardiopulmonary
resuscitation (CPR), first-aid, and automated external defibrillator (AED) training, human
trafficking intervention, information security awareness, mental health and substance abuse,
Prison Rape Elimination Act (PREA), Right Interactions (RI) update, professionalism,
interpersonal communication, and ethics, sexual harassment, suicide awareness and
prevention, and trauma responsive practices. All seven staff completed all trainings required by
other rules and manuals. There were two additional trainings as outlined in the program’s
contract including workplace violence and the iChoose System. All seven staff completed all
additional trainings required by contract. All three supervisory staff completed the required eight
hours of additional annual training for supervisors. All instructors were qualified to deliver the
trainings provided. The program submitted an annual in-service training plan/calendar prior to
implementation. The training plan/calendar was approved by required personnel, to include the
assistant secretary for the Department’s Office of Residential Services, and the director of the
Department’s Office of Talent, Leadership, and Culture.
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 written policy and procedures which outline the grievance process.
Grievance forms, along with Request to Speak forms, were observed to be located on both
living unit areas. Locked drop boxes are also located in living areas and are checked daily by
staff. The program maintains all grievances for the year in a binder. The program had a total of
five grievances for the annual compliance review period. All five were reviewed. Each of the five
were responded to within the required time frame. Each indicated the grievances were resolved
and were signed by youth and staff. Grievances include an informal, formal, and appeal phase.
Youth who wish to complete a grievance will complete the informal phase by presenting the
grievance to any staff member. Seven youth were interviewed. Two reported they have never
submitted a grievance. The remaining five were able to summarize the grievance process. All
seven youth confirmed they could ask staff for assistance when completing a grievance. The
facility administrator was interviewed and stated all staff receive pre-service training on the
grievance process and procedures. The facility administrator was also able to summarize the
program’s grievance process. Seven staff were interviewed and summarized the grievance
procedure.
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program provides life and social skills addressing communication, interpersonal
relationships and interactions, non-violent conflict resolution, anger management, and critical
thinking and decision-making. The program addresses the needs of the targeted gender group.
The program is an all-male residential program. Services are provided through a group setting,
where discussion and role play take place. The program provides the Impact of Crime (IOC)
curriculum which is considered their primary service. Life Skills Training and Anger Management
groups are provided for youth. Each life skills group is either a primary or clinical group;
therefore, the groups are not applicable for review for the annual compliance review period. In
addition to the life skills intervention services provided, the program also incorporates additional
life skills for youth to include self-image and self-improvement, Smoking: Myths and Realities,
Alcohol: Myths and Realities, Marijuana: Myths and Realities, Advertising, Violence and the
Media, Coping with Anxiety and Anger, Communication Skills, Social Skills, Assertiveness, and
Resolving Conflict. Seven youth were interviewed. All seven gave examples of life skill type
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groups they have participated in within the program. The designated mental health clinician
authority (DMHCA) was interviewed and stated youth are encouraged to use their skills daily
with a review of lessons at the beginning of the next group. Their progress with the use of skills
is measured in their Individualized Treatment Plans.
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 activities consisting of restorative accountability,
accountability, and competency development. Activities provided include feeding local homes
community, participation with local community partners such as Greater Peace Missionary
Church, Ronald McDonald House, and Sacred Heart Hospital. During Thanksgiving 2023, youth
made and delivered fifty meals to local communities. In addition, youth have assisted in local
clean-up activities and painting projects. Youth also provided Christmas cards for a local
hospital. The facility administrator (FA) maintains a Restorative Justice Binder which includes
activities, photographs, sign in sheets, and vehicle logs, confirming the practice. Off-site
activities are facilitated in conjunction with a community advisory board member. The facility
administrator was interviewed and stated they conduct Impact of Crime (IOC) classes twice a
week. Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol
(SPEP) primary service at Crestview Youth Academy. For details related specific to IOC service
delivery, please refer to the annual SPEP report. The FA reported, due to the unique population
between the secure and moderate they get creative with different projects. The secure youth are
not approved to go out into the community, so they engage in restorative activities and projects
like replacing the carpets, painting, building the greenhouse, making meals for the homeless
during Thanksgiving, and giving cards to the local nursing home. Although the moderate youth
participate in many of these projects, they also go out in the community and have fed the
homeless, fed families at local essential service charities, assisted at a local bakery, painted
businesses locally, and assisted several local schools prepare for the current school year. The
youth complete work in the victim gardens every year. Seven of seven interviewed youth
reported they participate in IOC at the program.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a written policy and procedures which clearly identify entering and updating
alerts in the Department’s Juvenile Justice Information System (JJIS) and an internal alert
process. The program has an alert board located in the conference room which shift briefing
exchange takes place. The alert board is color coded with each youth posted. Each youth is
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listed along with a color photo and alert information noted. The board is maintained daily by the
case management staff. In addition, master control has an alert board which notes youth on any
special precautionary status. Medical staff also maintain a list of medical internal alerts beside
the master alert board. Observations of the kitchen area found alerts posted for youth with
dietary restrictions or food allergies. Seven youth were reviewed for internal alert system and
JJIS alerts. A total of fourteen alerts for the seven youth were reviewed. Each were entered by
the required program staff. All appliable alerts matched both the JJIS and internal alerts
provided by the program. Four of the fourteen alerts had updates to the alert which were
completed later than the date the alert was documented as active. One was done fifty-three
days late, one was ninety days late, one was seventy-four days late, and one was seventy-nine
days late. Each of these four alert updates were late due to Department-wide system outages,
which was also confirmed by the facility administrator and medical staff. An interview with the
facility administrator was conducted and revealed medical issues pertaining to youth are
discussed in morning management meetings which nursing staff participate in on weekdays. A
printout of alerts is provided in these meetings. Seven interviewed staff all provided examples
as to how they are notified of youth alerts in the program. Staff gave examples such as alert
boards, master control, shift briefing, and logbooks. The nurse was interviewed and stated
healthcare staff are responsible for updating the program’s medical alert system.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains youth records in separate binders including an Individual Healthcare
Record, individual management record, and a mental health record. Seven reviewed individual
management records contained all required information for each youth and were divided into
each required section. All reviewed records were labeled ‘confidential’. Youth records are
secured in locked rooms with “confidential” posted outside of room doors as required.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has community advisory board meetings conducted on a quarterly basis.
Documentation was reviewed, confirming the program’s practice. There was evidence the
program solicits the involvement of community advisory board members from all required types
of community partners. Meetings, including agendas, and sign-in sheets were observed for each
quarter of the annual compliance review period. One meeting, conducted on October 8, 2024,
did not have participation from any invited community members. The program then rescheduled
the meeting for December 3, 2024. One member was selected and interviewed by telephone.
The member stated they enjoy participating in the meetings and are notified of meeting dates by
the facility administrator through email. They stated they believe the meetings are productive
and would like to continue participating. The facility administrator was interviewed and stated
the community advisory board provides suggestions and ways of how to assist the program and
youth while in and out of the program. Times of meetings are varied based on participants’
schedules.
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1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a written policy and procedures outlining evaluations of staff performance
which indicate all staff will receive an initial ninety-day performance evaluation and then one
annually thereafter. Three sampled job descriptions were reviewed ensuring each staff’s
performance standards were clearly identified. Position tiles included the safety and security
specialist, master control operator, and case manager. A review of seven staff personnel records
found performance evaluations were completed by the program as required. Job descriptions
matched performance standards for each job reviewed. All position descriptions were reviewed
and confirmed staff whose job functions include implementation of the program’s behavior
management system (BMS) were clearly identified. The program’s contract was reviewed and
confirmed all key positions were filled with the exception of the facility administrator, as the
position was recently vacated as of September 1, 2024. The former facility administrator, still
employed with the provider, was on-site assisting the annual compliance review process, and
stated the program is in the process of searching for a replacement. The program employs a
recreational therapist who holds the required credentials for the position. The program’s daily
program schedule includes recreational activity times outlined. Seven staff were interviewed.
Five of seven staff reported they received an evaluation annually. In addition, three of the seven
reported they received an evaluation monthly. One of the seven also stated they received an
evaluation at ninety-days. The facility administrator was interviewed and stated staff are
provided an evaluation at ninety-days, then annually thereafter. The facility administrator reports
although they have experienced staff turnover, they have been able to maintain good staff
morale. The program has revamped the morale committee and attempted to do monthly events
for spirit weeks, celebrating birthdays, food supplies, snacks, trivia games, potlucks, movies,
and safety practice games. In addition, they have utilized retention bonuses and pay for staff.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s Memorandum of Negotiation (MON) was reviewed and found additional contract
required services outlined which are considered Special Contract Conditions. The services
included youth participation with Alcoholics Anonymous/Narcotics Anonymous (AA/NA),
provisions for reading materials and media center, peer advisory council and religious
opportunities, and community involvement in local activities. The program’s previous facility
administrator (FA) was interviewed and confirmed the program offers these special contract
services for all youth, and provided the Special Contract Conditions for review. The program has
a volunteer who comes to the facility monthly to facilitate the AA/NA meetings. Special Contract
Condition services are offered for all youth in the program. Sign-in sheets were observed which
confirmed the practice. The program has a media center which was observed during the annual
compliance review week. Religious opportunities are facilitated by a local pastor who comes
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weekly and is under direct supervision by staff at all times when on-site. The FA provided
photographs of youth baptisms which occurred during the annual compliance review period.
Peer advisory council meetings occur twice monthly. The student council binder was observed
which included agendas, sign-in sheets, and minutes of these meetings. Youth have access to
the program’s computer lab through High School High Tech classes. Meeting minutes and
agendas were also observed for this practice. High School High Tech offers certifications in
cardiopulmonary resuscitation (CPR), first-aid, Occupational Safety and Health Administration
(OSHA), and finance courses. Certifications for youth were observed. In addition, the program
offers training and certifications for Able Trust Florida, Horticulture, Animal Care, FloridaReady
to Work, Forklift Simulation, and Culinary Arts. The facility administrator maintained a binder
with youth certifications received for these activities which included fifty-seven youth receiving
certifications in culinary arts, thirty-four for animal care, five certifications for OSHA-10, fourteen
for forklift operations, and thirty-seven for Florida Ready to Work.
1.18 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’s data trend analysis method includes all incidents sent to the provider’s corporate
office which are compiled into Key Performance Indicators (KPIs). This information is compiled
monthly. The data is transformed into graphs which consist of all incidents reported to the
Department’s Central Communications Center (CCC), and incident reports. Information is
reviewed and determined whether increases or decreases in incidents have occurred monthly.
Information is also discussed as a standing agenda item monthly in an all-team meeting at the
program. Samples of this documentation were observed for the annual compliance review
period, which confirmed the program’s practice. In addition, Right Interactions (RI) incidents are
sent in monthly to the Department’s Office of Residential Services personnel. RI trends and
analysis reports are complied monthly. The facility administrator reports the program completes
monthly monitoring verification with the provider’s corporate team. A Teams meeting with
corporate personnel is done quarterly to discuss all this information, to include therapeutic
treatment provided, incidents, management accountability, case management services, medical
and mental health services, and safety and security issues. Documentation of the quarterly
meetings was observed which confirmed the program’s practice.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a written policy and procedures addressing initial contacts to the
parents/guardians, juvenile probation officer (JPO), and committing court. Seven youth case
management records were reviewed for initial contacts with parents/guardians and court
notifications. All youth records included documentation showing the parents/guardians were
notified within twenty-four hours of admission, along with a written letter mailed to the
parent/guardian and committing court within forty-eight hours of admission. Each youth record
included documentation the courts and the JPOs were notified within five working days of the
youth admissions.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a written policy and procedures addressing the orientation process. Seven
youth case management records were reviewed for youth orientation documentation. All youth
records included documentation the program provided orientation the day of each admission. All
youth records included documentation the orientation included services available, daily
schedule, expectations and responsibilities of youth, written behavioral management system
(BMS) located in the youth handbook including rules for governing conduct and positive and
negative consequences for behavior, availability of the access to medical, mental health, and
substance abuse services, access to the Florida Abuse Hotline, the Department’s Central
Communication Center (CCC), the program’s zero-tolerance regarding sexual misconduct, the
right to report and be free from retaliation as a result of reporting such misconduct, the agency’s
sexual misconduct response policies and procedures, special accommodations which are
available to ensure all written information about sexual misconduct policies, items considered
contraband, performance planning process involving the development of goals for each youth to
achieve, dress code and hygiene practices, procedures on visitation, mail, use of telephone,
expectations for release from the program, access grievance procedures, emergency
procedures, facility tour, assignment to a living unit, room, and treatment team, and medical
topics outlined in Florida Administrative Code. Each youth record included a youth checklist and
a signature page the youth and assigned case manager signed upon completion of the
orientation. One youth was admitted during the annual compliance review week. An observation
of the intake was completed, and the program completed the youth orientation as directed by
their written policy and procedures. Seven youth were interviewed, and each indicated they
received and signed for an orientation packet within twenty-four hours of admission.
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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 written policy and procedures to address written consent of youth eighteen
years of age or older. Seven case management records were reviewed for written consent of
youth eighteen years of age or older. One case management record was applicable, two
additional records were provided by the program for a sample size of three. All three records
included documentation written consent was obtained for each youth upon entering the
program, if already eighteen, or if the youth turned eighteen while in the program upon their
birthday.
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 maintains a written policy and procedures which outline the classification system
and promote safety and security, effective delivery of treatment services based on the
determination of each youth’s individual needs and risk factors, and address items outlined in
Florida Administrative Code. Seven youth case management records were reviewed for
classification factors, procedures, and reassessments for an increase in activities. The
program’s classification form was provided and included all required elements. All seven youth
records included documentation of initial classifications being completed on the youth’s
admission date. The initial classification factors included the youth’s physical characteristics,
age and maturity level, identified special needs, history of violence, gang affiliation, criminal
behavior, sexual aggression or vulnerability to victimization, youth’s perception of vulnerability,
youth’s history of potential or verified human trafficking, suicide risk, medical risk, escape risk,
and security risk. Two of the youth records included documentation the youth had a suicide risk.
All youth records included documentation the youth had a medical risk. None of the youth
records indicated a risk of escape. Three records included documentation the youth had a
security risk. The Department’s Juvenile Justice Information System (JJIS) included all alerts
and any issues affecting classification. All seven youth were classified for purposes of being
assigned to a living area and sleeping area. All seven youth having factors identified during or
after the classification process were immediately entered into the program’s internal alert
system and JJIS. A reclassification is completed at the end of thirty days for the purposes of re-
assessing security measures and at the time, an increase in the youth’s privileges to include
participation in work projects or the other activities involving tools, and participation in off-
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campus activities are reviewed. All seven youth records included documentation the youth had
an increase in privileges or freedoms of movement and all were permitted to participate at the
time of their reassessments. The facility administrator was interviewed and stated youth are
assessed upon admission to ensure whether they may be vulnerable to victimization from
others. If the assessment indicates vulnerability due to factors such as young age, small size, or
disability, then they would be placed in a room at the front of the hall for closer monitoring and
possibly shower separately.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a written policy and procedures for screening youth entering the program to
determine if the youth is a criminal street gang member or is affiliated with any criminal street
gangs. Seven youth case management records were reviewed. One youth was identified as
being gang affiliated. An additional two youth case management records were provided for
review. All three records included documentation local law enforcement was notified of
suspected gang activity. All three youth records included documentation the youth’s home
county law enforcement was notified of the youth’s gang affiliation prior to the Monitoring and
Quality Improvement seven-day notice. All three gang alerts were entered into the Department’s
Juvenile Justice Information System (JJIS) in a timely manner. All three case management
records confirmed notifications were shared with the education provider and the assigned
juvenile probation officer (JPO).
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a written policy and procedures for youth identified as a gang member or
associate to participate in prevention or intervention activities provided by the program. Seven
youth case management records were reviewed, and only one was applicable for gang
prevention and intervention activities, an additional two youth case management records were
provided for review. All three youth records included documentation youth were identified as a
gang member or an affiliated gang member. All three youth records included documentation the
youth participated in gang prevention and intervention strategies. All three youth records had
performance plans which included gang goals and interventions to complete prior to release
from the program. The program utilizes Impact of Crime (IOC) and monthly group sessions with
the gang liaison utilizing the ARISE – Gangs: 50+ Stories of Fractured Lives curriculum. IOC
groups are held once a month for one hour each session, additionally the youth participate in
town hall meetings where gang prevention and association are discussed. All sign-in sheets
were reviewed for the monthly gang groups. The program’s written policy and procedures
addressed providing the youth an opportunity, if they desire, to develop a plan to no longer
affiliate with a criminal street gang. The facility administrator was interviewed and was able to
summarize the program’s gang prevention and intervention strategies.
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2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a written policy and procedures to address the individualized needs of youth
admitted to the program through a comprehensive assessment process to include the
Residential Assessment for Youth (RAY) and the Youth Needs Assessment Summary (YNAS).
Seven case management records were reviewed for the initial RAY and reassessments. All
seven case management records documented the initial RAYs were completed within the first
thirty days of admission. The initial RAY was maintained in the Department’s Juvenile Justice
Information System (JJIS) for three of the seven youth. The remaining four youth’s initial RAYs
were not completed in JJIS due to Department-wide system outages during this time frame. Six
of seven case management documented the RAY Reassessments were completed every
ninety-days after the initial assessment, one youth was not applicable due to the length of
admittance being less than ninety-days. All reassessment documentation was maintained in the
youth’s official case record. No reassesssments were needed based upon intervention and
treatment team meetings.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a written policy and procedures to address the individualized needs of youth
during the admission process through assessments which include the Residential Assessment
for Youth (RAY) and the Youth Needs Assessment Summary (YNAS). Seven case
management records were reviewed for YNAS completion requirements. All seven case
management records included documentation each YNAS was completed within thirty days of
admission. Five of the youth YNASs were documented in the Department’s Juvenile Justice
Information System (JJIS), and two youth records were not in JJIS due to Department-wide
system outages. Each of the youth YNASs documented the youth’s top three criminogenic
needs.
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2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program has a written policy and procedures for performance plan development with the
treatment team and the youth based upon the initial assessment. Seven case management
records were reviewed for performance plan development, goals, and transmittals. All seven
youth records included documentation the initial Individualized Performance Plans were
developed within thirty days of the youths’ admission. The initial performance plans were all
developed after the initial Residential Assessment for Youth (RAY) was completed. The
intervention and treatment team members who were present during the development of the
Individualized Performance Plan included the intervention and treatment team leader, youth,
administrative representative, living unit representative, treatment staff, educational staff, and all
parties who have significant responsibility in goal completion. All seven case management
records included documentation the signature pages were mailed to the parents/guardians with
a stamped return envelope. None of the signature pages were returned to the program;
however, the program conducted its due diligence. All seven original signature sheets were
attached to the original performance plans and were maintained in the official case
management record. All records included documentation the performance plans included
individualized goals based upon the prioritized needs reflecting risk and protective factors
identified during the initial RAY process. All seven Individualized Performance Plans included
the top three criminogenic needs identified from the initial RAY. All youth records had a goal of
skills where specific delinquency interventions were included, and all seven youth records had
target court-ordered sanctions. Transition activities were included in the initial performance
plans. All youth records included youth responsibilities to accomplish goals, program staff
responsibilities, and target dates for goal completion. All youth records included documentation
the performance plans and transmittal letters were mailed within ten working days to the
committing courts, juvenile probation officers, and parents/guardians. All seven interviewed
youth confirmed they actively participated in their performance plans.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a written policy and procedures which address performance plan revisions
and transmittals. Seven youth case management records were reviewed for performance plan
revisions. Six records included documentation performance plan revisions were completed
when the youth demonstrated progress toward completing a goal, one youth record was not
applicable due to not being admitted into the program long enough to have a revision
completed. No youth had newly acquired information or demonstrated any lack of progress
toward completing a goal at the time of the annual compliance review. All six performance plans
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were revised when the Residential Assessment for Youth (RAY) Reassessment results were
warranted.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a written policy and procedures for the development of performance
summaries and transmittals. Seven youth case management records were reviewed for
Performance Summaries and transmittals. Six of the seven records included documentation the
initial Performance Summaries were completed ninety days after the initial performance plans.
Six of the seven youth had updated Performance Summaries completed every ninety days after
the initial Performance Summary. One of the youth did not have any further Performance
Summaries due at the time of the annual compliance review, due to the youth not being at the
program longer than ninety days. All six youth Performance Summaries included the status of
each youth on the performance plan goals, overall treatment progress, academic status to
include credits, youth behavior, level of motivation/readiness to change, interaction with peers,
interaction with staff, overall behavior adjustment to the program, and significant positive and
negative events. None of the seven youth were applicable for a Performance Summary with the
justification for release. All youth records included documentation the youth were allowed to
read and add comments prior to signing, the youth were provided a copy, and the original
summary was filed in each case management record. All youth records included documentation
the Performance Summary was signed by the treatment team leader, program director or
designee, and youth. Documentation indicated a copy of the summary was sent within ten
working days to the committing courts, juvenile probation officers (JPO), and parents/guardians.
Three closed case management records were reviewed for release summary information. All
three closed youth records included the original Performance Summary with the justification for
release and the Pre-Release Notification (PRN) was sent to the assigned JPOs. The release
summary and PRN were sent at least forty-five days prior to the youth’s planned release. All
three closed case management records included documentation of signed Performance
Summaries and PRNs. All closed records included documentation the program provided written
notification to the youth parents/guardians regarding the planned release once the PRN was
approved. All closed records included documentation the exit Residential Assessment for Youth
(RAY) was completed upon each youth’s release from the program. None of the three youth
required victim notification of release letters. None of the three reviewed youth were applicable
for the Sexually Violent Predator Program (SVPP) screening.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a written policy and procedures to promote parent/guardian involvement from
the time the youth is admitted until release from the program. The case management records
included documentation of parent/guardian involvement through invitations to the assessment
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process, participation in the development of the youth’s performance plan, progress reviews,
formal treatment teams, and transition planning. If the parents/guardians were unable to attend
in person, they were invited to attend by telephone. The annual compliance review team
observed a treatment team meeting during the annual compliance review week, which
confirmed parent/guardian participation. Parents/guardians participated in the treatment team
meetings by telephone. The program sends letters to the parents/guardians to notify them of
when treatment teams and family days are scheduled. The youth get monthly telephone calls
with their parents/guardians. The program also has visitation every week. On special occasions,
families are given the opportunity to participate in family therapy sessions virtually through a
video conferencing platform. All seven interviewed youth confirmed parent/guardian involvement
in their treatment teams. The facility administrator was interviewed and stated all youth
parent/guardians are given copies of youth performance plans. Parents/guardians are also
mailed letters informing them of dates and times of treatment team meetings.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a written policy and procedures for the multidisciplinary treatment team
meetings, formal and informal. Seven case management records were reviewed for formal and
informal treatment team documentation. All records had documentation formal treatment teams
were conducted every thirty days. The formal treatment team forms included the youth’s name,
date of review, meeting attendees, comments from treatment team members, brief synopsis of
the youth’s progress, performance plan revisions, progress on performance plan goals, positive
and negative behaviors, treatment progress, and Residential Assessment for Youth (RAY)
Reassessments results. None of the reviewed youth had documentation of behaviors resulting
in physical interventions. All formal treatment team documentation was contained in the case
management records. Seven case management records were reviewed and included
documentation informal treatment teams were conducted, at least bi-weekly alternating formal
treatment team meetings. The informal treatment team forms included the youth’s name, date of
review, meeting attendees, comments from treatment team members, brief synopsis of the
youth’s progress in the program, performance plan revisions, progress on performance plan
goals, positive and negative behaviors, treatment progress, and RAY Reassessment results.
None of the seven records included behaviors resulting in physical interventions. All seven case
management records included documentation the youth were provided an opportunity to
demonstrate skills acquired in the program. The youth’s juvenile probation officer (JPO),
parent/guardian, and any other pertinent party were invited and encouraged to attend treatment
team meetings. All informal treatment team meeting documentation was contained in the youth
records. All seven interviewed youth stated the staff talk with them about their performance, to
include their progression in the performance plan goals, positive/negative behaviors, and
treatment progress.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 26 of 63 (Revised September 2022)
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a written policy and procedures to address transition planning, transition
conference, and the Community Re-Entry Team (CRT) meetings. Three closed case
management records were reviewed for this documentation. All three case management
records included documentation the transition conferences were held at least sixty days prior to
the youth’s targeted release date. The treatment team members at the transition conference
included the youth, treatment team leader, the facility administrator or designee, and other team
members. All youth records included documentation the assigned juvenile probation officer
(JPO), parents/guardians, education staff, and any other pertinent parties were invited to attend.
All youth records included documentation the team reviewed transition activities on the
performance plans, revised performance plans when necessary, identified target completion
dates, and identified persons responsible for completion of goals during the transition
conference. All youth records included the treatment team leader obtained attendees’ dated
signatures, representing their acknowledgement of the transition goals and accountability for
completion. In all three youth records, there was documentation the copy of the transition plan
was sent with a request for return with signature to anyone not in attendance. All three transition
plans were submitted electronically to the assigned JPOs. All three youth records included
documentation a CRT meeting was held prior to youth release. All three youth and their
assigned case managers attend the CRT meetings.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a written policy and procedures for completion requirements of youth exit
portfolios. Three closed case management records were reviewed for exit portfolio documents.
All youth records included documentation the exit portfolios were discussed and initiated during
the transition conference. One of the three youth records included a Department of Highway
Safety and Motor Vehicles state-issued identification card (ID). In two of the youth records, the
assigned case manager requested the documents for the ID and a birth certificate, however,
documents were never sent to the program. In the remaining record there was a copy of the
youth’s ID, birth certificate, and Social Security card. All three records included the transition
plan, calendar of dates, times, and locations of upcoming community appointments, educational
records/documents, school transcripts, résumés, and sample employment applications. All three
youth records included documentation the exit portfolios were verified during the exit
conferences. All youth records included documentation the exit portfolios were completed and
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Office of Accountability and Program Support Page 27 of 63 (Revised September 2022)
provided to the youth upon release. All youth records included documentation the case manager
forwarded the exit portfolio to the assigned juvenile probation officer (JPO). A review of the
program’s contract confirmed it did not include additional requirements for the exit portfolio.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a written policy and procedures to ensure an exit conference is held for each
youth prior to release from the program to review the status of the transition goals, planning
established at the transition conference, and to finalize release planning and preparation for the
youth to reintegrate into the community. Three closed case management records were reviewed
for exit conference documentation. All youth records included documentation the conference
was conducted after the program notified the assigned juvenile probation officer (JPO) of the
youth’s release. All youth records included documentation the exit conference was conducted at
least fourteen days prior to release. All youth records included documentation which indicated
the date of the conference, signatures, and a summary of any pending transition goals. The
Department’s Juvenile Justice Information System (JJIS) included documentation each youths’
admission date and termination date matched what was in the youth’s case management
record. All three case management records included documentation the status of transition
activities were established at the transition conference and plans finalized for the youth’s
release were reviewed. All youth records included documentation the exit conference was
attended by the intervention and treatment team leader, parents/guardians, education
representative, JPOs, youth, and other pertinent parties. There was documentation all exit
conferences were held separately from the transition conferences and the Community Re-Entry
Team meetings.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a formal process to promote constructive input by youth admitted to the
program. The program has implemented town hall meetings, a student council, and distributes
evaluation surveys to the youth upon their exit from the program. The program’s town hall meets
on a weekly basis for one hour and the student council meets twice monthly. While in these
meetings, youth discuss various topics of concern and any issues the youth notice at the
program to brainstorm possible resolutions. Reviewed documentation included sign-in sheets,
meeting minutes, and physical copies of the youth surveys located in the youth’s closed
records. The program’s policy and procedures require advisory board meetings on a monthly
basis; however, the program completes them on a weekly basis and the program director
reviews them on a monthly basis. All seven interviewed youth confirmed they participate in town
hall meetings, and have open communication with staff or can fill forms out to express their
thoughts. The facility administrator was interviewed and stated youth are able to complete
Request to Speak forms which are located in the dayrooms. Town hall meetings are conducted
weekly and advisory board meetings are held bi-weekly.
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Office of Accountability and Program Support Page 28 of 63 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program has a designated mental health clinician authority (DMHCA) who is a licensed
mental health counselor. The DMHCA has a current and active license which expires on March
31, 2025. There were no other DMHCAs utilized during the annual compliance review period.
The DMHCA is on-site forty-hours a week and ensures appropriate coordination and
implementation of mental health and substance abuse services. The program maintains the
DMHCA position description within the program’s policy and procedures, which was reviewed.
The program does not currently have a back-up DMHCA. One of the therapist’s working at the
program has been promoted to the assistant DMHCA; however, is not taking the position until
licensed, which will be in the end of January 2025. The DMHCA reported overseeing the
completion of the daily group therapy sign-ins and individual therapy progress notes to ensure
youth are receiving the services which are outlined in their individual treatment plans. The
schedules are created for the mental health therapists regarding services. The DMHCA also
reported providing individual and family therapy services to youth identified as having acute
needs, as well as therapy sessions as needed. The DMHCA reported communication happens
formally in a supervision setting one hour a week with all clinical staff. Informally, communication
happens as needed on a daily basis to review due dates, documents, staff cases, and to
monitor fidelity to groups.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) who serves as the clinical director is
the only licensed staff at the program. The DMCHA ensures the clinical staff are working under
their supervision and are performing services they are qualified to provide.
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Office of Accountability and Program Support Page 29 of 63 (Revised September 2022)
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) is the clinical supervisor in the
program. The DMCHA ensures all non-licensed clinical staff are performing services which they
are qualified to provide based on education, training, and experience. Weekly supervision
documentation was provided for review and all non-licensed mental health clinical staff received
a minimum of one hour a week of on-site, face-to-face, direct supervision by the DMHCA. All
supervision was documented on the Department’s Licensed Mental Health Professionals and
Licensed Substance Abuse Professionals Direct Supervision Log form. The program maintains
a Chapter 397 license which was observed to be posted in the lobby of the program. The
Chapter 397 license expires on April 1, 2025. The mental health staff are scheduled to be on-
site five days a week Monday through Friday from 9:00 a.m. to 5:00 p.m. The therapists rotate
weekend coverage and average six hours on Saturdays and Sundays. Six non-licensed clinical
staff records were reviewed. All six held a master’s-level degree from an accredited university or
college in an appropriate human services field. Five of the six clinical staff completed training for
conducting Assessments of Suicide Risks. One therapist was recently hired and was still in
training at the time of the annual compliance review.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Seven youth mental health and substance abuse records were reviewed for the mental health
and substance abuse admission screenings. All seven youth received the Massachusetts Youth
Screening Instrument, Second Version (MAYSI-2). All records included documentation the
screener reviewed available information to include the commitment packet and reports for the
youth. All initial screenings were completed on the dates of admission for each youth. Trained
staff completed the seven screenings, in full, within the Department’s Juvenile Justice
Information System (JJIS). All seven screenings indicated a referral was needed for further
evaluation. All seven records included documentation the appropriate referrals were made for
each youth as documented on the program’s referral form. The program’s policy indicates all
youth receive an Assessment of Suicide Risk (ASR) upon admission. All seven youth received
an ASR upon admission to the program during the intake process which was documented in
each record. None of the youth were found to be in crisis during admission to the program. One
of the seven youth were placed on precautionary observation beyond their intake process. In all
seven youth records, a referral form was completed and indicated each youth received a referral
for ASRs and comprehensive evaluations. The reason for each referral was documented on the
form. The program maintains a written policy and procedures for the implementation of a
standardized mental health and substance abuse screening process. The reviewed policy
included a review of the commitment packet information, reports, records, administration of the
MAYSI-2, and any necessary referrals for the youth. The policy also includes staff training in
mental health and substance abuse issues and the MAYSI-2 and a standardized process for
youth in need of immediate attention.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 30 of 63 (Revised September 2022)
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The designated mental health clinician authority (DMHCA) was interviewed regarding mental
health and substance abuse evaluations provided at the program. The DMCHA reported all
youth receive a comprehensive mental health and substance abuse assessment within twenty-
four hours of intake to the facility by a licensed mental health clinician. Seven youth mental
health and substance abuse records were reviewed for a mental health and substance abuse
assessment and/or evaluation. All seven reviewed youth records included documentation a new
combined mental health and substance abuse evaluation was completed for each youth within
thirty days of their admission. All seven records included signed consents for substance abuse
services. All seven evaluations were completed by non-licensed mental health clinical staff and
each was reviewed and signed off on by the DMHCA. All seven reviewed evaluations included
demographics, reason for evaluation, relevant background information, behavioral observations,
Mental Status Examination, interviews of youth, discussion of findings, diagnostic impressions
including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V),
patterns of alcohol and other drug abuse, impact of alcohol and other drug abuse on major life
areas, risk factors of continue alcohol and other drug abuse, and recommendations.
Seven youth mental health and substance abuse records were reviewed for the Initial Mental
Health and Substance Abuse Treatment Plans. All seven initial treatment plans were developed
within seven days of the initiation of treatment on the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. None of the youth entered the program on
psychotropic medications; however, all initial treatment plans indicated for each youth to see the
psychiatrist as needed. All seven initial treatment plans were signed by the non-licensed mental
health clinical staff, the DMHCA, youth, parents/guardians were indicated to be in attendance by
telephone, treatment team leader, program management, and medical staff. Seven youth
records were reviewed for Individualized Treatment Plans. All reviewed treatment plans included
psychiatric services. All treatment plan reviews were conducted every thirty days and were
documented on the Department’s Individualized Mental Health and Substance Abuse Treatment
Plan Review form. All reviewed treatment plans included the non-licensed mental health clinical
staff, DMHCA, youth, treatment team leader, program management, living unit representative,
education representative, and a medical team member signatures. All treatment plans included
documentation the parents/guardians and assigned juvenile probation officers (JPOs) were in
attendance during treatment plan reviews by telephone. All treatment plans included
individualized prescribed services with goals and objectives for each youth.
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Office of Accountability and Program Support Page 31 of 63 (Revised September 2022)
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
Seven youth mental health and substance abuse records were reviewed for mental health and
substance abuse treatment. All seven records included initial treatment plans completed within
seven days of initiation of treatment. All seven initial treatment plans were documented on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. None of the youth
selected for review entered the program on psychotropic medications. All initial treatment plans
were signed by the mental health staff, designated mental health clinician authority (DMHCA),
youth, treatment team leader, program management, and medical staff. Each initial treatment
plan included documentation the parents/guardians attended the meeting by telephone. The
individualized treatment plans included psychiatric services for all seven youth. Although the
youth did not come to the program on psychotropic medications, it was recommended each
youth see the psychiatrist for an initial evaluation and then as needed. All individualized
treatment plan reviews were completed on the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan Review form. All treatment plan reviews were
completed every thirty days. All treatment plan reviews included signatures from the mental
health staff, DMHCA, youth, parents/guardians, juvenile probation officers (JPOs), treatment
team leader, program management, living unit representative, education staff, and medical staff.
The parents/guardians and JPOs all attended the meetings by telephone. All reviewed treatment
plans included each youth’s prescribed services with individualized goals and objectives. A
review of the program’s logbooks, group sign-in sheets, and video revealed groups are being
held on the days and times scheduled by the program.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
Seven youth mental health and substance abuse records were reviewed for treatment and
discharge planning. All seven records included documentation each youth was assigned to a
treatment team upon arrival to the program. Documentation reviewed reflected treatment team
members were in attendance for treatment team meetings including the youth, program
administration, residential living unit, education staff, medical staff, and mental health and
substance abuse staff. It was documented the parents/guardians of the youth attended all
treatment team meetings by telephone. All seven youth were determined to be in need of
substance abuse treatment, group counseling, and family counseling, and received all required
treatment from a licensed or non-licensed professional in accordance with each treatment plan.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 32 of 63 (Revised September 2022)
All seven youth had a properly executed Authority for Evaluation and Treatment (AET). All seven
youth records included documentation of a signed Youth Consent for Substance Abuse
Treatment. All seven youth received individual psychotherapy and/or counseling and
psychosocial skills training. A review of progress notes determined all the youth received
services as stipulated on their individualized treatment plans. None of the selected youth were
applicable for discharge summaries. Three closed youth mental health and substance abuse
records were reviewed for discharge summaries. All three closed records included discharge
summaries documented on the Department’s Mental Health/Substance Abuse Treatment
Discharge Summary form. A review of documentation revealed the discharge summaries
included any future services needed and the discharge plan was discussed with the youth,
parents/guardians, and juvenile probation officers (JPOs).
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program’s required clinical groups according to the contract include Trauma Focused
Cognitive Behavioral Therapy, Skillstreaming the Adolescent, Seven Challenges, and Life Skills
Training. All seven interviewed youth reported participating in group and individual counseling
sessions. Six of seven youth were able to report what type of counseling they participate in and
how often. One youth reported participating in both types of services, however, did not provide
the amount of times each takes place. The designated mental health clinician authority
(DMHCA) reported services include individual counseling, group counseling, substance abuse
counseling, and family therapy sessions. The facility administrator (FA) reported the program
provides specialized treatment for youth with borderline developmental disabilities,
developmental disabilities, and Substance Abuse Treatment Overlay Services.
The DMHCA is on-site for forty-hours each week and the clinical staff are on-site seven days
each week. For Substance Abuse Treatment Overlay Services, the counselor to youth ratios do
not exceed sixteen youth. All non-licensed staff hold a master’s-level degree. The program also
provided individual therapy at least once every two weeks, or more often as needed, family
therapy at least monthly, and the psychiatrist provides services at least once every two weeks
as required. The licensed mental health counselor provided therapeutic services, psychometric
assessments and evaluations, complex case consultation, behavior therapy and analysis,
involvement in treatment planning, and staff training and consultation. Group therapy includes
five total mental health and substance abuse groups with one life skill group each week. The
program provides services for youth with developmental disabilities which include individual
therapy provided at least weekly, family therapy provided at least twice a month, and the
psychiatrist provides services at least weekly. Group therapy for youth diagnosed with a
developmental disability consists of three mental health and substance abuse groups each
week. Therapists who work with these youth have caseloads of no more than ten youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 33 of 63 (Revised September 2022)
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program provides psychiatric services through a psychiatrist who holds a clear and active
license which expires on January 31, 2026. The program also employs a psychiatric advanced
practice registered nurse (APRN) who holds a clear and active license which expires on April
30, 2026. The psychiatrist is available for emergency consultation twenty-four hours a day,
seven days a week. The psychiatrist provides a brief update for each youth to the treatment
team regarding their psychiatric status. The psychiatrist and psychiatric APRN provide
evaluations and recommendations for the youth in the program. All recommendations for the
youth are documented within the treatment plans. The psychiatric APRN’s education,
experience, and licensure are in psychiatry as documented on the Department of Health
website. The psychiatric APRN has a Collaborative Practice Protocol in place and was provided
for review. The sign-in and sign-out logs for the psychiatrist and psychiatric APRN were
reviewed, and each was on-site as required by the agreements. The program did receive
permission from the Department’s Office of Health Services to conduct tele-psychiatry due to
the previous psychiatrist leaving employment. The psychiatrist reported being on-site on a bi-
weekly schedule for medication management. The psychiatrist reported providing diagnostic
services, medication management, and supportive therapy. The psychiatrist also reported
meeting bi-weekly to monthly with the designated mental health clinician authority (DMHCA).
The therapy staff communicate with the psychiatrist during face-to-face sessions, or as needed.
The psychiatrist reported not having concerns with the mental health and substance abuse
services at the program. The DMHCA reported holding staffings with the psychiatrist bi-weekly
to discuss youth on medications and any possible referrals or issues. Seven youth mental
health and substance abuse records were reviewed for psychiatric services. None of the youth
entered the program on psychotropic medications. It is the program’s policy to refer all youth for
a psychiatric interview upon admission. All seven youth completed a psychiatric interview within
thirty days of admission to the program. All seven initial diagnostic psychiatric interviews
included the youth’s history, Mental Status Examination, the youth’s diagnosis based upon the
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), treatment
recommendations, and initial treatment goals. None of the youth were prescribed medications
as a result of the initial psychiatric interview. All initial treatment goals for the youth were for the
youth to see the psychiatrist as needed. All seven initial psychiatric interviews were documented
on the Department’s Clinical Psychotropic Progress (CPPN) form. All seven CPPN forms were
clearly marked as an “Initial Diagnostic Psychiatric Interview”. Three of the seven youth were
prescribed psychotropic medications as a result of psychiatric interviews conducted at later
dates. All three youth received medications reviews every thirty days. The elements
documented on page three of the CPPN included identifying data, diagnoses, target symptoms,
evaluation and description of effect of prescribed medication on target symptoms, the name,
dosage, and quantity of the medication, side effects, youth’s adherence to the medication,
height, weight, and blood pressure, telephone contact to the parents/guardians, along with the
dates and signatures of the psychiatrist. One of the three youth prescribed medication was
applicable and monitored for Tardive Dyskinesia, as required.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 34 of 63 (Revised September 2022)
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a written Suicide Prevention Plan detailing suicide prevention procedures in
accordance with Florida Administrative Code. The written plan included identification and
assessment of youth at risk of suicide, staff training which is six hours annually, suicide
precautions, levels of supervision, referrals, communication, notifications, documentation,
immediate staff response, and a review process which includes the process for suicide attempts
and mortality reviews. The program’s Suicide Prevention Plan has an established review
process for every suicide attempt or mortality. The established review process 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 for changes in policy, training,
physical plant, medical or mental health services, and/or operational procedures. The written
Suicide Prevention Plan was reviewed annually by the designated mental health clinician
authority, state director, and facility administrator on January 2, 2024.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
Seven youth records were reviewed for suicide prevention services. An Assessment of Suicide
Risk (ASR) was completed for all seven youth during their admission to the program. The ASRs
were completed on the Department’s ASR form within twenty-four hours of the youth’s
admission. One of the seven youth entered the facility on precautionary observation. The youth
was maintained on precautionary observation and constant supervision until the Follow-Up ASR
indicated suicide precautions could be discontinued. When the youth’s Follow-Up ASR indicated
suicide precautions could be discontinued, the youth was stepped down to close supervision
prior to transition to normal routine and standard supervision. Close supervision was maintained
until it was determined no longer necessary by the designated mental health clinician authority
(DMHCA) or licensed mental health professional. Discontinuation of close supervision was
documented in the youth’s mental health/substance abuse record by a mental health clinical
staff and there was documentation of a conference held by the facility administrator and
licensed mental health professional to reduce level of supervision. An alert in the Department’s
Juvenile Justice Information System (JJIS) was ended following the recommendations of the
ASR. The program has an internal alert system where the suicide alerts were documented.
There was documentation on the ASR indicating administration or supervisory staff provided
instructions related to the findings and suicide precaution decisions. While on precautionary
observation the youth was allowed to participate in select activities with other youth in
designated safe housing/observation areas of the facility. There were no other youth in the
program placed on precautionary observation during the annual compliance review period.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 35 of 63 (Revised September 2022)
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Each of the reviewed youth logs showed precautionary observation (PO) logs were maintained
for the duration the youth was on suicide precaution. Each log showed an appropriate level of
supervision and observations of the youth’s behavior documented in real time and not
exceeding thirty-minute intervals. There were no noted warning signs for each of the logs
reviewed. For the PO logs reviewed, there was documentation of the logs being reviewed and
signed by each shift supervisor and mental health staff. Each reviewed log noted safe housing
requirements.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
A review of seven pre-service and seven in-service training records confirmed each staff
completed the suicide prevention training, as required. Training included suicide drills, which
were held no less than quarterly on each shift during the annual compliance review period. The
program has three shifts and each of the three shifts completed suicide drills quarterly for the
duration of the annual compliance review period. A review of drills showed the designated
mental health clinician authority (DMHCA) ensures all staff complete cardiopulmonary
resuscitation (CPR), automated external defibrillator (AED), and use of knife-for-life drills
quarterly. Staff who are not present for the drills are given the opportunity to review the drill
scenario on recorded video with the DMHCA. The staff are given the opportunity to understand
the process and receive necessary training when needed. The program has two suicide
response kits in master control, each contain the knife-for-life, wire cutters, and needle nose
pliers. Seven staff were interviewed and each staff reported if a youth expresses suicidal
thoughts they are responsible for notifying mental health and to have the youth remain in
constant sight and sound supervision. Other answers provided were to put the youth on
precautions, notify the supervisor and facility administration, and to get the suicide kit and to talk
with the youth. Each of the seven staff also noted they conduct suicide drills monthly on each
shift. Three staff reported drills are conducted twice monthly. The facility administrator (FA)
reported the program provides initial training by the licensed mental health clinician (LMHC) on
suicide prevention along with training in the Department’s Learning Management System
(SkillPro) as well as ongoing training throughout the year in all-team meetings. Mock drills are
conducted monthly on various shifts to train on suicide attempts and self-injury.
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3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written crisis intervention plan which includes a notification and alert
system, means of referral, including youth self-referral, communication, supervision,
documentation, and review.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a written crisis intervention plan which includes a process for implementation
of a Crisis Assessment form. Seven youth mental health and substance abuse records were
reviewed for Crisis Assessments. None of the records were applicable. The program had one
youth to meet the requirements for a crisis assessment during the annual compliance review
period. A review of the record showed the Crisis Assessment form included the reason for the
assessment, Mental Status Examination and interview, determination of danger to self and/or
others, initial clinical impressions, supervision, treatment, follow-up recommendations, and
notification to the parent/guardian of follow-up treatment. The form was completed by the
designated mental health clinician authority (DMHCA), an alert was placed in the Department’s
Juvenile Justice Information System (JJIS) for the youth to be placed on precautionary
observation, and the youth remained on alert until a Follow-Up Crisis Assessment was
completed. During this time the youth remained on one-to-one supervision, properly
documented on the Department’s Mental Health Alert Observation Log. Documentation showed
the youth was placed on constant supervision upon arrival back to the program until a Follow-
Up Crisis Assessment was completed by the DMHCA. The youth was not involved in a Prison
Rape Elimination Act (PREA) incident.
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3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a written emergency mental health and substance abuse plan which 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 Baker Act, transport for emergency substance abuse
assessment and treatment under Marchman Act, documentation, training, and review.
3.18 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Seven youth mental health and substance abuse records were reviewed for Baker and
Marchman Act procedures. None of the records were applicable for Baker Acts or Marchman
Acts. During the annual compliance review period, the program had one Baker Act. A review of
the youth record showed a staff referral was made by program staff, who immediately notified
mental health staff and the facility administrator. Following the referral, the youth was placed on
one-to-one supervision until taken out of the program to the local Baker Act facility after the
authorization by the designated mental health clinician authority (DMHCA) and facility
administrator. The DMHCA completed the Assessment of Suicide Risk and Crisis Assessment,
and the youth’s supervision level was maintained until an appropriate assessment was
conducted. Once the youth was returned, the youth was placed on constant supervision and a
mental health referral was completed indicating a Mental Status Examination (MSE) to be
conducted.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Seven youth records were reviewed for safety plans and documentation showed all youth had a
safety plan which included warning signs, the youth’s baseline behaviors, crisis recognition,
coping strategies, intervention strategies preferred by the youth, and a debriefing process. The
safety plans were completed within fourteen days of admission in all seven records reviewed. All
seven records indicated the plan was jointly prepared with the youth, parent/guardian, and
clinical staff. All seven safety plans incorporated recommendations from previous or current
clinical assessments or screening instruments and incorporated trauma responsive practices.
The plans were reviewed and updated as necessary following any significant behavioral or
mental health event identified by the youth’s intervention and treatment team. A review of forty
safety plan reviews showed they were all updated every thirty days. Safety plans are reviewed
by staff who have contact with the youth. The plans are maintained in the youth mental health
and substance abuse records. Seven youth were interviewed and each confirmed participation
in their safety plan. The facility administrator was also interviewed and stated each safety plan is
updated on a monthly basis during their formal treatment team meetings.
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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 licensed physician for the program serves as the designated health authority (DHA). The
DHA holds an unrestricted license and meets all requirements for independent and
unsupervised practice in Florida. The DHA’s licensure expires on January 31, 2026. A review of
the Department of Health medical quality assurance website revealed no disciplinary cases or
public complaints on record for the DHA. The program has not employed a physician assistant
(PA) or advanced practice registered nurse (APRN) during the annual compliance review
period. A review of sign-in and out logs from last annual compliance review to present
documented the DHA was on-site at least once a week for a minimum of two hours a week.
There were two separate occasions where the DHA was absent; February 7, 2024, and May 20,
2022, where the back-up DHA provided on-site medical services. The back-up licensed
physician has an equal licensure, which expires on March 31, 2026. The DHA conducted all
administrative duties. There were no instances of the program conducting any telemedicine or
telehealth type services during the annual compliance review period. An interview with the DHA
confirmed their role in completing tasks, being on-call, and ensuring clinical services are
conducted timely.
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 registered nurse (RN) and two licensed practical nurses (LPNs) to provide
on-site nursing coverage. The one RN, who serves as the on-site health service administrator,
provides direction to each of the LPNs while reviewing medical cases daily. Each of the licenses
for nurses who have worked at the program spanning the annual compliance review period
were discovered to be clear and active. All the reviewed nurses had a current certification in
cardiopulmonary resuscitation (CPR). The required on-site nursing hours were in accordance
with the contract requirement of eighty hours. A review of nursing on-site hours demonstrated
the program’s nursing staff were following contracted requirements.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The designated health authority (DHA), facility administrator,
and psychiatrist revised and signed the program’s health-related FOPs as required. In addition,
nursing staff reviewed, signed, and dated a cover page on which all health-related FOPs,
treatment protocols, and other procedures were listed. There were no indications the FOPs
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required any changes during the annual compliance review period. There was one new nurse
hired during the annual compliance review period. The new nurse was in receipt of a
comprehensive clinical orientation to the Department’s healthcare policies and procedures,
which was administered by the program’s regional nurse supervisor. Only the DHA authorizes
and approves treatment protocols and or standing procedures at the program.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for completion of an
Authority for Evaluation and Treatment (AET). Five of the seven youth’s IHCRs contained a
legible copy of an AET; the word “COPY” was found stamped on each. One of the remaining
two youth was under the care of the Department of Children and Families (DCF) and a court
order was present in the IHCR. The one other youth was eighteen years old and did not require
an AET. The applicable AETs were each signed by the youth’s parent/guardian. The AETs were
also signed by a Department representative. Each of the applicable AETs were found valid at
the time of the youth’s admission into the program. An interview with nursing confirmed the
program has a policy for addressing AETs for youth.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for parental/guardian
notification and consent when new medications and treatments are prescribed. Four of the
seven youth were applicable, and each contained documentation of parental/guardian
notification when necessary. The parent/guardian provided consent as required for each of the
four applicable youth. Progress notes were reviewed and supported contact made to each of the
parent/guardian when necessary. Notifications were sent to parents/guardians, utilizing
appropriate Department forms. None of the reviewed youth were taking any psychotropic
medication at admission. Three of the seven youth were later prescribed psychotropic
medication after admission. In each of the three applicable cases, the parent/guardian provided
verbal consent for administering psychotropic medication. All seven youth had a shot record
which was verified within thirty days of the youth’s admission to the program. The program uses
MyFloridaShots to verify all youth immunizations. There were no youth who were applicable for
religious exemption from immunization. An interview with nursing confirmed the practices and
procedures for parental/guardian notifications at the program.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for youth screening upon
admission of any healthcare concerns which may require a referral for further assessment. All
IHCRs contained a Facility Entry Physical Health Screening (FEPHS) form, which was
completed on the date of admission. The reviewed FEPHS forms were completed by a
registered nurse (RN) or licensed practical nurse (LPN). There was no indication any of the
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FEPHS were completed by direct care staff. None of the youth were out of physical custody of
the program for more than twenty-four hours.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for orientation to the
general process of healthcare delivery services at the program. Each youth was in receipt of an
orientation, which they signed for upon completion of all healthcare services and health
education at the program.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for applicable notification of
the designated health authority (DHA) or designee upon admission to the program. Pursuant to
the program’s written procedures, notification occurs to the DHA regardless of need or youth
condition. All reviewed IHCRs found documentation of this practice contained within the
progress notes within twelve hours of the youth’s admission. An interview with nursing
confirmed the practices observed for notifying the DHA upon a youth admission to the program.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for completion of the
Department’s Health-Related History (HRH) form. All youth had a completed and/or updated
HRH form within seven days of admission. The reviewed HRHs were each completed prior to
the Comprehensive Physical Assessment (CPA) being completed. Each of the HRHs were
reviewed by the designated health authority (DHA) or designee as required. An interview with
nursing confirmed who is responsible and the time frame for completing the HRH for each youth
admitted to the program.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for completion of a
Comprehensive Physical Assessment (CPA) form for each youth admitted. All reviewed youth
had a CPA completed within seven days of the youth’s admission to the program. Each CPA
was completed in full by the designated health authority (DHA), with no exceptions. A refusal
form was signed by each youth when part of the examination conducted was refused by a
youth. Each youth’s problem list was updated when applicable. All youth had at least one
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verified tuberculosis skin test (TST) documented. An interview with nursing confirmed the
frequency of when the DHA completes a CPA and practices for administering TST screenings.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed to ensure youth are
evaluated, screened, and subsequently treated for sexually transmitted infections (STIs). Each
of the reviewed youth were clinically screened, evaluated, and tested, which met the intent of
this indicator as it pertains to STIs. All seven youth were offered counseling, testing, and, if
indicated, treatment or referral for human immunodeficiency virus (HIV). Six of the seven youth
consented and received HIV testing. The one remaining youth signed a refusal form to not have
any further testing conducted. The six applicable youth had HIV testing results filed in a sealed
envelope marked “Confidential” contained in the IHCR. The envelopes each documented
where the designated health authority (DHA) reviewed and signed. There was no indication of
alerts posted of any youth’s HIV status within the program’s internal alert system. The program
maintains a written policy and procedures, which specifically address HIV test results and how
to handle them in accordance with Chapter 381, Florida Statute. Seven youth were interviewed
and confirmed they are able to request HIV testing. An interview with nursing confirmed
practices and procedures for evaluating, referring, screening, and testing youth for STIs at the
program.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for inclusion of the sick call
process. Five of the seven reviewed youth were applicable for submission of a sick call
complaint. There was a total of eight sick calls submitted from the youth reviewed. None of the
youth presented with a similar sick call complaint three or more times within a two-week period.
All of the sick call complaints submitted were completed on a Sick Call Request form, which was
completed by the youth. Six of the eight sick calls were completed by a licensed practical nurse
(LPN). All six were then reviewed on the same day by a registered nurse (RN). The remaining
two sick calls were conducted by a RN. All eight sick calls were filed in each of the youth’s
IHCRs. There were no indications of any youth being placed into restricted housing. The sick
calls were documented on the Sick Call Index and Sick Call Referral Log. Sick call is
administered twice daily, as required. Reviewed documentation demonstrated only licensed
nurses conduct sick calls. A review of written facility operating procedures (FOPs) confirmed the
program has established practices for supervisory staff review of any sick call when medical
staff are not available, within four hours of the youth submitting a request. The program has an
exam table available to conduct medical duties. No sick calls occurred during the on-site annual
compliance review. An interview with nursing confirmed practices and procedures for
addressing sick call request made by youth. Seven youth were interviewed and five confirmed
they were seen immediately by a nurse once they had submitted a sick call, the remaining two
confirmed they were seen within a day once they submitted a sick call request.
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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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for completion of episodic,
first-aid, and or emergency care. Five of the seven youth required first-aid or episodic care.
There was a total of seven episodes between the five youth. All on-site care was provided by a
licensed healthcare staff and documented in a problem-oriented manner. There were no
episodes where a non-healthcare staff provided first-aid or episodic care to youth. The program
has four first-aid kits, two of which are utilized for transportation. All first-aid kits are monitored
and reviewed by medical staff monthly. The program has one automated external defibrillator
(AED). The AED is monitored monthly by medical staff. The AED pads and battery have been
changed and are up to date. An on-site test was conducted by medical staff with no issues. The
program has emergency numbers only accessible to staff. A list of staff who are trained and
authorized to administer the epinephrine auto-injector was found on-site; training was conducted
by a registered nurse (RN) and is completed annually. A review of seven staff training records
revealed staff met training requirements regarding episodic, first-aid, and emergency care. A
review of drills documented the program conducted on-going announced and unannounced
monthly medical drills for each of the three shifts. Medical drills included the use of
cardiopulmonary resuscitation (CPR). This affords direct care staff to participate in a least one
medical drill which includes the use of CPR annually. When staff are not present for a medical
drill, the program provides an opportunity for staff to review the drill upon returning to work.
There were no episodic care events to observe during the on-site annual compliance review
week. The program maintains Narcan in the medical office. There are nine doses locked in a
cabinet and two in the locked medication cart. Only medical staff and trained non-healthcare
staff have access to Narcan supplies. The Narcan is counted weekly by medical staff. An
interview with nursing confirmed the monitoring and replenishment of first-aid kits, and AED
equipment. The medical department also ensures medical drills include the demonstration of
CPR and AED usage. An interview with seven youth was conducted and each confirmed they
could see a dentist and medical doctor if needed. An interview with seven staff was conducted
and six of the seven stated they are personally allowed to contact 9-1-1 if necessary. The
remaining staff stated they would call nursing, depending on the circumstances.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for referrals and
coordination of medical services to an off-site healthcare provider. Five of the seven youth
required off-site care. There was a total of ten referrals made between the five applicable youth.
None of the off-site care was for emergency purposes. In nine of the ten off-site care referrals
conducted, a parental/guardian notification was documented. In the remaining one referral,
there was no documentation of parental/guardian notification having been made documented in
the youth’s IHCR. All applicable discharge instructions were filed accordingly in the IHCR. The
designated health authority (DHA) reviewed and signed all necessary discharge instructions.
Four of the five youth required follow-up appointments. Three of the four had the necessary
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follow-up appointments completed. The remaining youth was not required to have a follow-up
until January 2025. An interview with nursing confirmed the practices and procedures for
providing off-site care to youth.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for screening of chronic
conditions and receipt of regularly scheduled evaluations and necessary follow-up. Two of the
seven records were applicable, an additional record was requested to make the minimum
sample size three for this indicator. The three youth met criteria for a chronic condition and were
subsequently placed on the chronic illness list. Additionally, the Department’s Problem List for
each youth was appropriately updated within the IHCR. Each of the youth were either in receipt
of a periodic evaluation or scheduled to be seen as required. An interview with the facility
administrator confirmed there is a procedure for communication which addresses youth with
medical issues. An interview with the designated health authority (DHA) confirmed the
requirements for conducting periodic evaluations for youth with chronic conditions. An interview
with nursing confirmed the practices for monitoring youth with chronic conditions.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for implementation of
medication management. Six of the seven youth were applicable for the inclusion of prescribed
medication. One of the six youth was taking a prescribed medication upon admission. The
remaining five youth were later seen either by the designated health authority (DHA) or
psychiatrist and prescribed medication. All six youth had current and valid orders to administer
medications. Each of the orders were found documented on a Practitioner Order form and filed
in the youth’s IHCR. All the youth had a standard Department Medication Administration Record
(MAR) used, with all required elements for documenting medications administered. Two of the
six youth had appropriate documentation where trained non-healthcare staff administered
medication. At a minimum, nursing staff conducted weekly side-effect monitoring which was
documented on the MAR. One youth was applicable for having refused medication treatment.
The one youth signed a refusal form, which was filed in the IHCR. On two separate MARs for
two youth the count for medication was documented incorrectly. A review of subsequent MAR
and medication located in the medication cart revealed the count was annotated incorrectly;
there was no missing medication for each case observed. None of the youth required parenteral
medication. None of the youth were on psychotropic medication at time of admission. Three of
the seven youth were later prescribed psychotropic medication. Each of the three youth were in
receipt of medication monitoring every thirty days. The program does not have any standing
orders for psychotropic medications. The program does not have any emergency treatment
protocols or pro re nata (PRN) orders for psychotropic medications. Medication pass occurs
around 6:30 a.m. and 6:30 p.m.; therefore, no medication administration observation was made.
An interview with youth confirmed nursing staff administer medications. An interview with
nursing confirmed there are procedures and practices for administering medications.
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Additionally, nursing staff account for medications and disposal when necessary. Training is
provided to non-healthcare staff by a registered nurse (RN) annually.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has processes in place to address sharps and medications, to include secure
storage of all medications, inventories, and disposal when necessary. Observations confirmed
all sharps and medications were securely stored and inaccessible to youth. A count was
conducted for over-the-counter (OTC) medications and sharps. The program at the time of the
annual compliance review did not have any controlled medications to review; however, the
program has a lock box in the medication cart to store controlled medications in the event a
youth is prescribed them. All counts for OTCs and sharps revealed no exceptions. An interview
with nursing confirmed there are practices and processes in place to address handling of
medications and sharps.
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 an infection and exposure control plan which is written in accordance with
Occupational Safety and Health Administration (OSHA) federal regulations and the Centers for
Disease Control and Prevention (CDC) guidelines. The program makes Hepatitis B
immunizations available for all staff. The plans include all required elements and are reviewed
by necessary staff at a minimum of annually. The program has safety and protective equipment
available for all staff as observed in a sample of first-aid kits. There has been no indication the
program was required to report to the Department’s Central Communications Center (CCC),
local county health department, and/or CDC for any infectious diseases or outbreaks. An
interview with the facility administrator director confirmed the location of the infection and
exposure control plans which are reviewed at least annually. An interview with nursing
confirmed the location of the infection and exposure control plans which are reviewed at least
annually.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a writtesn policy and procedures to address youth supervision. The
program’s policy states program staff shall maintain active supervision of youth, including
interacting positively with youth, engaging in a full schedule of activities, closely observing
behavior of youth, and changes in behavior, while consistently applying the behavior
management system. The program has a ratio of one staff to eight youth during daytime
activities and a ratio of one staff to twelve youth during sleeping hours. During the annual
compliance review, observations of the staff to youth ratio were made each day to ensure
compliance with ratios. There were no issues observed. A video review of educational services
spanning the annual compliance review period found staff to youth ratio was out of compliance
on October 24, 2024. Staff to youth ratio was one staff to nine youth from 10:21 a.m. to 10:24
a.m. No additional exceptions were identified. Staff and youth were following the posted daily
activity schedule. Youth supervision was observed during movements to and from class, to and
from meals, and during searches. At no time during any observation period was the staff to
youth ratio out of compliance. Positive interactions were observed between staff and youth. An
interview with three random staff confirmed each was accurately able to provide the number of
youth being supervised.
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 maintains a written policy and procedures to address implementation of the
behavior management system (BMS). A review of the program’s BMS was conducted to ensure
appropriate parties were involved in the development, implementation, and maintenance of the
(BMS). The program’s policy includes a protocol where staff are provided feedback regarding
implementation of the BMS. There is a designated trainer who provides training to all staff as
well as educational staff on the program’s BMS. Seven pre-service training records were
reviewed and documentation confirmed each had completed training in the program’s BMS.
Seven youth records were reviewed to confirm the program’s BMS was included in youth
orientation. Each record contained documentation confirming a review of the program’s BMS.
The BMS is also documented in youth handbooks. Visual observation confirmed the program
BMS is posted throughout the living units and hallways of the program. The program has not
had any modifications to its BMS since the last annual compliance review period. The program
BMS includes all required elements such as promoting safety, respect, fairness, promoting and
protecting youth rights, positive and negative consequences, constructive disciplinary actions,
and opportunities for positive reinforcement. The BMS also includes recognition of
accomplishments and positive behaviors at a four to one ratio, promoting socially acceptable
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means, a process for staff to explain the reasons for the sanctions as well as a means for youth
to explain their behaviors, opportunities for staff to discuss with youth the impact behaviors may
have on others, reasonable reparations for harm caused to others, a means for discussing
alternate behaviors, promoting positive dialog and peaceful conflict resolution, and separation of
youth from population is minimal. A review of the program’s BMS confirmed it did not contain
practices of denial of a youth’s basic rights, did not promote group punishment, punishment of
youth by another youth, increased length of stay, or disciplinary confinement. Visual
observations also confirmed staff and youth interactions did not include such practices. The
program does provide a variety of rewards and incentives such as outings, mega Monday, fat
Friday, rewards ceremonies, additional telephone privileges, and canteen.
Seven staff were interviewed, and each was able to effectively explain the program’s BMS.
Each staff was able to identify the types of rewards the program provides as part of the BMS as
well as identify when rewards are issued. Some examples of rewards mentioned by staff are
awards ceremonies, extra telephone calls, fun days, mega Monday, fat Friday, snacks, and
video games. Seven staff reported youth rights cannot be taken away consequently for
inappropriate behaviors. Staff were able to articulate how youth are informed of consequences
as well as how youth can explain their behaviors. All staff reported no youth are placed on room
restriction. Seven youth were interviewed, and all were able to articulate the consequences the
program has for inappropriate behaviors. Some examples provided were points taken away,
catch days, getting a behavior report, level suspension, and losing canteen. Seven youth were
able to articulate the kinds of rewards youth were able to earn at the program. Some examples
provided were mega Mondays, spades tournaments, additional telephone calls, monthly reward
ceremonies ,and canteen. Seven youth reported staff are consistent with rewards and
consequences. Seven youth were able to explain the difference between each level and how to
move from level to level. Seven youth reported youth are not allowed to punish other youth. The
facility administrator (FA) was interviewed and was able to accurately explain the program’s
BMS. The FA reported the program uses the four to one ratio where the treatment team ensures
positive reinforcements are applied. The FA further stated the treatment team monitors
consequences in the program through the BMS and the implementation of the BMS is
discussed during all team monthly meetings, shift supervisor meetings, and through evaluations.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
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The program has a total of seventy-three cameras of which all were functional at the time of the
annual compliance review. Camera recordings are stored for a minimum of sixty days. A review
of documentation confirmed ten-minute checks are performed by staff at or within ten-minute
increments and are documented in real time. Each reviewed check sheet indicated staff initialed
or signed each check sheet. Staff were observed on video walking up and down hallways
performing checks utilizing flashlights when necessary. Observations confirmed checks were
done as required. A total of twenty-four logs of thirty-minute increments were reviewed for each
month of the annual compliance review period. There were no discrepancies observed. Seven
staff were interviewed, and all reported room checks are conducted every eight to ten minutes
when youth are placed in their rooms.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program maintains a written policy and procedures to address census, counting, and
tracking of youth. The program shall always ensure the location of all youth through active
supervision and the implementation, monitoring, and use of an accounting system of scheduled,
unscheduled, and emergency counts. An observation of counts was conducted during the
annual compliance review week. Master control radioed throughout the program for a scheduled
head count and the count was cleared. A review of logbooks was conducted for the annual
compliance review period. The logbook review confirmed counts are conducted at the beginning
of each shift, after outdoor activities, as well as during emergency situations. Each logbook
contained a total daily census, headcounts, youth movement, new admissions, releases, direct
discharges, transfers, and youth temporarily away from the program. Seven staff were
interviewed, and all were able to articulate how and when youth counts are conducted. Seven
staff were able to articulate what procedures are utilized when youth count cannot be
reconciled. Seven staff were able to articulate when emergency counts are conducted.
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5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a written policy and procedures addressing logbook entries and shift
report reviews. Logbooks were bound with numbered pages. Entries were made in ink with no
erasures or white-out areas. No logbook entries were destroyed or removed. The logbooks
contained errors struck through with a single line and initialed by the staff correcting the error. All
entries included the date and the time of events, with the names of the staff and youth involved,
a brief description of the events, and the names and signatures of the staff making the entries.
No reviewed logbook entries indicated there was a report to the Florida Abuse Hotline or the
Department’s Central Communications Center (CCC). Logbooks are not maintained on the
living units. The activity schedule and logbook entries document minimal interference during
educational instruction. A review of logbook entries confirmed educational classes were
conducted as scheduled, youth arrived and departed school on time, and recreational activities
were conducted as scheduled. Logbooks are maintained in master control. Staff are debriefed
during shift change and are given access to information from previous shifts summarizing
events and incidents documented in the program’s logbooks. Previous shift logbook reports are
reviewed and signed by incoming staff. The program’s logbooks contained documentation of
emergency situations, special instructions for supervision and monitoring, population counts at
the beginning and end of shifts, perimeter security checks and other security checks conducted
by staff, transports away from the facility including name of staff, youth involved and destination,
and admissions and releases. Based on logbook entries reviewed, there were no incidents
involving the use of mechanic restraints, no requests for law enforcement access, information
relating to escapes or attempted escapes, and no youth were removed from the mainstream
population.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program maintains a written policy and procedures addressing key control. The program’s
policy includes the control and use of keys as well as key assignment and usage, including
restrictions on usage, inventory and tracking of keys, secure storage of keys, procedures
addressing missing or lost keys, and reporting and replacement of damaged keys. Upon arrival
to the program, staff will submit their personal keys to the master control technician. Staff’s
personal keys are placed within a lockbox located in master control. Staff are then provided with
a set of assigned keys. Key designation along with the date and time are notated. An
observation of the key inventory was conducted to ensure inventory matched actual key logs. All
keys were in their correct location and matched the key number and total number of keys listed.
The key storage area is secured when not in use. Permanent keys are assigned to designated
staff. Documentation of monthly checks were done for the annual compliance review period and
confirmed the program is following its practice. Restricted keys are documented in the key log
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and permanently assigned to those staff authorized by the facility administrator (FA) to maintain
those keys. The program’s process for reporting and replacing damaged keys is to report to the
supervisor and complete a maintenance request. The key is then taken out of count until
replaced and then placed back onto inventory count. A review of the Department’s Central
Communication Center (CCC) revealed the program had no incidents reported during the
annual compliance review period related to key control concerns. Three staff were informally
interviewed regarding their assigned work keys. Each staff was able to identify the correct
number of keys on their ring as well as identify the function of each key. Seven staff were
interviewed, and all stated staff keys are given to master control upon entry and personal keys
are securely stored.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a written policy and procedures which address illegal and prohibits
items from being introduced into the program. The program’s system includes the program
defining items which are considered contraband, providing youth with a list of contraband items,
informing youth of consequences of having contraband in their possession, searching the
physical plant, searching the grounds of the facility, searching youth, and searching incoming
and outgoing mail. Documentation review confirmed the program’s visitor logbook contains a
contraband attestation statement. During the annual compliance review period, the program
hired a total of twenty-two new staff members. Documentation confirmed each staff member has
a completed attestation form on record. The program’s policy and procedures address staff who
are found in possession of contraband in the program and further state staff will be subject to
disciplinary action up to and including dismissal. The program’s policy and procedures indicate
law enforcement will be contacted in the event items considered contraband are found. The
program’s policy and procedures clearly delineate items which are considered contraband.
During the annual compliance review period, the program had no items of contraband
confiscated. According to a review of the Department’s Central Communications Center, there
were no reports of incidents where illegal contraband was turned over to law enforcement. The
program’s logbooks, incident reports, search reports, and results were reviewed to determine
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frequency and quality of searches with no issues. The facility administrator was interviewed and
reported any suspicion of youth, staff, or visitors having contraband shall be dealt with
immediately to ensure the safety and security of the program. All discovered contraband shall
be destroyed, disposed of, sent to the youth’s home, or kept as evidence to submit to law
enforcement as indicated for illegal contraband. Youth are made aware of contraband
discovered and plans for disposition. Possession of contraband presumed illegal shall require
notification to law enforcement, establishment of chain of custody to include documenting when,
where, and who discovered the item. If the nature of the contraband requires notification to law
enforcement or filing criminal charges, the contraband shall be considered evidence and must
not be altered in any way. Discovery of illegal contraband shall require an internal incident
report and reporting to the CCC and the Incident Reporting and Analysis System (IRAS). Seven
staff were interviewed and were able to explain the program’s process for youth room searches.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
Youth were observed being searched during movement before and after classroom activities,
before and after group, during admission, and following access to tools and equipment. During
the search process, all youth were treated with dignity and respect. All searches observed were
conducted by the appropriate number and gender of staff. The observed searches were
determined to be thorough, and staff were observed explaining the purpose and extent of the
searches. All youth searches were conducted as required by the Right Interaction manual. A
video review of five staff and visitor searches was conducted with no issues observed. Visitors
and staff were observed walking through the metal detector, an electronic wand was utilized,
then a pat search was conducted, and personal items were searched. During the annual
compliance review week, observations of searches before and after visitation, before and after
transport, and before and after off-campus activities were not able to be observed. Seven staff
were interviewed, and all reported youth are searched every time there is movement. Seven
youth were interviewed, and all reported searches occur when returning from off campus, after
outdoor activities, when items are missing, after visitation, after meals, and 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 maintains a written policy and procedures to address the maintenance of vehicles
used for the transportation of youth. The program has two vehicles utilized for the transportation
of youth. The program’s two transportation vehicles as well as five additional staff vehicles were
randomly checked to ensure the vehicles were secured when not in use. During the check
process, it was discovered one of the program’s vehicle’s doors was not secured. Each vehicle
had an updated safety inspection documented with identified and corrected deficiencies. The
maintenance record documentation is maintained by the program’s physical plant manager.
Each vehicle contained an annually inspected fire extinguisher, approved first-aid kit, seatbelt
cutter, window punch, and the appropriate number of seatbelts. The door to the youth
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passenger area was not able to be opened from the inside in either vehicle. One of the two
vehicles did contain a safety screen as it is utilized to transport secure youth.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a written policy and procedures for the transportation of youth. Based on
a review of the program’s policy, a cellular telephone is issued to transporting staff. The ratio for
staff transporting youth is maintained at one staff to five youth. A transportation was able to be
observed during the annual compliance review. Observations determined staff to youth ratio
requirement was maintained and there was one staff of the same gender present during the
transport. Staff and youth were observed wearing their seatbelts and youth were not attached to
any part of the vehicle. The program provides transportation for secure youth. No transportation
for a secure youth was observed during the annual compliance review week; however, the
transportation vehicle for transporting secure youth contained a safety screen. To ensure all staff
transporting youth maintain a current and valid driver’s license, the program’s human resource
department obtains monthly driving record information from the Department of Highway Safety
and Motor Vehicles.
Seven youth were interviewed, and all youth reported they have never been handcuffed to any
part of the vehicle while on transport. All youth reported they have never seen anyone place
contraband in a transport vehicle. Seven staff were interviewed. Four of seven staff reported
youth are secured by seatbelt. Five of seven staff reported youth are secured by shackles,
handcuffs, or mechanical restraints. Five of seven staff reported the type of communication
device provided during transport was a mobile telephone. One of seven staff reported they had
never participated in a transport. The remaining staff reported a radio was provided. Five of
seven staff reported the emergency equipment in the transport vehicles was a first-aid and
emergency kit. One of seven staff reported they were unsure as they had only been employed
for two days. The remaining staff reported they had not participated in a transport. Seven staff
reported personal vehicles are not allowed as transportation vehicles. Seven staff reported
vehicles are searched for contraband prior to and after each use. Six of seven staff were able to
explain the program’s emergency response process during transport. The remaining staff
reported they had not participated in a transport. Three of seven staff reported the staff to youth
ratio during transport is one staff to five youth. One staff reported the staff to youth ratio during
transport is two staff to one youth. One reported the staff to youth ratio during transport is one
staff to eight youth. One staff reported the staff to youth ratio during transport is always a
minimum of two staff. The remaining staff reported they were unsure. Seven staff reported
transport vehicles for secure youth contained a safety screen. The facility administrator (FA)
was interviewed and reported the program does have a van with a safety screen utilized to
transport secure youth.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a written policy and procedures addressing weekly safety and security
audits. The facility administrator (FA) is responsible for conducting the weekly security and
safety inspections as well as developing and implementing warranted corrective action as a
result of safety and security deficiencies identified during internal or external review, audit, or
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inspection. Safety and security audit documents were reviewed for the annual compliance
review period and were found to be following requirements. The program’s preventive
maintenance checklist was reviewed to ensure maintenance and repairs were conducted as
outlined in Florida Administrative Code.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a written policy and procedures to address tool inventory and
management. The program’s policy outlines and addresses the issuance, inventory, and control
of equipment and tools. All tools are inventoried prior to and after work activities. The program’s
physical plant manager conducts a daily inventory of tools with sharp edges or points. Inventory
of items without sharp edges are conducted daily and monthly. A review of the program’s
inventory forms confirmed the program’s practice. The program prohibits the use of machetes,
bowie knives, or other long blade knives. The program’s procedure for missing or lost tools is to
immediately notify the FA, supervisors, and master control, complete a facility lockdown, and
conduct a facility search until the item is located. The program had no instances of lost or
missing tools during the annual compliance review period. When there is a dysfunctional tool
requiring disposal, the program’s procedure is to discard or replace the item and place the new
item on the inventory log. A total of ten tools, including kitchen tools, were reviewed to compare
with inventory. Each tool was accurately identified on the inventory list. Each tool was observed
to be secured and contained markings for easy identification.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a written policy and procedures addressing youth tool handling and
supervision to ensure tools are used safely. The program’s policy and procedures include the
elements such as supervision requirements when youth use tools, issuing tools, established
ratios, tool distribution and collection, and search criteria during work projects. An observation of
youth utilizing tools was made during the annual compliance review to ensure compliance. The
program maintained a one staff to five youth ratio when youth were using tools, during
searches, and during tool distribution and collection. Youth who are permitted to utilize tools
have passed training and have an approved risk assessment. Seven youth records were
reviewed, and each was found to have a completed risk assessment. Seven staff were
interviewed, and all reported youth are allowed to use mops and brooms. Seven youth were
interviewed, all reported they are allowed to use mops, brooms, and scrub brushes.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains established guidelines for outside contractors regarding tool control and
restrictions. Upon arriving to the program, outside contractors receive instructional guidance for
tool management, contraband, and authorized areas. The program’s guidelines for outside
contractors’ tools includes tools being checked upon arrival and departure, tool restrictions while
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in the facility, youth restriction from the work area, and missing tool follow-up. A review of three
invoices for completed projects was reviewed and each invoice date matched the dates of
outside contractors’ sign in forms. A review of contractor sign in forms revealed staff inventoried
the contractors’ tools and equipment upon arrival and departure from the program.
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 maintains a written policy and procedures for fire, safety, and evacuation drills.
Documentation review for the annual compliance review period confirmed the program conducts
emergency and Continuity of Operations Plan (COOP) drills monthly on each shift on a rotating
basis with no exceptions noted. A review of documentation confirmed drills contained all the
required elements such as type of drill, date and time of drill, drill participants, brief scenario,
findings, and recommendations. Based on observations, fire evacuation routes and egress
plans were posted throughout the facility. A review of documentation and visual observations
confirmed the facility has twenty-nine fire extinguishers. Documentation further confirmed each
fire extinguisher was inspected annually.
Seven staff were interviewed, and all were able to articulate they participated in various
emergency and disaster drills within the past twelve months. Seven youth were interviewed, and
all youth reported they have been instructed on what to do in case of a fire. Three of seven
youth reported drills are conducted twice a month. Two youth reported drills are conducted
every two weeks. One youth reported drills are conducted once a month. The remaining youth
reported drills are conducted randomly. The facility administrator was interviewed and reported
fire, medical, mental health, and COOP drills are completed monthly. Right Interactions drills are
conducted quarterly.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program maintains a Continuity of Operations Plan (COOP) of which a copy is maintained
in the facility administrators office as well as in master control. The COOP was submitted to the
Department on April 8, 2024, and was approved by the Department’s Office of Residential
Services on April 24, 2024. The program’s COOP addresses alternative relocation sites
approved by the Department. The program Emergency Disaster Preparedness Plan and COOP
is a combined plan. Emergency supplies and equipment are in the kitchen, the facility
administrator’s office, and the storage area designated for COOP supplies. Youth records are
packed and secured and ready for transport to the evacuation site. The program maintains
youth records in case of emergencies. Seven youth records were reviewed for inclusion of
critical information. Each record contained information including the youth’s full name, the
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Department identification number, date of birth, gender, race, admission date, parent/guardian
contact information, who to notify in case of an emergency, the assigned juvenile probation
officer’s contact information, name of committing judge, state attorney, public defender,
committing offense and judicial circuit, if the judge retains jurisdiction, victim notification contact
information, physical description of the youth, overall health status, personal physician, and a
photograph of the youth. The facility administrator was interviewed and reported COOP is
always available for staff located in master control.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains a written policy and procedures for storage and inventory of flammable,
poisonous, and toxic materials. The program’s policy and procedures state all materials shall be
stored in a secure area inaccessible to youth and kept under strict control. Areas used to store
toxic chemicals are the kitchen, maintenance shed, and storage closets on living units. All areas
observed were secured. A sampling of an inventory of ten items was conducted. Each item
contained a Safety Data Sheet (SDS), and the inventory of each item matched the actual items
observed. A list of approved positions and titles of individuals authorized to handle toxic items
was also identified and includes the facility administrator, assistant facility administrator, case
manager, safety and security specialist, shift supervisor, physical plant manager, unit manager,
and master control technician. The program’s policy and procedures on the disposal of
flammable, toxic, caustic, and poisonous items state the maintenance mechanic or other trained
staff who have safety equipment for diluting, handling, and disposing of hazardous waste shall
be responsible for disposing of hazardous items and toxic materials in accordance with
Occupational Safety and Health Administration (OSHA) standards. The program disposes of
hazardous waste by method of bio-hazardous waste contractor. An informal interview was
conducted with the program’s physical plant manager to determine disposal practices. The
physical plant manager reported the bio-hazardous waste contractor is contacted and informed
of the need of disposal. The program is then informed by the contractor to transport the waste to
the contract site for disposal.
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5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a written policy and procedures addressing youth handling and
supervision for flammable, poisonous, toxic items, and materials. According to the program’s
policy, youth are not permitted to use, handle, or clean dangerous or hazardous chemicals,
respond to chemical spills or clean, or handle or dispose of any person’s biohazardous material,
bodily fluids, or human waste. The program maintains strict control of flammable, poisonous,
and toxic items and materials. Observed chemical storage areas were secured and inaccessible
to youth. Seven youth were interviewed. All seven youth reported they never use any chemical
or cleaning products.
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5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a written policy and procedures addressing visitation and
communication for youth. The program’s policy regarding youth visitation and correspondence
states the programs shall provide the opportunity to promote communication and engagement
which foster family reunification and community connections. The program’s visitation schedule
is in the front lobby of the program as well as within the youth handbook. Visitation is scheduled
for Saturday and Sunday from 1:00 p.m. to 4:00 p.m. A review of the visitation log confirmed
adherence to the schedule. The facility administrator can approve an alternative schedule in the
event the need arises. Youth are allowed to complete one fifteen-minute telephone call to
approved people a week. A review of the telephone log was conducted and confirmed
adherence to the schedule. Mail correspondence is allowed Monday through Friday. Youth are
permitted to send mail correspondence two times a week. A review of the mail correspondence
log confirmed adherence to the schedule. According to policy and procedures, outgoing mail is
searched. According to documentation review, the program utilizes American Sign Language
services for language translation. The program had no youth who were victims of human
trafficking and the need for communication with the juvenile probation officer to be contacted to
verify parents/guardians were not under current or past investigation for human trafficking-
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related charges. Seven youth were interviewed. Seven of seven youth reported they were able
to call or write their parent/guardian.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a written policy and procedures addressing recreational and leisure
activities. The program has an activity schedule posted within each living unit as well as within
youth handbooks. The posted activity schedule documents a range of supervised indoor and
outdoor activities including large muscle activities for youth to participate in. A review of the
program’s logbooks verified adherence to the schedule. Scheduled activities promote social and
cognitive skill development, creativity, teamwork, healthy competition, mental stimulation, and
physical fitness. Recreational activities were unable to be observed during the annual
compliance review week. The recreational therapist’s credentials were reviewed and met all
requirements. Seven youth records were reviewed for recreational therapy inclusion within their
Individualized Performance Plan. Each youth plan contained recreational therapy. Seven youth
were interviewed. All youth reported physical activities are provided for at least one hour. Some
examples of activities provided are football, basketball, kickball, soccer, and dodgeball.
5.23 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program maintains a written policy and procedures addressing the search and inspection of
controlled observation rooms. Five youth records were reviewed for control observation.
Documentation in each record confirmed staff conducted an inspection of the room prior to
placing the youth in the room, and a staff of the same gender searched the youth before leaving
the youth alone in the controlled observation room. Rooms designated as controlled observation
rooms met all the required elements including a minimum of thirty-five unencumbered square
feet, hardwood or metal doors with shatter-resistant windows, vents not easily accessible and
covered with small mesh or metal plates, fire retardant plastic mattresses, recessed lighting
fixtures covered with shatter-resistant material, shatter resistant window or glass windows
covered with security rated screens, no electrical outlets, and electrical switches outside
sleeping room or covered if inside the room.
5.24 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program maintains a written policy and procedures addressing controlled observation.
During the annual compliance review period, the program had a total of seven youth who were
placed on controlled observation. A sample of five youth records were reviewed for controlled
observation. At the time of placement, none of the youth were exhibiting behaviors indicative of
a mental health crisis or suicide. Documentation in each record confirmed a supervisor or
higher-level staff authorized the placement. In each confinement, the youth was acting
aggressively toward others, exhibiting violent behaviors which if continued, would likely result in
injury to or harm to self or others, or substantial property damage, the youth was physically out-
of-control, and less restrictive methods were ineffective, and staff needed to quickly gain control
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and order for program safety and security. Documentation in each record confirmed staff
advised youth of the reason for the placement and a healthcare professional or staff of the same
gender as the youth completed the health status checklist. There was no instance in which any
youth complaints or injuries were observed requiring healthcare assessment and treatment.
There was no confinements exceeding twenty-four hours.
5.25 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program maintains a written policy and procedures addressing controlled observation
safety checks and release procedures. Five youth records were reviewed for control observation
release procedures. In each record, documentation confirmed staff conducted safety checks at
least every fifteen minutes, completed the first page of the controlled observation report, and
submitted it to a supervisor. All checks and observations were documented on the controlled
observation safety checks form. Documentation in each record confirmed the facility
administrator (FA) or supervisor with delegated authority gave written approval before each
youth was released from controlled observation. A review of records confirmed all controlled
observation reports, the health status checklist, and the controlled observation safety checks
forms were maintained in an administrative file and in each youth’s record. In each case, the
facility administrator or designee approved of youth release from observation. All observation
reports were approved within fourteen days of youth’s release from observation and staff
determined whether an in-house alert was warranted upon release.
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Office of Accountability and Program Support Page 59 of 63 (Revised September 2022)
Standard 6: Educational Services
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
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), or Special Conditions. 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.
Contract Specific Career and Technical Education Services: The program currently provides
Occupational Safety and Health Administration (OSHA 10), Cardiopulmonary Resuscitation
(CPR)/First Aid (FA), Florida Ready to Work Soft Skills, ServSafe, Horticulture, Animal Care,
and Forklift Simulation. A review of sign-in sheets and certifications were observed for the
annual compliance review period and found nine youth received certifications for OSHA-10,
sixty-nine youth received CPR/FA certifications, nineteen received certifications for ServSafe,
seventeen youth received certification in Horticulture, twenty-four youth participated in the
Animal Care program through PAWS, and fourteen youth received certification in the Forklift
training simulation program. The program’s schedule indicated career and technical education
services are provided Monday through Friday. The program provides career and technical
education services according to the provider’s contractual agreement.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide educational access. The program
provides education services through Florida Virtual School (FLVS). A review of the program’s
activity schedule and the daily academic schedule indicated the program’s activity schedule
incorporates the daily school schedule. No discrepancies were found. The interview with the
lead teacher indicated all the youth receive credit for completing a course. They also reported
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the school schedule is adhered to. Seven youth were interviewed and six indicated there are no
interruptions during school. Twelve randomly selected days in the logbook throughout the
annual compliance review period indicated education classes started and ended on time or
within a few minutes of the schedule. There were three days the youth did not come back to
class after lunch. Observations of the program video on three days found the video observation
showed teachers were late during scheduled classroom time. The students were in class on
time.
6.03 Educational Access (Education Contract Provider) Non-Applicable
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.
Education services are provided through a contract with Florida Virtual School (FLVS). The 250-
day calendar is distributed over twelve months and includes twenty days for teacher training and
planning. A review of the daily school schedule revealed education provides six fifty-minute
classes from 8:30 a.m. through 2:45 p.m. with a sixty-minute lunch break from 12:05 p.m.
through 1:05 p.m., fulfilling the weekly requirement of twenty-five hours of instructional time. The
interview with the lead teacher indicated all the youth receive credit for completing a course.
They also reported the school schedule is followed. Observations of the program video on three
days showed teachers were late during scheduled classroom time. The students were in class
on time.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The program’s career education program is appropriate for the educational abilities and goals of
the youth, and length of stay of the youth in the program. Career education programming
includes communication, interpersonal, and decision-making skills. The program’s moderate risk
component is a Type 2 program, which allows youth to explore and gain knowledge of
occupation options and work to achieve essential prerequisites to skill training. The program’s
high-risk component is required to be a Type 3 program and offers Career and Professional
Education (CAPE) courses addressing prerequisites needed for specific occupation for youth.
The program’s high-risk component currently does not provide these CAPE courses as
required.
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6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The educational provider’s contract with the Department requires the provider to develop an
Education Transition Plan for each youth. Upon entering a residential commitment program, an
education transition plan must be developed for each youth. Three closed case records were
reviewed; two contained an education transition plan and all three had an Electronic Educational
Exit Plan (EEEP). All reviewed closed youth records entered the program before July 1, 2024,
when the new education provider, Florida Virtual School (FLVS), started, so they would not have
had an education transition plan developed by the current provider; however, any open youth
records do not reflect the provider began developing an EEEP for any of the program youth
upon admission. FLVS has recently developed an EEEP template and trained staff to implement
an EEEP for each youth moving forward. The interview with the instructional leader indicated
exception student education (ESE) services are provided for students with disabilities, English
language learner (ELL) services are provided for language learners, and intervention groups for
those below grade level in reading and/or math are provided. The Instructional leader reported
an EEEP form is completed with each student which discusses their educational needs and
goals after leaving the program.
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The contracted educational provider has policy and procedures in place to provide qualified
instructional personnel. A review of the educational instructional staff for the program, including
flex teachers who provide virtual education at the program, indicated all the teachers have an
active certification, according to the Florida Department of Education website. Flex teacher
certifications suggest all are currently certified in their teaching subjects Three teachers were
teaching in their field and were teaching courses out of the field. The provider sent parent
notification for those teachers who were also teaching out of the field; however, the letter did not
indicate which subjects were taught out of their field. One teacher was providing exceptional
student education (ESE) services at the program, and their certifications as an ESE instructor
were provided.
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Office of Accountability and Program Support Page 62 of 63 (Revised September 2022)
6.07 Florida Youth College (Education Contract Provider) Satisfactory Compliance
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
A sample of three closed youth records were reviewed. All three youth had documentation of a
referral to the Florida Youth College.
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Three closed youth records were reviewed. All three records had documentation to support the
day, date, and time of their Florida Youth College orientation. Each of the three youth had a
career plan based on the youth’s interests and aptitude. One of three had documentation in
notes supporting a thirty-day follow-up occurred. The remaining two youth records had case
notes attempting to contact the youth, however, did not receive communications back from the
youth. After several month of attempts both cases were closed.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 63 (Revised September 2022)

report_type: QI Residential

program_name_raw: Crestview Youth Academy