summary: QI Residential - FY23-24 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Miami Youth Academy
TrueCore Behavioral Solutions, LLC
(Contract Provider)
10855 Southwest 84th Street
Miami, Florida 33173
Review Date(s): September 19-22, 2023
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Andrice Holley, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Rob Aguis, Career and Technical Education Deputy Director (Standard 1)
Markita Andrews, Broward Youth Treatment Center, Director of Case Management (Standard 2)
Christine Calvert, Office of Accountability and Program Support, Regional Supervisor (Standard
3)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Tonya Gittens, Office of Accountability and Program Support, Regional Monitor (Standard 4
Peter Keelan, Office of Education, Regional Education Coordinator, South Region (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Interviews)
Program Name: Miami Youth Academy MQI Program Code: 1289
Provider Name: TrueCore Behavioral Solutions, LLC Contract Number: 10000
Location: Miami-Dade County / Circuit 11 Number of Beds: 24
Review Date(s): September 19-22, 2023 Lead Reviewer Code: 199
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
1.15 Advisory Board
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 70 (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 Delinquency 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 Failed
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 70 (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
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 70 (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 * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 70 (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 70 (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 Satisfactory
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
5.25 Controlled Observation Non-Applicable
5.26 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 70 (Revised September 2022)
Program Overview
Miami Youth Academy is a twenty-four-bed program, for fourteen to eighteen-year-old
males, located in Miami, Florida. The program is operated by TrueCore Behavioral Solutions,
LLC, through a contract with the Department. The program provides Substance Abuse
Treatment Overlay Services (SAOS) to include substance abuse assessments, treatment, and
relapse prevention. In addition, the program fosters each youth by providing services to include
Thinking for a Change (T4C), Impact of Crime (IOC), Cannabis Youth Treatment (CYT),
Pathways to Self-Discovery and Change, Life Centered Education (LCE), Coping with Stress,
Coping with Depression, ARISE, and Living in Balance. The program provides recreation,
individual, group, and family therapy. Program administration is comprised of a facility
administrator (FA), a director of clinical services, and a health services administrator (HSA).
Case management services are provided by one case management staff and one director of
case management/transition services manager. Mental health staff at the program include the
director of clinical services, one full time licensed therapist, one part-time licensed therapist, two
non-licensed therapists, and one recreation therapist. Medical services are offered seven days a
week and are provided by four registered nurses (RNs). One RN serves as the HSA. The
program contracts with a licensed medical doctor (MD) to serve as the designated health
authority (DHA). The DHA is on-site once a week for four hours. Educational services are
provided by the Miami-Dade County Public Schools (MDCPS) on a year-round basis. The layout
of the program includes one main building which consists of a dormitory area, kitchen, two
classrooms, living, and dining areas. The program has twenty-four operating security cameras
providing coverage, which were all operational at the time of the annual compliance review. At
the time of the annual compliance review, the program had six vacancies, which included one
staff mentor, one youth specialist II, two youth specialist Is, one assistant facility administrator,
and one physical plant worker.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 70 (Revised September 2022)
Strengths and Innovative Approaches
• The program provides activities in the community intended to increase youth awareness
and empathy for crime victims and increase personal accountability for youth's criminal
actions. The youth participate in outings to Farm Share in Homestead, Florida, where
they work as a team in assembly line packaging of food items for community distribution
to the needy. Youth have set records filling distribution bins.
• Promoting educational success, a laptop is provided to high school or high school
equivalency diploma (GED) graduates.
• The program youth benefit by vocational skills development in agriculture with learning
about how to grow organic vegetables The program teaches youth about starting and
maintaining a vegetable garden through cycle of seasons.
• The program has increased youth participation in community church events and
baptisms with their community partners at local churches.
• The program youth benefit from tutoring services provided through a local tutoring
company.
• Miami Youth Academy, in partnership with and assistance from the Center for
Educational Excellence in Alternative Settings (CEEAS), unveiled Google's G Suite
application in their education department. This platform, utilized by Chrome Books,
enables both teachers and students to collaborate and personalize their projects using
writing, drawing, presentation, and calculation tools which are cloud-based. Students
enjoy having ownership over their creative work and teachers have seen an increase in
student engagement.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 70 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program maintains a policy and procedures to ensure all newly hired staff and volunteers
receive an initial background screening. The Annual Affidavit of Compliance with Level 2
Screening Standards was submitted to the Department’s Background Screening Unit on
December 7, 2022, meeting the annual requirement. The teachers, funded by the Department of
Education, received an annual screening on December 7, 2022, meeting the annual
requirement. The program had twenty-two new staff hired since the last annual compliance
review. A review of the fourteen applicable direct care staff records confirmed pre-employment
assessments were administered. A review of each staff’s record verified staff completed a
background screening prior to contact with youth and confidential youth records. Each staff’s
criminal history report was reviewed. There were no staff applicable for an exemption prior to
working with youth. There were no staff applicable for a break in service. The program added
each staff to their Clearinghouse employee roster and completed a background screening when
the Department staff was hired by a provider or when a provider was hired by another
contracted provider company.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program maintains a policy and procedures to ensure all staff and volunteers receive a
background rescreening every five years from their initial date of employment. The program had
no staff and/or volunteers applicable for a five-year rescreening since the last annual
compliance review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 70 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program maintains a policy and procedures ensuring an abuse-free environment. There
was one incident alleging abuse reported to the Department’s Central Communications Center
(CCC) related to physical abuse since the last annual compliance review. There were no
applicable cases for any potential human trafficking victims, children of sexual exploitation, or
labor trafficking reported. The code of conduct was not reviewed or signed by the reviewed staff.
A program tour was conducted and confirmed the Florida Abuse Hotline and the CCC telephone
numbers were posted throughout the program. The program’s steps for reporting abuse include
each staff shall contact the abuse registry or the CCC for youth eighteen years of age and older.
When reporting general incidents, the facility administrator (FA), assistant facility administrator
(AFA), unit manager, or lead nurse is approved to call in CCC reportable incidents. The program
completed a Trauma Responsive and Caring Environment (TRACE) self-assessment on
February 21, 2023. The one applicable incident related to physical abuse since the last annual
compliance review was reviewed and was found to be unsubstantiated. The staff involved was
no longer working at the program at the time of the annual compliance review. Five interviewed
youth stated they feel safe in the program. Each stated they have never been stopped from
reporting abuse to the Florida Abuse Hotline or the CCC, if eighteen years or older, since at the
program, and all stated they know the phone number for the Florida Abuse Hotline. Each youth
stated staff are respectful when talking with them and other youth. Four youth stated they have
never heard staff use profanity when speaking to them or other youth, and one stated they have
heard staff use profanity when speaking to other youth. Each youth stated they have never
exchanged emails, telephone numbers, or social media contact information with staff. Five
interviewed staff stated they have never observed another staff telling a youth they could not
call the Florida Abuse Hotline. Four stated they have never observed another staff using
profanity when speaking to youth, using threats, intimidation, or humiliation when interacting
with youth, and one stated they have observed another staff using profanity when speaking to a
youth. All stated they know the phone number for the Florida Abuse Hotline. An interview with
the facility administrator (FA) stated staff must adhere to the code of conduct. If a staff is
arrested, it must be reported to the supervisor immediately. The FA stated staff must not violate
program rules of safety and security and not bring contraband on the premises or in the
program. Staff will not purposely damage the program’s property and they will not physically
assault youth or staff. Staff will not sleep while on-duty supervising youth. Staff are supervised,
are given performance feedback, and are monitored through coaching sessions, written
warnings, suspensions, and/or up to including termination. An interview with the FA stated the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 70 (Revised September 2022)
program has had no disciplinary actions on staff due to allegations of abuse towards a youth
since the last annual compliance review. The FA stated any allegation of abuse must be
reported to the CCC immediately.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program maintains a policy and procedures to ensure immediate action is taken to address
incidents of physical, psychological, and emotional abuse. The program had one incident
alleging abuse towards a youth since the last annual compliance review. The program was
unable to address allegations of physical abuse, because the staff no longer worked at the
center when the allegation was reported. An interview with the facility administrator (FA) stated
the program has had no disciplinary actions for staff due to allegations of abuse towards a youth
since the last annual compliance review. The FA stated any allegation of abuse must be
reported to the Department’s Central Communications Center (CCC) immediately.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a policy and procedures for reporting incidents to the Department’s Central
Communications Center (CCC) within the required two-hour time frame. The program had a
total of fourteen CCC incidents reported since the last annual compliance review. A review of
five CCC reports confirmed all incidents documented the incident date and time, date and time
program became aware of incident, and were reported within the two-hour time frame. Each of
the reviewed CCC incidents documented type of incident and were documented in the program
logbook, as required. There were no additional incidents or grievances which should have been
reported to the CCC noted during the annual compliance review. The program had an increase
of two reportable incidents to the CCC since the last annual compliance review.
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program maintains a policy and procedures related to Protective Action Response
(PAR)/Right Interactions (RI) including the use of verbal and physical intervention techniques
and mechanical restraints. A review of the program’s PAR/RI binder indicated there was a total
of thirty-one PAR/RI incidents since the last annual compliance review. A review of five PAR/RI
Reports indicated each was completed prior to the end of the staff’s workday and included
statements from all staff involved. A review of the five PAR/RI Reports confirmed there were no
injuries to the staff or youth requiring notification to the Department’s Central Communications
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 70 (Revised September 2022)
Center (CCC). There were no youth applicable for a PAR/RI medical review. In each of the
reviewed reports, a post-PAR/RI interview was conducted by administration within thirty minutes
and reviewed by the facility administrator (FA) within seventy-two hours. According to the FA,
the program’s reason for the PAR/RI incident increase since last year, was due to the increased
behavioral needs of youth in the program. Most of the PARs/RIs came from youth who were
either transferred in or transferred out of the program with negative behavioral issues. The
program’s PAR/RI plan was approved by the Department’s Office of Talent, Leadership and
Culture. The program’s PAR rate during the most recent quarter was 5.44, which is above the
statewide Residential PAR/RI rate of 1.35. An interview with the FA stated the process for
monitoring PAR/RI incidents and use of force is for all PAR/RI Reports and incidents to be
reviewed in the morning management meeting. The PAR/RI incident reports and videos are
reviewed by the PAR/RI instructor, assistant facility administrator (AFA), and/or FA. Five staff
were interviewed and two staff stated they have used PAR/RI, and three stated they have not
used PAR/RI. The two staff who indicated they have utilized a PAR/RI technique stated they
start with verbal redirection, and depending on the escalation of events, then PAR/RI is used.
Staff added, codes are called for assistance and a PAR/RI Report is written at the end of every
shift.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program maintains a policy and procedures outlining the pre-service training requirements
for newly hired staff. Five staff training records were reviewed for pre-service trainings. Each
training record confirmed staff completed a minimum of 120 hours of training within 180 days of
hire. Each staff completed the essential skills trainings as outlined in the program’s policy prior
to any contact with youth to include cardiopulmonary resuscitation (CPR), first-aid, automated
external defibrillator (AED), Protective Action Response (PAR)/Right Interactions (RI),
professionalism and ethics including standards of conduct, facility or program operating
procedures, suicide awareness and prevention, emergency procedures, child abuse reporting,
and Prison Rape Elimination Act (PREA) trainings. Reviewed documentation confirmed each
staff completed additional pre-service trainings to include active shooter preparedness,
adolescent development and behavior, balanced and restorative justice, Central
Communications Center (CCC) reporting, civil rights, communication, Health Insurance
Portability and Accountability Act (HIPPA), diversity, Department of Juvenile Justice history,
Equal Employment Opportunity (EEO), gang awareness, human trafficking, infection control,
information security awareness, mental health and substance abuse, motivational interviewing
(MI), quality report writing, safety, security, and supervision of youth, sexual harassment,
standards of conduct, trauma responsive practices, and two staff received Juvenile Justice
Information System trainings. Pre-service trainings are provided through a combination of
instructor-led, web-based courses, and on-the-job training. Documentation confirmed all
instructors were qualified to deliver the trainings provided.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 70 (Revised September 2022)
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a written in-service training plan which was submitted to the Department’s
Office of Talent, Leadership, and Culture and approved on December 20, 2022. According to
the program’s contractual requirements, specific training is required for different position
classifications such as management, case managers, mental health, and direct care staff. Five
staff training records, including two supervisor’s training records, were reviewed for in-service
training. Each staff completed certifications in first-aid, cardiopulmonary resuscitation (CPR),
automated external defibrillator (AED), and Protective Action Response (PAR)/Right
Interactions (RI). Each staff completed training in active shooter preparedness, human
trafficking intervention, information security awareness, mental health and substance abuse,
professionalism and ethics including standards of conduct, facility or program operating
procedures, suicide awareness and prevention, emergency procedures, and Prison Rape
Elimination Act (PREA). Supervisors are required to have an additional eight hours of training in
the areas of coaching, leadership, and personal accountability. A review of two supervisor
training records confirmed completion of eight hours of management and supervisory training
inclusive of coaching, leadership, and personal accountability. The program specializes in
Substance Abuse Treatment Overlay Services; however, all staff received training for Mental
Health Overlay Services, Substance Abuse Treatment Services, Comprehensive Services for
Major Disorders, and Intensive Mental Health Treatment Services. Documentation confirmed all
training was delivered by qualified trainers and documented in the Department’s Learning
Management System (SkillPro). Reviewed documentation confirmed the program has an annual
in-service training calendar which is updated as changes occur.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program shall establish written procedures specifying the process for youth to grieve
actions of program staff and conditions or circumstances in the program related to the violation
or denial of basic rights. The program has a three-phase grievance process which includes
informal, formal, and appeal phases. The informal phase process consists of the youth
attempting to resolve a complaint or situation with staff on-duty at the time of the grievance. The
formal and appeal phases include the documented intervention of administrative staff. Youth are
informed of the grievance process at the time of admission. All youth have access to the
grievance forms, as they are available to youth and are located in the day living area. The
program had no grievances submitted since the last annual compliance review. All grievances
submitted shall be maintained in a designated grievance binder. Five interviewed youth were
able to explain the program’s grievance process and stated they can receive assistance if they
need to complete a grievance. Five interviewed staff knew the program’s grievance process.
The interviewed facility administrator (FA) stated the grievance process includes phases
including the informal phase, in which a youth should discuss with the staff member they are
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 70 (Revised September 2022)
filing the grievance on. Stage two is the formal phase, in which the assistant facility
administrator (AFA) responds. The final phase is the appeals stage in which the FA conducts a
meeting with the youth.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program provides interventions and treatment which incorporates evidence-based models
which are cognitive-behavioral. The program’s contract requires the program to provide
supplemental groups which are Impact of Crime (IOC), Thinking for a Change (T4C) Cannabis
Youth Treatment (CYT), Pathways to Self-Discovery and Change, Life Centered Education
(LCE), Living in Balance (LIB), Coping with Stress, and Coping with Depression. The program’s
evidenced-based and promising practices utilized in the program are the non-clinical groups
T4C, ARISE and IOC. The program’s only non-clinical group remaining is ARISE. ARISE is a
curriculum which is used when youth are not enrolled in T4C or IOC; therefore, ARISE has not
had to be utilized since the last annual compliance review. The clinical and primary groups are
reviewed elsewhere. The program has two non-clinical staff trained to provide the ARISE
groups when needed. The staff’s education and work experience were considered by the
program when determining staff delivery of delinquency intervention services. One staff’s level
of education is a Bachelor of Science degree, and one has a high school diploma. Both staff
were trained to facilitate ARISE on August 17, 2022. An interview with the facility administrator
(FA) indicated the evidence-based and promising practice intervention models utilized in the
program are IOC, T4C, and the ARISE Foundation life management skills curriculum. An
interview with the designated mental health clinician authority (DMHCA) stated therapists
provide the group services.
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’s treatment services include the use of the social and life skills curriculum Life
Centered Education (LCE). The curriculum provides life and social skills intervention services
addressing communication, interpersonal relationships and interactions, non-violent conflict
resolution, anger management, and critical thinking, including problem solving and decision
making. Services are taught by trained mental health/substance abuse (MHSA) staff. LCE is
held twice a week on Mondays and Fridays. A review of the program’s activity schedule and
group sign-in sheets confirmed life skills services were held, as required. In addition to the life
skills interventions services, the program incorporated additional life skills for the youth through
Thinking for a Change (T4C), Impact of Crime (IOC), Living in Balance (LIB), Anger
Management for Substance and Mental Health, Cannabis Youth Treatment (CYT), Strategies
for Anger Management, Adolescent Coping with Depression, Seeking Safety, Coping with
Stress, Shyness and Social Anxiety, Mindful Meditation, Pathways to Self-Discovery and
Change, and ARISE. Five youth were interviewed, and each stated they participate in life skills
groups/activities. An interview with the facility administrator (FA) stated within this reporting
period, youth were provided groups using the Young Men's Work and Talks with Young Men
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curricula, although these have been discontinued. Youth also participate in recreation activities.
An interview with the designated mental health clinician authority (DMHCA) stated youth are
provided an opportunity to practice skills through their daily use of the positive performance
system and how they navigate advancement through level system. Youth participate in daily
meetings where they are provided an opportunity to appropriately air their grievances and
issues, can demonstrate their leadership skills, and present their levels where they are
encouraged to recognize and address their strengths and weaknesses or areas in need of
improvement.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s only restorative justice awareness group offered is Impact of Crime (IOC). The
program’s restorative justice intervention provides a delinquency intervention which is promising
practice. The program’s restorative justice activities are designed to assist youth to accept
responsibility for harm caused by their past criminal actions, challenging them to recognize and
modify their irresponsible thinking. The activities are designed to teach youth about the impact
of crime on victims, their families, and their communities, to expose youth to victim’s
perspectives through victim speakers, in person, on videotape, audiotape, or through victim
impact statements, and to provide opportunities for youth to participate in reparation activities
intended to restore victims and communities, such as restitution activities and community
service projects. Sign-in sheets, handouts, and logbooks were reviewed to confirm groups were
conducted, with no issues noted. In addition to the restorative justice groups the program
incorporated community service project activities for the youth. An interview with the facility
administrator (FA) indicated the youth participate in going to clean local parks, as well as
feeding the homeless. The FA reported the youth do restorative justice projects monthly in
addition to IOC. An interview with the designated mental health clinician authority (DMHCA)
confirmed the groups provided at the program. Five interviewed youth indicated they participate
in IOC and Thinking for a Change (T4C) groups.
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 maintains a policy and procedures for an internal alert system designed to inform
staff of youth with health-related concerns, mental health concerns, and/or safety and security
risks. The program maintains an on-going alert system to ensure information pertaining to a
youth’s special conditions, suicide risks, safety, and/or security risks which are effectively
communicated to staff in a manner which protects the youth’s privacy. Alerts are identified
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during an interview with the youth at time of admission and/or a review of documentation in the
admission packet. Alerts are entered into the Department’s Juvenile Justice Information System
(JJIS) and added to the program’s internal alert system. The internal alert list is posted in the
conference room, logbooks, and in shift briefing reports. Each department head is responsible
for entering and closing out their alerts. The alerts identify the youth’s allergies, security risks,
suicide risks, health conditions, mental health status, medications, and dietary restrictions.
During the annual compliance review week, five youth identified with alerts were reviewed.
Documentation confirmed all youth were placed on the alert system with the name and title of
staff entering or removing an alert. Documentation of alerts and dates were entered in the
program’s logbook. All alerts were entered into the internal alert system and JJIS on the same
date. An interview with the facility administrator (FA) stated management review the alerts
through the program's internal alert board in the conference room, logbook and through shift
briefing reports and each department head is responsible for entering and closing out their own
alerts. An interview with the nurse stated the registered nurse (RN) and licensed practical nurse
(LPN) are responsible for updating the medical alert system. An interview with five staff stated
they each are informed of the youth's alerts including mental health, medical, and security
through the alert board in the break room, upon admission, through the printout alert sheet, daily
briefings, and logbook.
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 a policy and procedures for record management. The program
maintains two separate youth records which include an individual healthcare and an individual
case management record. A review of five youth Individual Healthcare Records (IHCRs)
confirmed each contained the youth’s name, Department identification number, date of birth,
county of residence, and committing offense. A review of five youth individual case
management records confirmed each contained sections including the legal information,
demographics and chronological information, correspondence, case management and
treatment activities, and miscellaneous information. Records were observed to have been
marked, “Confidential.” Youth records are secured in a designated office within the program
which is inaccessible to youth.
1.15 Advisory Board Failed 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 established a community advisory board (CAB) which meets at least every ninety
to 120 days to serve as a support to the program. During the annual compliance review week, a
review of the program’s advisory board binder and sign-in sheets confirmed meetings were not
conducted at least every 120 days and there was no documentation confirming a rescheduled
meeting was held within the quarter. It was confirmed the program missed meetings during the
first and third quarters since the date of the last annual compliance review. The facility
administrator (FA) solicits active involvement from a law enforcement representative, judiciary,
community, victim advocate or victim services, business community, school board, and faith
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community. The FA recruited victims, victim advocates, and parent/guardian whose child was
previously, rather than currently, involved in the juvenile justice system. Sign-in sheets from
quarterly advisory board meetings were reviewed to confirm the program’s practice. During the
annual compliance review week, a board member was interviewed by telephone and confirmed
involvement in the program’s activities. An interview with the FA stated the CAB meets
quarterly, and includes church members, local mentors, education, victim advocate, and other
members.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program maintains a policy and procedures to ensure the staff annual performance
evaluations are based on their established performance standards. A review of five staff
personnel records confirmed three were applicable and received a ninety-day performance
evaluation and two staff were applicable and received an annual evaluation since the last
annual compliance review. Each evaluation included staff comments, signatures, and dates as
well as the supervisor’s signatures, dates, and performance rating calculations. Each reviewed
evaluation confirmed the performance standards matched the job descriptions for each staff. An
interview with the facility administrator (FA) indicated each staff, within ninety days of hire, is
evaluated for performance of job duties. They are provided with feedback and areas for
improvement. The staff and their supervisor develop goals for the year. Annually, staff are re-
evaluated for performance of their job duties. Upon promotion, a staff may be evaluated as well.
The FA indicated the program has a system in place to address turnover and staff morale. The
program has a morale committee which focuses on involving staff with parties, gifts, and any
other positive event to boost morale. Five staff were interviewed regarding how often they
receive a formal evaluation based on their performance. Four staff stated yearly, two staff
indicated monthly, one stated every three months, and one stated every sixty days. Five staff
were interviewed and three staff stated communication at the program was good and two staff
stated communication was very good.
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 implements special contract conditions as outlined in the program’s contract. The
program’s contract had a Memorandum of Negotiation (MON) during the procurement process.
The special contract conditions include having one health services administrator (HSA), two
registered nurses (RNs), and one licensed practical nurse (LPN). One RN is designated as a
value-added service, and all positions were confirmed by the program’s roster. During the
annual compliance review week, the program’s MON requirements were reviewed. It was
confirmed all staff were trained in first-aid and cardiopulmonary resuscitation (CPR) through pre-
service and in-service trainings. The program shall provide all youth with polo shirts and khaki
pants, which was confirmed by on-site observations. Each youth shall have a choice of selection
of hairstyles, which was confirmed by on-site observations. The program shall provide bus
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tickets, pursue reduced hotel rates, and transportation for families in need, and pay for a one-
night stay for special cases. The program provided a letter from a youth thanking the program
for assisting with travel arrangements for their parent/guardian to visit them. The program shall
offer a monthly parent/guardian support group. Reviewed documentation supported the program
had parent/guardian support groups and treatment involving youth, as required. The program
provided post-secondary career and technical training financial assistance, which was
confirmed by copy of the course schedule and class census. The program shall provide Life
Centered Education (LCE) curriculum which focuses on reentry needs for continuing education,
employability skills, independent living skills, self-determination, and interpersonal skills. The
curriculum shall be delivered twice a week by a trained therapist or certified addictions
professional. Documentation was provided and reviewed confirming the staff were providing
services, as required. The transition service manager (TSM) shall organize a transition portfolio
as appropriate to the needs of the youth. A review of six youth transition exit portfolios and the
staff roster confirmed the TSM organizes a transition portfolio. The provider shall utilize the
Ergometrics Pre-Hire Assessment to screen applicants before they are hired. Documentation
was provided to confirm the program uses the assessment to screen applicants before they are
hired. The program shall administer a bi-annual in-service training for staff in behavior
motivation, human relations, conflict, trauma informed care, Prison Rape Elimination Act
(PREA), and leadership. Training sign-in sheets were reviewed and confirmed the program’s
practice. The program shall have a least one pet which will teach responsibility and adopt
healthier behaviors. The program has a glass aquarium tank with fish. Feeding of the fish and
cleaning of the aquarium tank is done by youth in conjunction with the behavior management
system. The program shall contract with a certified behavior analyst for up to four hours each
week. Service logs and invoices were reviewed and confirmed the program’s practice. An
interview with the facility administrator (FA) stated all value-added items are conducted, with the
exceptions which are amended in the contract. Five youth were interviewed, and each
confirmed they have participated in specialized services offered by the program.
1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
A review of the program’s contract reflected pre-vocational and vocational services are required
and include the career and technical education services required by contract to include
Business Education Lab – Microsoft, Florida Ready to Work Career Readiness/Work Ready,
Soft Skills Training, Occupational and Safety and Health Administration (OSHA) 10, Digital
Training, cardiopulmonary resuscitation (CPR)/first-aid, and Horticulture. Reviewed
documentation inclusive of the 2022 to 2023 and 2023 to 2024 school years confirmed seventy
youth received Safe Staff/ServSafe services, thirty-eight youth received Ready to Work Career
Readiness services, thirty-seven youth received Ready to Work Soft Skills services, fifty-two
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youth received OSHA-10 services, seven youth received Digital Training, thirteen youth
received Microsoft Office services, and fifty-one received CPR/first-aid services. Reviewed
documentation identifying new services included in the updated contract confirmed thirty-seven
youth received a certification in Florida Ready to Work Soft Skills and seven youth received a
certification in Digital Training. A review of documentation confirmed career and technical
education services OSHA-10, Work Ready, Soft Skills, Digital Training, and SafeStaff are all
completed during the school day on various days for various youth on a rotating schedule.
CPR/first-aid is conducted one time per month. Microsoft Office is conducted off-site one time
each week. Microsoft Office off-site is conducted by a non-profit organization and has run out of
funding since August 2023 and therefore has been put on hold while the provider secures
further funding. Horticulture is a continued work in progress and was out on pause. The Master
Gardner Program will provide instruction for Horticulture and new relationships are being
established to begin this program again. Five youth were interviewed, three stated they
participated in ServSafe and OSHA-10 and two stated they did not participate in services. An
interview with the facility administrator stated OSHA-10, Ready to Work, ServSafe, job
applications, résumés, and career assessments are contract specific pre-vocational and
vocational services provided at the program.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program uses several systems for the purpose of tracking data and outcome measures.
The program has implemented an internal database and dashboard system which allows for
daily data entry by every program. The program utilizes data on a daily, weekly, monthly,
quarterly, and yearly basis. It informs policy development and programming. Data flows from the
program level to the senior leadership level and back, on an ongoing basis. During the annual
compliance review week, a review of surveys, provided documentation, and the data dashboard
confirmed the program’s practice. The program’s practice in sharing information with providers
and stakeholders on a quarterly basis is through quarterly advisory board meetings, residential
meetings, and reports sent monthly to contract managers. A review of dashboard surveys and
additional documentation confirmed the program’s practice. The program is implementing
collected data to improve their processes through reports which have an immediate impact on
training and reinforcing practices. Additionally, trends are reviewed for possible policy changes
or, if necessary, ancillary trainings. R
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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 regarding initial contact and parent/guardian
notification. The program notifies the youth’s parent/guardian by telephone within twenty-four
hours of the youth’s admission, and by written notification within forty-eight hours of admission.
The program also notifies the youth’s committing court, assigned juvenile probation officer
(JPO), and applicable post-residential services case manager in writing within five working days
of any admission. Five youth records were reviewed, and each contained documentation the
program notified each parent/guardian by telephone, within twenty-four hours of the youth’s
admission. Each of the five reviewed records included documentation indicating the program
notified the court in writing within forty-eight hours of the youth’s admission. Five youth records
contained supporting documentation to confirm the youth’s JPO, committing court, and all
required parties were notified within five working days of admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a written policy and procedures regarding youth orientation, where they
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. A review
of five youth case management records showed documentation of orientation being conducted
with each youth within twenty-four hours of admission into the program. The program orientation
included services available to the youth, daily schedule, expectations and responsibility of
youth, written information on the program’s behavior management system, items considered
contraband, information on how to access medical and mental health services, access to the
Florida Abuse Hotline or the Department’s Central Communications Center if the youth is over
eighteen years of age, the introduction and description of the Prison Rape Elimination Act, and
how to report sexual misconduct. Orientation also included the performance planning process,
dress code and hygiene requirements, procedures regarding visitation, mail, and use of the
telephone, anticipated length of stay, community access, grievance procedures, emergency
drills, physical design of the program, and assignment to a living dormitory. Five reviewed youth
records contained a signed orientation checklist documenting youth participation in the
orientation process and the receipt of an orientation packet, as well as a copy of the program’s
youth handbook. Five interviewed youth stated they received an orientation to the program
within twenty-four hours of admission. All five interviewed youth reported their orientation
included program rules, procedures, schedules, and all other pertinent information. All five
interviewed youth were able to explain the orientation process. An observation of an orientation
was not possible during the annual compliance review week, since the program had no
admissions scheduled.
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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 which addresses obtaining written consent of
youth who are eighteen years of age or older. Five youth case management records were
reviewed, and none were applicable for being eighteen years or older. Three additional records
were reviewed. Each record contained consent forms signed by the youth allowing the program
to share with the parent/guardian any information related to the youth's physical or mental
health screenings, assessments, or treatment.
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’s policy and procedures outline the classification process. This includes a
classification system which promotes safety and security, as well as effective delivery of
treatment services, based on determination of each youth’s individual needs and risk factors.
The program’s classification factors included physical characteristics, age, maturity level, history
of violence, gang affiliation, criminal behavior, physical and sexual aggression level, suicide risk,
as well as the youth’s current risk to reoffend. Five youth case management records were
reviewed. Each reviewed record had an initial classification which was completed on the day of
admission. The initial classification forms included a review of the youth’s physical
characteristics, age, maturity, a history of violence, gang affiliation, criminal behavior, and
sexual aggression or vulnerability to victimization. Each completed classification form also
included the identification of suicidal, mental, behavioral, medical, or security risks. A review of
five youth case management records reflected each youth had an initial classification completed
upon admission for purposes of assigning the youth to a living area, sleeping room, and youth
group. The program’s policy and procedure also address when a reassessment is warranted
based upon changes in the youth’s supervision status, new and updated alerts, relevant
information available to the treatment team, and/or behavioral concerns. It is the program’s
practice to complete a monthly reassessment for each youth. Reviewed documentation
supported monthly reassessments were completed in each of the five youth case management
records for consideration of increased privileges, work project participation, and off-campus
activity participation. An interview with the facility administrator (FA) stated youth with higher
behavior problems are typically placed in rooms together. The youth’s prior victimization is
assessed using the Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) and
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youth identified as having prior victimization are placed strategically away from peers identified
as aggressive on the VSAB.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures addressing gang identification which includes
notification to law enforcement. The program assesses each youth at intake for suspected gang
involvement. The policy includes the notification to the local law enforcement agency and the
youth’s home county law enforcement agency. Five reviewed youth case management records
showed three youth were applicable for gang identification. Each of the three youth records
confirmed the notification to the law enforcement was made to the identified local law
enforcement agency and the youth’s home county law enforcement agency. The supported
documentation also showed the educational staff and the youth’s assigned juvenile probation
officer (JPO) were also notified. Each youth’s record contained a documented alert in the
Department’s Juvenile Justice Information System.
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 maintains a gang binder which contains information on youth who have been
documented as gang members or associated with a gang. The program has a written policy and
procedures to ensure youth identified as gang related are provided gang prevention and
intervention activities. In addition, the policy and procedures ensure a plan can be developed for
youth who wish to disassociate with a criminal street gang. The program’s gang prevention and
intervention curriculum used is Gangs: Fifty Stories of Fractured Lives. In addition, the program
facilitates the Impact of Crime (IOC) curriculum to address gang intervention activities. The
program maintains sign-in sheets to document youth participation in gang prevention and
intervention activities. Five youth case management records were reviewed and three were
applicable for youth gang involvement and association. Each of the three applicable youth have
participated or were currently participating in the anti-gang intervention curricula. Each of the
youth Individualized Performance Plans (IPPs) included goals for gang prevention and
intervention strategies. An interview with the facility administrator (FA) stated the program
designates a member of the case management team to be a gang liaison who is trained to
identify youth who may be affiliated with an antisocial peer group/gang. The gang liaison
maintains documentation identifying these youth and conducts gang prevention groups monthly.
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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 maintains a written policy and procedures outlining the Residential Assessment for
Youth (RAY) and RAY Reassessment process of the youth admitted to the program. Five
reviewed youth case management records indicated the RAY was completed within thirty days
of each youth’s admission to the program. Each initial RAY was maintained in the youth’s case
management record and completed in the Department’s Juvenile Justice Information System
(JJIS). Four reviewed case management records were applicable for a RAY Reassessment.
Documentation supported each RAY Reassessment was completed within ninety-days of the
initial RAY. Each RAY Reassessment was maintained in the youth’s case management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
The program has a policy and procedures addressing the Youth Needs Assessment Summary
(YNAS) process, which is completed within thirty days of the youth’s admission. Five reviewed
case management records contained a completed YNAS. All reviewed records documented the
YNAS was completed within thirty days of the youth’s admission. Reviewed documentation
supported each YNAS was documented in the Department’s Juvenile Justice Information
System (JJIS) and a copy was maintained in each youth’s case management record.
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 in place regarding the Individualized
Performance Plan (IPP) being developed within the initial thirty days of each youth’s admission.
A review of five youth case management records revealed all records contained an initial IPP
which was created within thirty days of the youth’s admission and after the initial assessment.
All five youth records documented the youth’s plan was developed with participation of the
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treatment leader, youth, parent/guardian, medical representative, living unit representative,
administrative representative, mental health representative, education staff, and all parties who
have significant responsibility in goal completion. The administrative and living unit
representatives participated and signed all five IPPs. Each reviewed IPP clearly documented
the youth’s top three criminogenic needs and individualized goals based upon the prioritized
needs reflecting the risk and protective factors identified in the Youth Needs Assessment
Summary (YNAS) and Residential Assessment for Youth (RAY). Each of the youth’s IPP’s
outlined all the required elements such as the youth’s individualized goals, youth and staff
responsibilities, delinquency interventions, court sanctions, target completion dates, and goals
for transition. All five reviewed IPPs outlined staff and youth responsibilities to accomplish the
goals. All five youth case management records contained documentation indicating a copy of
the IPP was sent to the committing court, assigned juvenile probation officer (JPO), and
parent/guardian. There were no applicable youth receiving services from the Agency for
Persons with Disabilities (APD) or the Department of Children and Families (DCF). Five youth
were interviewed. Each youth indicated participating in the development of the IPP, knew which
goals they were working on, and were provided a copy of their IPP.
2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
The program has a written policy and procedures to address the revision of each youth’s
performance plan based upon the Residential Assessment for Youth (RAY). Three of five
reviewed youth records were applicable for a performance plan revision. Reviewed practice
indicated the multidisciplinary treatment team met formally approximately every thirty days to
discuss each youth’s Individualized Performance Plan (IPP) and documented the youth’s
demonstrated progress toward completing each goal. Two of five reviewed youth records
demonstrated lack of progress towards completing a goal. One of five reviewed youth records
indicated a need to facilitate transition activities during the last sixty days of youth’s stay.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a written policy and procedures to address the completion of performance
summaries and the transmittal of the summaries. Four reviewed open youth case management
records were applicable for the completion of a ninety-day summary. All four youth records
indicated each had performance summaries completed within the required ninety-day time
frame. All summaries included reports on the youth’s status on each Individualized Performance
Plan (IPP) goal, youth’s overall treatment progress based on their treatment plan, and the
youth’s academic status, including performance and behaviors in school. In addition, the youth’s
behavior including the level of motivation and readiness for change, interactions with peers and
staff, overall behavior adjustment to the program, and the youth’s significant positive and
negative events were included. All four youth were provided the opportunity to review the
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performance plan and add comments prior to signing and were provided a copy of the
summary. Each summary was filed in the youth’s case management record. All four
performance summaries were signed and dated by the treatment team leader, staff preparing
the summary, program director, and youth. All four summaries were sent within ten workings
days to the committing court, youth’s juvenile probation officer, and parent/guardian. Three
release summaries were reviewed, and each included the original summary, along with
justification for release, sent with the Pre-Release Notification (PRN) to the juvenile probation
officer (JPO). Each release summary and PRN was sent at least ninety-days prior to the
planned release. A signed copy of the PRN was retained in each youth’s case management
record. None of the five reviewed case management records were applicable for Victim
Notification of Release letters to be mailed to the victims at least ten days prior to the youth’s
release.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures which address the encouragement of parent/guardian
involvement in case management assessment, participation in the development of the youth’s
performance plan, progress reviews, and transition planning. Program practice is to provide all
parents/guardians advanced notice of the scheduled formal treatment team meetings with date
and times. Each letter also indicated if they cannot attend by telephone on the day of the
meeting, they may participate by providing verbal or written input prior to the meeting. Two
treatment team meetings were observed during the annual compliance review week which
confirmed the parent/guardian provided input by telephone. Five interviewed youth verified the
parents/guardians participate in case management services during treatment team. The
program also hosts family days once a quarter and weekly visitation. An interview with the
facility administrator (FA) stated upon admission, case managers call the youths'
parents/guardians and schedule the classification meeting, coordinating all of the departments
in the program. Parents/guardians are given the opportunity to communicate concerns and
pertinent information, as well as receive information from each department. Case managers
send out a parent/guardian handbook and other documentation outlining the services provided
by the program, the positive performance system, and other relevant information. Case
management staff communicate with parents/guardians regarding their child's progress during
monthly formal treatment team meetings, as well as during transition and exit conferences.
Parents/guardians are notified of these meetings by letter. Case managers also invite
parents/guardians for family day every three months and encourage parents/guardians and
siblings to come. Case management is also responsible for coordinating weekly phone calls
between youth and their parents/guardians.
2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
The program has a written policy and procedures for the intervention and treatment team to
reference or incorporate each youth’s treatment plan into the youth’s Individualized
Performance Plan (IPP). Five youth case management records were reviewed, and all had a
separate academic plan. Documentation supported all five youth academic plans were
incorporated into their IPP. All five youth records indicated the program incorporates medical,
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mental health/substance abuse, and therapeutic activities into the youth’s treatment plan based
on the development levels and needs of the youth. No reviewed youth case management
records were applicable for the youth being in the custody of the Department of Children and
Families (DCF) or the Agency for Persons with Disabilities (APD).
2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
The program has a written policy and procedures addressing formal and informal treatment
team meetings. Five youth case management records were reviewed for formal treatment team
meetings. All documented formal treatment team reviews were conducted at least once every
thirty days and informal treatment team reviews were conducted at least once within every thirty
days for all five youth reviewed. Reviewed documentation confirmed formal treatment team
meetings included the youth’s name and date of review. Attendees consisted of the youth, case
management staff who act as the treatment team leader, clinical staff, education, medical staff,
living unit representative, and a program administration representative for each of the five
applicable youth. Education staff provided written input and the parent/guardian and juvenile
probation officer (JPO) participated by telephone. The Residential Assessment for Youth (RAY)
was reviewed, and, when necessary, revisions to the individual treatment and/or performance
plans are discussed at the formal review. Each formal treatment team review included
comments from treatment team members, a brief synopsis of the youth’s progress in the
program, performance plan revisions, progress on performance plan goals, positive and
negative behaviors, behaviors resulting in physical interventions, treatment progress, and RAY
Reassessment results. Each youth was provided an opportunity to demonstrate skills acquired
in the program and all formal treatment team meetings were documented in the youth’s record.
Five youth case management records were reviewed for bi-weekly informal treatment team
meetings. Each record confirmed informal treatment teams meetings were held as required and
included all elements. An observation of a formal treatment team meeting was conducted during
the annual compliance review week and verified the participants reviewed the performance
goals, positive and negative behaviors, RAY Reassessment results, and treatment progress.
The youth was able to demonstrate the skills learned and discuss progress made while at the
program. Five interviewed youth stated staff review youth performance to include progress on
performance plan goals, positive and negative behavior, and treatment progress and are given
an opportunity during treatment team meetings to demonstrate any skills learned in the
program.
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2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a policy and procedures in place regarding transition planning, conferences,
and Community Re-Entry Team (CRT) meetings. Five closed youth records were reviewed. The
reviewed documentation validated a transition conference was held at least sixty days prior to
the targeted release date. All five youth records documented the program sent written
notification to all required participants including the parent/guardian, the youth’s juvenile
probation officer (JPO), educational staff, and other pertinent parties. All youth records
documented the youth, treatment team leader, clinical, medical, and education staff participated
in the transition conference as evidenced by the signatures on the transition plan signature
page. The JPO and parent/guardian participated by telephone. Each youth’s JPO,
parent/guardian, education staff, and any other pertinent parties were invited to provide written
input if they were unable to participate in person. During the transition conference, participants
reviewed the transition activities outlined on each youth’s Individualized Performance Plan
(IPP). All records documented a copy of the plan was sent with a request for return with
signature to anyone not in attendance who had a responsibility for completion of transition
goals. All plans were transmitted electronically to the JPO and the returned email
acknowledgement receipt was printed and filed with the plan. There were no applicable
revisions to the IPPs reviewed. Documentation supported target completion dates and persons
responsible for goal completion were identified at each completed conference. Each of the five
closed youth records contained documentation indicating the invitation to the CRT meeting.
Each closed youth record confirmed the youth participated in a CRT meeting prior to their
release from the program.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a written policy and procedures pertaining to exit portfolios. Five closed youth
case management records were reviewed for compliance with the completion of exit portfolios.
Exit portfolios included all educational documentation, school transcripts, a résumé, sample
employment applications, and educational/vocational certificates earned in the program, along
with a calendar of upcoming appointments. Four records contained an identification card, Social
Security card, and a birth certificate, and one did not. The program provided attempts to obtain
these items and the parent’s/guardian’s documented refusal to provide documentation and/or
assistance. All records contained documentation the exit portfolio was discussed and started at,
or prior to each youth’s exit conference. Documentation showed, upon release from the
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program, each youth was provided a copy of their exit portfolio. Each case management record
reflected the program staff forwarded to exit portfolio information to the juvenile probation officer
(JPO).
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program maintains a written policy and procedures pertaining to exit conferences. A review
of five closed case management records found an exit conference was conducted at least
fourteen days prior to each youth’s release date. Reviewed documentation for all five exit
conferences supported the youth, case manager who also acted as the treatment team leader,
the facility administrator or designee, educational staff, mental health staff, and medical staff
participated. The parent/guardian, and the assigned juvenile probation officer (JPO) participated
by telephone. The transition activities and target dates were reviewed, and all required
signatures were obtained. The date of admission and release coincided with the dates entered
in the Department's Juvenile Justice Information System (JJIS). Documentation showed a copy
of the exit conferences were electronically sent to the assigned JPO for all five youth and mailed
to each parent/guardian. The status of transition activities was established at the transition
conferences and plans were finalized for each youth’s release reviewed.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a youth advisory board (YAB) which consists of youth who have exhibited
leadership and mentoring skills while in the program. The YAB is a formal board meeting held
once a month where the youth in the program work directly with staff formulating ideas to
promote a positive relationship and input between youth and staff. Youth have the opportunity to
provide the board members feedback to discuss during the YAB meetings. The program also
utilizes the “Let’s Talk” forms which provide youth the opportunity to address issues, problems,
or concerns which may not require a grievance. Daily meetings are held with the youth to
address any immediate issues and provide the youth with staff expectations. The YAB book was
reviewed and confirmed the program’s practice. Interviews completed with five youth confirmed
the program has a process allowing them to provide input about what happens at the program.
During the intake process, case management sends out a parent/guardian survey which asks
the parent/guardian what they want their child to be working on. An interview with the facility
administrator (FA) stated the program’s formal process to solicit input from youth on systemic
issues is through the YAB, “Let’s Talk” forms, grievance forms, youth surveys, and youth
meetings with the FA and assistant facility administrator (AFA).
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program provides Type 2 career education programming which is directly instructed and
supervised by the Miami-Dade School District. The course curriculum includes, but is not limited
to, the instruction of interpersonal communication skills, personal accountability, awareness, as
well as other abilities which contribute to positive post release employment and living
experiences. All five reviewed records contained a completed résumé, and four contained a
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sample of a completed employment application. One of the records was not applicable for an
employment application due to the youth’s age. All reviewed records contained a post release
calendar which identified immediate post release appointments including the location of a
Career Source office near the youth’s home address. Four of the five reviewed records also
contained copies of appropriate documentation to gain employment, which included birth
certificates, Social Security cards, and a valid Florida identification card. One of the five
reviewed records did not contain these documents; however, according to an interview with
program staff, they reached out to the parents/guardians on several occasions to provide the
documents, and the parents/guardians either refused or did not respond to such requests. This
was noted in the youth’s chronological notes. All five records documented all parties involved in
the planning and construction of the youth’s post-release discharge plans were aware of such
planning. These individuals included the youth, the youth’s parents/guardian, the youth’s
juvenile probation officer, the program’s case managers, as well as input from the program’s
educational representatives. An interview with the facility administrator (FA) stated career
education services are provided to all youth, including certifications, training, and general
education about the process of applying for and maintaining employment. An interview with the
lead teacher indicated Occupational Safety and Health Administration 10, General Industry
Training, SafeStaff Food Handling, ServSafe Manager Training, Florida Ready to Work Soft
Skills Training, Digital Skills Training, and Academic Employability Training are career education
services and assessments are provided to youth in the program
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program’s education component is directly managed and supervised by the Miami-Dade
County School District. Reviewed logbook entries, youth interviews, and an interview with the
lead educator confirmed the education component operates on a year-round basis providing the
youth with at least 250 days of instruction distributed over twelve months with a minimum of
twenty-five hours of instruction weekly. A review of the annual academic calendar and daily
academic bell schedule reflected the youth received 251 days of annual academic instruction,
with ten days set aside for teacher training. The program’s academic schedule began at 8:00
a.m. and concluded at 1:50 p.m., with lunch occurring between 12:20 p.m. and ending at 1:00
p.m. The daily amount of instruction was 300 minutes each day, which translates to twenty-five
hours of weekly instruction. Daily classes were being conducted with minimal interruptions and
the youth were receiving academic credit for all completed academic work/assignments. A
review of logbooks for three randomly chosen days, as well as review of three video samples all
confirmed class was being conducted in accordance with the written academic schedule. This
was also documented in the program’s logbooks dated for the same days of the viewed
movement videos, in addition to a review of logbooks since the last annual compliance review.
An interview with the lead teacher stated the programs educational instruction schedule is
adhered to. Five interviewed youth stated there were minimal class disruptions at the program.
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2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
Five closed records were reviewed, and each contained a completed an Educational
Transitional Plan which was created within ten days of the youth entering the program and
concluded upon the youth’s release from the program. Each plan identified key services and
monitoring responsibilities by certain individuals essential to the plan’s creation and success.
The identified services were directly related to the youth’s reintegration back to their home
community, the recommended education placement upon their release, and the continuation for
the post-release provision of support services for the youth. The individuals involved in the
creation of the transition plan included the youth, the youth’s parents/guardians, the youth’s
juvenile probation officer (JPO), a representative of the program’s educational component, the
program’s transitional representative, as well as a representative of the youth’s home school
district. One of five reviewed records was not applicable for an Educational Transition Plan to be
acknowledged by their home school district for the provision of future services. This was
because the youth had earned their high school equivalency diploma (GED) during their stay at
the program. Five interviewed youth stated they were involved in the creation of their
Educational Transition Plan. An interview with the lead teacher confirmed academic goals
including diploma options, post-secondary options, and employment goals, services, and
interventions are based on the student’s assessed educational needs which are addressed in
the transitional plan.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program maintains a written policy and an attached comprehensive plan for the delivery of
mental health and substance abuse services. The program maintains a policy and a plan for the
coordination of mental health and substance abuse services. Additionally, the program
maintains a director of clinical services job description. The director of clinical services, also
referred to as the designated mental health clinician authority (DMHCA), acts as the program’s
mental health and substance abuse authority and is responsible for the oversight of all on-site
clinical services. The DMHCA is a licensed clinical social worker (LCSW). A review of the
license showed it was free and clear in the State of Florida with an expiration date of March 31,
2025. There was one additional DMHCA utilized since the last annual compliance review. The
previous DMHCA was a LCSW in the State of Florida. A review of the license showed it expires
March 31, 2025. The DMHCA is scheduled to be on-site Monday through Friday from 9:00 a.m.
through 5:00 p.m. A review of the job description, schedules, and an interview with the DMHCA
reflected they were on-site for a minimum of forty hours each week and on-call twenty-four
hours each day. The program has one additional full-time licensed staff and a pro re nata (PRN)
licensed staff equipped to perform as back-up to the DMHCA for absences. Both staff are
licensed mental health counselors (LMHCs). A review of each license showed they were free
and clear in the State of Florida with and expiration date of March 31, 2025. The interviewed
DMHCA reported their responsibilities include ensuring documentation is completed timely and
accurately. The DHMCA is responsible for reviewing the Comprehensive Mental Health and
Substance Abuse Assessments within ten calendar days of completion, and Individualized
Treatment Plans/treatment plan reviews are completed within five days of completion.
Additionally, the DMHCA is responsible for the reviewing and approval of various assessments
which include suicide risk assessments, Crisis Assessments, screening for Vulnerability to
Victimization and Sexually Aggressive Behavior (VSAB), American Society of Addiction
Medicine (ASAM) assessments, and Mental Status Examinations. The DMHCA reviews group
sign-in sheets daily and individual, group, and weekly progress notes are reviewed weekly
through an online tracking system to ensure services have been provided. The DMHCA attends
treatment teams, pre-classification, classification, needs assessment, transition staffing, and exit
conferences to ensure individualized treatment is consistent across the multidisciplinary team.
The DMHCA also completes group fidelity checks for clinical and delinquency groups monthly to
ensure the application of services is within guidelines. The DMHCA maintains a caseload, as
needed, conducting individual and family sessions. The DMHCA provides coverage for
individual and group therapy, and other assessments, as needed. The interviewed DMHCA
confirmed the responsibility for ensuring all clinical treatment programming complies with all
requirements.
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3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and a plan for the coordination of mental health and
substance abuse services. In addition to the designated mental health clinician authority
(DMHCA), the program employs a second licensed staff, a pro re nata (PRN) licensed staff, an
assistant board-certified behavior analyst, and a behavior analyst. A review of the back-up and
PRN licensed staff credentials reflected both staff are licensed mental health counselors
(LMHCs). A review of each license showed they were free and clear in the State of Florida with
and expiration date of March 31, 2025. Behavior analysts are subcontracted through a provider
company to provide on-site weekly services. A review of the behavior analyst assistant and the
supervising behavior analyst reflected both carried certifications which expire November 30,
2024. The program’s DMHCA ensures all licensed clinical staff are performing services they are
qualified to provide based on education, training, and experience. The program’s licensed staff
was in accordance with contract. The program was recently awarded a probationary Chapter
397 license through the Florida Department of Children and Families to provide substance
abuse services to adolescents. The license was issued on September 8, 2023 and expires
December 7, 2023. Prior to obtaining the license, the program’s practice was to only have
licensed staff provide substance abuse treatment. The program’s contract includes the use of a
psychologist, as needed. The program does not currently hold an agreement with an outside
psychologist; however, provided their documented efforts to obtain one. The interviewed
DMHCA and regional compliance staff reported the licensed staff have been providing all
services which would have been provided by a contracted psychologist since the last annual
compliance review.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and a comprehensive mental health and substance
abuse services plan. The plan requires all mental health/substance use treatment services
provided at the program to be provided by, or under the supervision of, the licensed designated
mental health clinician authority (DMHCA). Each therapist who provides substance use and/or
mental health services is provided weekly face-to-face supervision for a one-hour duration. All
clinical supervision shall be documented and maintained within a supervision log by the
DMHCA. A review of clinical supervision since the last annual compliance review was
completed. The program had two current and one previous counselor and a behavior analyst
applicable for clinical supervision. A review of all non-licensed counselors reflected clinical
supervision was provided for all weeks in which services were provided without exception. The
supervision sessions were completed either individually or in a group setting using the
program’s form which included all elements of the Department’s Licensed Mental Health
Professional and Licensed/Certified Substance Abuse Professionals Direct Supervision Log
form. The behavior analyst’s clinical supervision was documented through the behavior analyst
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notes. While the meetings with the DMHCA were not documented on the correct supervision
form, the meetings, as indicated in the notes, met all elements of the required items listed on the
Department’s form. The supervision notes indicated meetings were occurring more frequently
than the weekly requirement. Follow-up discussion and interviews occurred with the
Department’s Office of Health Services and the program’s DMHCA regarding the findings.
Documentation supported the behavior analyst and DMHCA staffed youth three to eight times a
month. The DMHCA attested the meetings were as in depth, if not more comprehensive, than
the clinical supervision sessions regularly held. The DMHCA reported moving forward the
behavior analyst will attend clinical group supervision on the scheduled day. If the behavior
analyst cannot attend the scheduled group supervision session, the DMHCA will schedule to
meet individually and document all discussions on the correct clinical supervision form. The
program was recently awarded a probationary Chapter 397 license through the Florida
Department of Children and Families to provide substance abuse services to adolescents. The
license was issued on September 8, 2023 and expires December 7, 2023. Prior to obtaining the
license the program practice was to only have licensed staff provide substance abuse
treatment. The program’s contract requires a recreation therapist. A review of the recreation
therapist credentials reflected they met the education requirements of the position. The
program’s licensed staffing was in accordance with contract and no vacancies were reported at
the time of the annual compliance review. A review of the non-licensed staff credentials for the
three non-licensed staff at the program since the last annual compliance review reflected each
held a master’s degree in a human services field and their credentials were vetted through the
Department’s Office of Health Services. A review of the twenty hours of training in suicide risk
and Crisis Assessment for the two current master’s level staff reflected one had completed the
administration of at least five Assessments of Suicide Risk or Crisis Assessments conducted
on-site in the physical presence of the licensed DMHCA. One staff had not yet completed the
training; however, was not yet completing suicide or Crisis Assessments at the program.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program maintains a written policy and a comprehensive mental health and substance
abuse services plan. The mental health and substance abuse needs of youth at the program are
identified through a comprehensive screening process which ensures referrals are made when
youth have identified mental health and/or substance use needs or are identified as a possible
suicide risk. Immediately upon the youth’s arrival to the program, an initial mental
health/substance abuse screening process is initiated by the multidisciplinary treatment staff to
ensure the identification of mental health/substance abuse issues requiring immediate attention
and/or further assessment and evaluation. The screening process is designed to gather
information on the youth prior to the youth entering the general population. The program utilizes
the Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) for all initial
screenings. The program also completes an Admission Classification form to document the
review of information gathered through collateral sources, previous assessments, and the
commitment packet. A review of five youth records confirmed each youth was administered a
MAYSI-2 on the day of admission. Each screening was completed by the trained master’s-level
counselor in the Department’s Juvenile Justice Information System and administered in a
confidential manner. Each reviewed MAYSI-2 was completed in full, and each indicated a
referral for additional assessment was needed. Each youth received scores above the cut-off in
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various domains of the screening. Additionally, it is the program’s practice to refer all youth for a
comprehensive assessment and the Department’s Assessment of Suicide Risk (ASR)
regardless of initial screening results. None of the reviewed screenings were applicable for a
staff override due to acquired information or observations. None of the reviewed screenings
indicated a youth was in crisis or required immediate interventions. The program completed a
referral for each youth which indicated the initial screening results and the need for additional
assessment. One youth was applicable for an identified risk of suicide and the program notified
the facility administrator (FA) and a referral for the required ASR was completed. A review of the
comprehensive plan confirmed it included a standardized screening process, staff training, and
referral procedures. The FA reported each youth is administered the MAYSI-2 with a masters-
level therapist to identify need for further assessment in multiple domains, including suicide,
substance use, and other mental health related areas.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a written policy and a comprehensive mental health and substance
abuse services plan. Due to the specialized population of youth admitted to the program, each
youth is automatically referred for a comprehensive mental health and/or comprehensive
substance abuse assessment. If a youth exhibits behaviors or other needs which require further
in-depth evaluations, the assigned therapist or observing staff shall initiate a referral for
additional assessment. The youth’s primary therapist is responsible for the completion of the
comprehensive mental health and substance use evaluation and obtains information through
interviews, face-to-face and telephonic sessions, and records review processes. The
comprehensive mental health and substance use evaluation must be completed within thirty
calendar days. Each assessment includes identifying information, reason for evaluation,
interview or procedures administered, a review of presenting issues, and relevant background
information which includes a comprehensive review of the youth’s home environment,
behavioral functioning, health, developmental milestones and problems, family systems issues,
educational functioning status, psychological needs, mental health treatment history, substance
use needs and history, history of physical abuse, sexual abuse, neglect, witnessing violence,
and other forms of trauma, and/or sexually deviant behaviors and prior treatment, medical
biological history and needs, and social and interpersonal relationships. Additionally, each
assessment includes behavioral observations, a Mental Status Examination, specialized needs,
abilities, and preferences, identified strengths and weaknesses, patterns of alcohol and other
drug use, impact of alcohol and other drug use on major life areas, risk factors for continued
alcohol and other drug use, discussion of findings, diagnostic impression/formulation, clinical
impressions, and treatment recommendations. A review of five youth records reflected each
youth was referred for a new Bio-Psychosocial Mental Health and Substance Abuse Evaluation
upon the day of admission. The program’s evaluations contained all comprehensive
assessment requirements. Each assessment was completed within thirty calendar days of
admission, by a non-licensed staff, and reviewed and signed by the licensed designated mental
health clinician authority (DMHCA) on the same day. Each assessment was completed in its
entirety and contained all mental health and substance abuse required elements. Each record
contained a consent for substance abuse treatment and each assessment documented the
substance abuse/use specific portions were completed by the licensed DMHCA.
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3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a written policy and a comprehensive mental health and substance
abuse services plan. Mental health and substance abuse treatment provided at the program is
guided by an individualized treatment plan which addresses the youth’s needs in accordance
with Florida Administrative Code. Treatment is provided by a licensed mental health
professional or therapist(s) working under the direct supervision of the licensed professional.
The program creates an initial treatment plan for all youth on the day of admission. A review of
five youth records reflected each youth had an initial treatment plan completed upon admission.
Each plan was documented on the program’s form and contained all elements of the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Each plan was
signed by the non-licensed therapist completing the plan. Each plan was signed by the licensed
designated mental health clinician authority (DMHCA) within ten days of completion. Each plan
was signed by all additional treatment team members who participated in the development of
the plan. Two plans were applicable for the youth being admitted on medications; however, the
initial plans did not list the specific medications and dosage. The plans stated the youth would
see the psychiatrist for medication management. The program’s regional compliance manager
met with the clinical team regarding the missing component during the annual compliance
review week. Each of the five youth had an individualized treatment plan developed within thirty
days of admission. Each plan was created on the program’s form and contained all elements on
the Department’s Individualized Mental Health/Substance Abuse Treatment Plan form. Each
plan was signed by a non-licensed therapist and reviewed and signed by the licensed DMHCA
within ten days of completion. Each individualized plan was signed by all treatment team
members, and documented parent/guardian telephone participation. The program’s practice is
to mail the plan to the parent/guardian for signature. Many plans contained a returned signature
page from the parent/guardian verifying the practice. Three youth were applicable for
medications at the time of their individual plan development, and each documented the specific
medication information. Each of the reviewed youth records were applicable for treatment plan
reviews. The five records were applicable for a total of twenty-five reviews. Each review was
completed at least every thirty days as required. Each review was documented on the
program’s form and contained all elements of the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan Review form. A review of treatment plans reflected
prescribed services included individual therapy, group therapy, family therapy, psychiatric
evaluation, applicable medication management, and the completion of a comprehensive
assessment. Reviewed goals and objectives were individualized for each youth. A review of
video, logbooks, and sign-in sheets for three separate clinical groups was completed. Each
video corresponded with the sign-in sheet documentation in regard to number of youth and
duration of the groups.
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3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program maintains a written policy and a comprehensive mental health and substance
abuse services plan. Mental health and substance abuse treatment provided at the program is
guided by an individualized treatment plan which addresses the youth’s needs in accordance
with Florida Administrative Code. Discharge planning processes begin at the time of each
youth’s admission to the program. Discharge criteria and a preliminary discharge plan are
documented on the youth’s individualized treatment plan. A review of five youth records
reflected the youth were assigned to a multidisciplinary team upon admission. The team
assignment was documented on the youth admission card in each record. The reviewed
admission cards and treatment planning documentation verified the teams consisted of the
youth, program administration, residential living unit representative, education, applicable
vocational staff, medical, mental health/substance abuse staff, and the parents/guardians. The
program was recently awarded a probationary Chapter 397 license through the Florida
Department of Children and Families to provide substance abuse services to adolescents. The
license was issued on September 8, 2023 and expires December 7, 2023. Prior to obtaining the
license, the program’s practice was to only have licensed staff provide substance abuse
treatment. Each of the five records contained a properly executed Authority for Evaluation and
Treatment form, a signed Youth Consent for Substance Abuse Treatment form, and a signed
Youth Consent for Release of Substance Abuse Treatment Records form. The program’s
treatment notes were documented on the program’s form and included all elements of the
Department’s Counseling/Therapy Progress Notes form. Treatment notes verified treatment
included individual psychotherapy and psychosocial skills training. Reviewed progress notes
confirmed each of the five youth were receiving services as prescribed in their individualized
plan with the exception of one monthly individual session missing for one youth. Five closed
youth records were reviewed for a discharge summary. Each summary was documented on the
Department’s Mental Health/Substance Abuse Treatment Discharge Summary form. No youth
were applicable for being released on suicide precautions requiring juvenile probation officer
(JPO) and parent/guardian notification. Each reviewed discharge summary documented the
services needed for the daily maintenance of positive improvement in behavioral, emotional,
and social skills made by the youth during treatment. The program’s practice is to discuss the
discharge summary with the JPO and parent/guardian during the exit conference and obtain the
parent/guardian signature upon release. The youth’s summary is emailed to the assigned JPO
and also sent by mail to the JPO with the youth’s treatment record. Reviewed documentation
verified these practices.
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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 maintains a written policy and a comprehensive mental health and substance
abuse services plan. Mental health and substance use treatment services are available on-site
through the provision of Substance Abuse Treatment Overlay Services (SAOS). All mental
health/substance use treatment services provided at the program are provided by, or under the
supervision of, the licensed mental health professional. At a minimum, specialized mental
health/substance use treatment shall include individual therapy sessions conducted on a weekly
basis, family therapy sessions provided monthly, supportive counseling as needed, and a daily
clinical group service which include processing groups, clinical education group forums, as well
as clinical social rehabilitation/psychoeducational group services. A review of the program
contract confirmed the specialized services include SAOS treatment. Five interviewed youth
reported groups included Cannabis Youth Treatment (CYT), Life Centered Education (LCE),
communication, social skills, Impact of Crime (IOC), and anger management. Interviewed youth
reported practicing and learning skills related to being accountable, coping, communication, and
anger management. Five interviewed staff verified only trained case managers or trained mental
health staff facilitate groups. The reviewed contract identified CYT, Pathways, and IOC as
primary groups. Additionally, the designated mental health clinician authority reported the
program made available Living in Balance, Seeking Safety, Anger Management for Substance
Abuse and Mental Health Clients, Adolescent Coping with Depression, Coping with Stress, The
Shyness and Social Anxiety Workbook, Cognitive Behavioral Therapy, LCE, and Thinking for a
Change groups to youth based on identified individual needs. The program’s mental
health/substance abuse treatment included groups seven days each week. The program
provides urinalysis drug testing upon admission, monthly, and when there is a suspicion of use.
Treatment notes verified services included individual, group, and family therapy. Reviewed sign-
in sheets verified mental health groups consisted of ten or fewer youth and substance abuse
treatment groups consisted of fifteen or fewer youth. The program’s group schedule, interviews,
and sign-in sheets verified youth received daily therapeutic activities to include substance abuse
education, relapse prevention, substance refusal skills, and coping skills. The program was
recently awarded a probationary Chapter 397 license through the Florida Department of
Children and Families to provide substance abuse services to adolescents. The license was
issued on September 8, 2023 and expires December 7, 2023. Prior to obtaining the license the
program’s practice was to only have licensed staff provide substance abuse treatment. A review
of sign-in sheets verified licensed staff were facilitating substance abuse groups. Reviewed
documentation verified youth with co-occurring disorders received comprehensive treatment,
clinical staff were on-site seven days each week, and caseloads were limited to no more than
ten youth. Documentation also verified youth are afforded the opportunity to participate in
Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) programming as outlined in
contract.
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3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
The program contracts with a psychiatrist for the management and oversight of psychiatric care.
The psychiatrist also supervises the treatment team and provides psycho-pharmacological
therapy to the youth who are receiving psychotropic medications. In addition to the psychiatric
evaluation, medical and psychiatric follow-up visits are conducted on an individualized basis as
determined by identified treatment needs. The program’s contracted psychiatrist is a medical
doctor with a specialty in adolescent psychiatry. A review of the license showed it was free and
clear in the State of Florida with an expiration date of Jan 31, 2025. A review of the contract
agreement and an interview with the psychiatrist confirmed they were on-call twenty-four hours
a day, seven days a week. The program does not utilize a psychiatric advanced practice
registered nurse (APRN). A review of sign-in logs since the last annual compliance review
verified the psychiatrist was on-site bi-weekly as required. A back-up psychiatrist was not
needed since the last annual compliance review. A review of the back-up psychiatrist’s license
showed they were an osteopathic physician in the State of Florida. The license was free and
clear with an expiration date of March 31, 2024. A review of the contract reflected the program
does not conduct tele-psychiatry. The interviewed psychiatrist reported they are responsible for
the coordination and implementation of the psychiatric services provided. The psychiatrist
reported conducting evaluation and treatment of youth in coordination with nurses,
psychotherapists, and clinical staff. They reported being on-site bi-weekly for four hours each
visit and meeting with the clinical treatment director during each visit. The psychiatrist confirmed
discussing initial diagnoses of the youth, following progress, providing psychotropic medication,
reviewing the symptoms, initiation of necessary court orders and Baker Acts, as well as
ensuring the youth are discharged with outside follow-up treatment. The psychiatrist reported
they would like to see an improvement in telephone communication; however, reported bi-
weekly face-to-face and necessary telephone communication with program staff was conducted.
The interviewed designated mental health clinician authority (DMHCA) verified the schedule and
services provided. A review of five youth records confirmed two youth were prescribed
psychotropic medication prior to admission and one youth was prescribed psychotropic
medications after admission. The two youth previously prescribed medication received a
psychiatric interview within fourteen days, and the youth admitted without medications received
a psychiatric interview within thirty days, as required. Each psychiatric interview documented
history, a Mental Status Examination, a Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) diagnosis which was consistent with the youth’s treatment plan, treatment
recommendations, applicable prescribed medications, the need for psychotropic medications,
target symptoms, initial treatment goals, potential side effects, risks and benefits of taking
medication, and frequency of medication management. Each of the three initial psychiatric
interviews were documented on the Department’s Clinical Psychotropic Progress Note (CPPN)
and contained all three pages. Each interview was labeled as an Initial Diagnostic Psychiatric
Interview. Each reviewed interview was applicable for the prescription of psychotropic
medications and documentation supported medication reviews occurred at least every thirty
days. The three youth were applicable for a total of twelve medication reviews which were all
documented on the Department’s CPPN. Each CPPN documented the medication identifying
data, diagnosis, target symptoms of each medication, evaluation and description of prescribed
medication on target symptoms, name and quantity of dosage, normal dosage range, ordered
dosage, frequency and route of administration, applicable reasons for changes in medication or
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dosage, side effects, adherence to medication regime, height, weight, blood pressure,
appropriate lab results, whether telephone contact was made with the parent/guardian,
psychiatrist signature, and date of signature. One youth was applicable for the monitoring of
tardive dyskinesia and the monitoring was documented as required.
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 maintains a written policy and a suicide prevention plan. The plan details the
procedures for identification and assessment of suicide risk, staff training, suicide precautions,
levels of supervision, referral, communication, notification, documentation, immediate staff
response, and a review process. The review includes the review of suicide attempts and a
mortality review process which encompasses circumstances surrounding the event, procedures
relevant to the incident, relevant training received by staff involved, pertinent medical and
mental health services of the victim, possible precipitating factors, change recommendations to
policy, training, physical plant, services, and/or operational procedures. The plan was last
reviewed and signed by the designated mental health clinician authority (DMHCA) on August
25, 2023.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
The program maintains a written policy and a suicide prevention plan. A review of five youth
records reflected each youth was screened upon admission for suicide risk. One of the five
youth was identified as a suicide risk; however, the program process is to refer all youth for
additional assessment. Each youth was assessed using the Department’s Assessment of
Suicide Risk (ASR) and deemed appropriate for standard supervision. An interview with the
designated mental health clinician authority (DMHCA) reflected the program had one youth
applicable for being placed on precautionary observation since the last annual compliance
review. A review of the applicable record indicated the youth was referred for an ASR and then
maintained on precautionary observation. Documentation reflected the youth was provided
supportive services by the mental health staff and a Follow-Up ASR was completed prior to the
removal from precautionary observation. The Follow-Up ASR was completed on the
Department’s form and the youth was maintained on suicide risk until the Follow-Up ASR
determined the youth was appropriate for close supervision status. The discontinuation of
precautionary observation was documented in the youth’s record and clearly provided the
details of a staffing between the facility administrator (FA) and the mental health staff. The youth
was maintained on close supervision until it was determined no longer necessary. The
discontinuation of close supervision was documented in the youth’s record and clearly provided
the details of a staffing between the FA and the mental health staff. The reviewed assessments
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were all completed by the licensed DMHCA in accordance with the program’s suicide prevention
plan. A review of the logbooks and the Department’s Juvenile Justice Information System
indicated alerts were entered, updated, removed, and communicated as required. There was
documentation in the youth’s record to support while determined a suicide risk, the youth was
allowed to participate in select activities. The program does not use secure observation
placement. A review of camera footage for the youth placed on precautionary observation
confirmed the youth was maintained on sight and sound supervision. The program practice is to
have potentially suicidal youth sleep in an open area and not behind a closed door. Five staff
were interviewed and reported the program’s suicide kits are located in sub-control, medical,
conference room, and laundry room. Each of the five staff reported mock suicide drills are
completed monthly on each shift.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a written policy and an emergency mental health and substance use
services plan. The plan includes the supervision and documentation requirements for potentially
suicidal youth. Program staff must remain within five feet of the youth at all times including in the
restroom, showers, and during sleep periods. All staff must maintain a Suicide Precaution
Observation Log form which documents behavioral observations on at least thirty-minute
intervals. An interview with the designated mental health clinician authority reflected the
program only had one youth on precautionary observation since the last annual compliance
review. The reviewed youth record contained a log completed on the Department’s Suicide
Precaution Observation Log. The logs reflected the youth’s behaviors were documented at least
thirty-minute intervals for the duration of precautionary observation placement. Initial placement
and warning signs were clearly documented on the log when the youth initially exhibited suicide
risk behaviors. The logs were signed by each shift supervisor and the mental health staff. Each
log documented safe housing requirements and the program’s practice is to attach an additional
form to the log titled “restriction checklist” which indicates supervision level, safe housing,
supervision requirements, permissible participation, and applicable restrictions.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a written policy and an emergency mental health and substance use
services plan. All staff receive a thorough mental health/substance use pre-service training
within the orientation process. The designated mental health clinician authority (DMHCA)
provides training to both direct and non-direct care staff within on-site job specific training for
identifying mental health and substance use issues and suicidal behaviors among children and
adolescents. The licensed DMHCA also addresses behavioral cues which indicate suicide risk
within the thorough reviews of the suicide prevention, crisis intervention, and emergency care
plans. Specific in-services are provided throughout the training calendar year, which address
mental health and substance use issues. Mental health/substance abuse drills are conducted at
the program under the supervision of the DMHCA quarterly on each shift. The drills are then
reviewed with all of the staff at the next monthly all-staff meeting to foster understanding and
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compliance with procedures. A review of five in-service and five pre-service training records
verified each staff received the required training in suicide risk and prevention. The program has
three suicide response kits, co-located with first-aid kits, located in the laundry room, conference
room, and the front office area. A review of mental health and mock suicide response drills since
the last annual compliance review verified the program was exceeding the quarterly
requirement. The program’s practice is to conduct drills each month on each shift. All drills
documented coordination and evaluation by the DMHCA. Documentation also supported the
program discussed drills during morning management meetings and during the monthly all-staff
meetings. The interviewed facility administrator reported every staff participates in mock suicide
and self-harm drills at lease quarterly and the DMHCA reviews and provides re-training for any
deficiencies noted. Five interviewed staff reported mock suicide drills are completed monthly on
each shift.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written policy and a corresponding crisis intervention plan. The
program’s primary goal of crisis intervention is to respond to youth in crisis in the least restrictive
method possible, and to protect the personal safety of the youth and others, while maintaining
control and safety of the program. Low level crisis intervention is typically provided by direct
care staff and/or supervisory staff through interventions within the behavior management
system or by therapeutic interventions. Most often, youth are able to respond to staff
intervention and the crisis is able to be de-escalated. In some circumstances, however, a
youth’s acute emotional or behavioral problem or psychological distress does not respond to
ordinary crisis intervention. In these instances, referrals to the mental health professional are
required. A review of the program’s crisis intervention plan indicated it included detailed
procedures a for a notification and alert system, means of referral, youth self-referral,
communication, supervision levels, documentation, and review. The plan was last reviewed and
signed by the designated mental health clinician authority on August 25, 2023.
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3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program maintains a written policy and a corresponding crisis intervention plan. All youth
whose acute emotional or behavioral problems or psychological distress does not respond to
ordinary crisis intervention shall be referred for a Crisis Assessment to be completed by the
therapist, working under the direct supervision of the licensed professional, or by the licensed
mental health professional. The identifying staff must notify the shift manager of the situation
and complete a referral requesting for the youth to be seen by a qualified mental health
professional. The shift manager then forwards the referral to the mental health professional. A
qualified mental health professional shall interview the youth and complete a Crisis Assessment
immediately or within two hours for emergencies, or within twenty-four hours based on the
needs of the youth. A review of five youth records reflected one youth was applicable for a
Crisis Assessment since the last annual compliance review. An interview with the designated
mental health clinician authority (DMHCA) indicated there was a total of three Crisis
Assessments completed since the last annual compliance review and the two additional
assessments were provided for review. Each assessment indicated the youth was not having an
emergency. Two assessments were completed the same day and the third was completed the
day after the referral. Each reviewed assessment documented the reason for assessment,
Mental Status Examination results, determination of danger, initial clinical impressions,
supervision recommendations, treatment recommendations, applicable follow-up
recommendations, and appropriate notifications to the parent/guardian of follow-up treatment.
All assessments were completed on-site by the licensed DMHCA. None of the assessments
indicated a mental health alert or an increased supervision level was warranted. None of the
youth required a Follow-up Crisis Assessment. Two assessments were following a Prison Rape
Elimination Act (PREA) allegation and youth were immediately referred and offered ongoing
mental health treatment services.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written policy and an emergency mental health and substance use
services plan. Any youth who presents as an imminent danger to themselves or others because
of mental illness or substance use impairment which requires emergency treatment shall
receive immediate care. Staff must ensure the medical stability of the youth and ensure the
youth has no further opportunity for additional attempts at self-harmful behaviors. The reviewed
plan outlines procedures for immediate staff response, notification, communication, supervision,
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authorization to transport for emergency services, transport for emergency evaluation under
Marchman Act or Baker Act proceedings, documentation, training, and review. The plan was
last signed and reviewed by the designated mental health clinician authority on August 25, 2023
3.17 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a written policy and procedures for the on-going safety planning process
for youth. A review of five youth records reflected each was applicable for an initial safety plan
and safety plan reviews. Each reviewed safety plan documented warning signs, baseline
behaviors, crisis recognition, jointly developed coping strategies, intervention strategies, and a
debriefing process. Each plan was completed within fourteen days of admission and jointly
prepared by the youth’s clinical staff, youth, and parent/guardian. Each plan incorporated
trauma responsive practices and applicable recommendations from clinical assessments. Each
plan was reviewed at least every thirty days and/or when updates were necessary due to
significant events. The five youth were applicable for twenty-nine safety plan reviews which
were completed as required. The program staff have access to treatment plans for regular
review and the plans are addressed during each treatment team meeting. The plans are kept in
a binder in the front of the program. Five youth were interviewed and each confirmed
participation in the development of their safety plans. Five interviewed staff reported reviewing
plans as needed and confirmed the plans were accessible to staff. Each of the five staff
reported reviewing youth plans in the past week. The interviewed facility administrator reported
safety plans are updated at least every thirty days and/or as needed.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a written policy and procedures which requires a contracted health authority to
provide on-site medical services to youth in the program. The program maintains an
independent contractor agreement with a State of Florida physician to serve as the designated
health authority (DHA). The DHA has a clear and active license in the State of Florida, which
expires on January 31, 2024, with specialty training in pediatrics. A review of the Florida
Department of Health records documentation showed the DHA had no disciplinary cases and/or
public complaints on record. The DHA is required by contract to be on-site for a minimum of two
hours a week with no more than nine days passing between on-site visits. A review of sign-in
sheets since the last annual compliance review showed the DHA was on-site as required with
the exception of one site visit being more than nine days between visits. The DHA was on-site
August 1, 2023, and then again on August 11, 2023. The program has a back-up DHA who has
a clear and active license in the State of Florida expiring on January 31, 2024. An interview with
the nurse stated the back-up DHA was not utilized during the annual compliance review period.
The program does not utilize an advanced practice registered nurse (APRN) or physician’s
assistant (PA). A review of the program’s contract and policy and procedures showed there was
no inclusion or approval from the Department’s Office of Health Services for tele-medicine/tele-
health services. An interview with the DHA stated their role in the program is to complete
Comprehensive Physical Assessments (CPAs) within seven days of youth’s arrival to the
program and every year thereafter. The youth with chronic problems are seen every two
months, and sick and/or episodic care youth, who have been escalated, will be seen weekly.
The DHA stated the nursing protocols and policy and procedures are reviewed, and they advise
when pertaining to medical issues. The DHA confirmed being on-site weekly and being
available by telephone twenty-four hours a day, seven days each week.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a written policy and procedures for all health-related procedures and protocols
utilized. The program provides on-site medical coverage seven days a week from 7:00 a.m. to
7:30 p.m. The program has two registered nurses (RNs), one licensed practical nurse (LPN),
and one pro re nata (PRN) RN. One of the RNs serves as the program’s health services
administrator (HSA). A review of the program’s medical schedule documentation showed the
HSA provides clinical supervision and medical services Monday through Friday from 7:00 a.m.
to 3:30 p.m. One RN is scheduled to work Monday through Wednesday 7:00 a.m. to 7:30 p.m.
and on Sunday 7:00 a.m. to 7:30 p.m. The LPN is scheduled to work Wednesday through
Saturday from 7:00 a.m. to 7:30 p.m. The program’s contract confirms the required schedule. A
review of licenses for the HSA and three current nursing staff providing services at the program
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found each had a clear and active license in the State of Florida. Reviewed documentation
confirmed all three RNs had current cardiopulmonary resuscitation (CPR) certifications.
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. The program’s designated health authority (DHA) conducts an annual review
of all health-related policies, procedures, and protocols. Reviewed documentation showed the
DHA reviewed, signed, and dated the FOPs on July 18, 2023, the facility administrator signed
on June 23, 2023, and the psychiatrist signed on August 26, 2023. The DHA reviewed and
signed all nursing protocols on June 25, 2023. The nursing staff signed a cover page
acknowledging review of all FOPs and treatment protocols on August 12, 25, 31, and
September 9, 2023. There were no noted applicable policy changes during the annual
compliance review period. The program had three new staff since the last annual compliance
review. There was documentation all three staff received a comprehensive clinical orientation.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a written policy and procedures to ensure the completion of the Authority for
Evaluation and Treatment (AET) for all youth admitted into the program. The program utilizes a
separate form for youth eighteen years of age or older providing consent for release of specific
information as noted on the Release of Information Authorization for Youth Eighteen Years of
Age and Older form and to whom the information can be released and shared. A review of five
youth Individual Healthcare Records (IHCRs) documentation showed each youth had a valid
AET and the word “Copy” was stamped on each youth’s AET. Each of the five AET forms were
signed by the youth’s parent/guardian. There was documentation the AET was signed by a
Department representative. There were no youth applicable for being eighteen years of age or
older, or in the care of the Department of Children and Families (DCF). An interview with
nursing staff stated new admissions are discussed with the case management staff prior to the
youth arrival, and if needed the juvenile probation officer (JPO) would be contacted through
case management to obtain a new AET. If the youth is eighteen years or older upon intake, or
when the youth turns eighteen, the youth will fill out two release of information forms to give
consent to release medical information.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a written policy and procedures to inform the parent/guardian of significant
changes in the youth’s condition and obtain consent when new medications and treatments are
prescribed. A review of five youth Individual Healthcare Records (IHCRs) documentation
showed consent was provided by each youth’s parent/guardian for over-the-counter (OTC)
medications. Three of the five youth were applicable for taking psychotropic medications.
Documentation showed in all three records a staff witnessed all telephone calls whenever a new
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psychotropic medication was prescribed or discontinued, or changes were made requiring
parental/guardian verbal consent. None of the three youth were applicable for being in the care
of the Department of Children and Families (DCF). Each of the five reviewed IHCRs
documented the program received and verified the youth’s vaccination records on the date of
admission. None of the youth were applicable for requiring new vaccinations or requesting
religious exemption. An interview with the nurse stated verbal consent is obtained for any OTC
medication which is not listed on the signed Authority for Evaluation and Treatment (AET), for
new prescriptions, significant dosage changes, or discontinuation of a medication. Medical staff
will then follow-up by mailing a written parental notification.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a written policy and procedures regarding healthcare screening for each youth
upon admission into the program. A review of five youth Individual Healthcare Records (IHCRs)
documentation showed each youth received a Facility Entry Physical Health Screening
(FEPHS) upon admission, by the programs registered nurses (RNs). None of the five youth
were applicable for a change in physical custody. An interview with the nurse stated newly
admitted youth are seen by medical staff immediately following the initial search. The nurse
stated new intakes are discussed prior to admission in collaboration with the administration
team. The nurse also confirmed the admission screenings are completed by all medical staff on-
site at the time of each youth’s admission.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a written policy and procedures to ensure each youth admitted into the
program receives a healthcare orientation. A review of five youth Individual Healthcare Records
(IHCRs) documentation confirmed each youth received an orientation to healthcare services at
the program upon admission. Each youth’s orientation included topics such as access to
medical care, sick call process, emergency situations, medication process, right to refuse care,
what to do in case of sexual assault or attempted sexual assault, non-disciplinary role of
healthcare staff, and standard universal precautions. All topics were documented on the Health
Education form and was signed and dated by each youth.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a written policy and procedures to notify the designated health authority (DHA)
by telephone, text message, or verbally, if on-site, of all youth admitted into the program
identified with chronic health conditions or youth in need of emergency care. A review of five
youth Individual Healthcare Records (IHCRs) reflected three youth were applicable for having a
known or suspected chronic condition. Documentation showed the DHA was notified within
twelve hours of admission. Two of the three youth were taking psychotropic medication upon
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admission, and there was documentation the psychiatrist was notified. An interview with the
nurse confirmed the nurse makes contact with the DHA upon each youth’s admission to the
program to obtain admission orders.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a written policy and procedures to address the completion of the Health-
Related History (HRH) form prior to the completion of the Comprehensive Physical Assessment
(CPA) upon each youth’s admission to the program. A review of five youth Individual Healthcare
Records (IHCRs) documentation showed an HRH was completed within the required seven
days of admission, and prior to each youth’s CPA. Documentation showed the designated
health authority (DHA) reviewed the HRH form for each of the five records. An interview with the
nurse stated the HRH is completed by the registered nurses (RNs) during the initial nursing
assessment.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a written policy and procedures ensuring each youth admitted shall receive
and/or shall have on record a current Comprehensive Physical Assessment (CPA) and Health-
Related History (HRH) form no later than seven calendar days of admission into the program. A
review of five youth Individual Healthcare Records (IHCRs) documentation showed each youth
had a new CPA completed by the designated health authority (DHA) within seven days of
admission, using the Department’s form. There was documentation each youth’s Medical Grade
was documented on the CPA. There was no sign of any missing/incomplete elements on the
reviewed forms. Four of five youth refused part of the exam. There was documentation on each
youth’s CPA documenting the refusal and included the youth’s signature by the applicable
portion of the CPA examination. One youth did not refuse. All sections of the CPA were
completed in full utilizing an “O” and/or applicable “X” markings except for sections numbered
nineteen through twenty-two, as those sections were not applicable to the male program.
Documentation confirmed the results of each youth Tuberculosis Skin Test (TST) were
documented on the CPA and the Department’s Infectious and Communicable Disease (ICD)
form and on the program’s TST/Purified Protein Derivative (PPD) form. An interview with the
nurse confirmed the initial CPA is completed by the DHA within seven days and annually
thereafter. The nurse stated the process and time frame for the tuberculosis screening is to be
completed upon admission and after applicable re-entry to the program.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a written policy and procedures ensuring all youth admitted shall be clinically
screened and medically evaluated for sexually transmitted infections (STIs) and human
immunodeficiency virus (HIV). A review of five youth Individual Healthcare Records (IHCRs)
documentation showed each youth was clinically screened and evaluated for STIs. Each of the
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five youth were referred for further evaluation and referred to the designated health authority
(DHA). Documentation showed each youth received a referral for testing and testing was
provided. Each youth’s testing, screening results, clinical evaluations, and diagnosis was
showed to be documented on the Department’s Infectious and Communicable Diseases (ICD)
form. Five youth IHCRs documented each youth was offered counseling and testing for HIV.
Four of the five youth refused the testing. There was signed consent documentation from the
one youth who did not refuse. The youth’s results were in a sealed envelope marked
“Confidential” and stored in the youth’s IHCR in the laboratory section of the record. There was
no documentation the DHA reviewed the sealed envelope. The program offered no additional
information regarding the missing documentation. There was documentation in the youth IHCR
a pre/post-test counseling was conducted. All youth consenting for testing is tracked on the
program’s HIV Testing Tracking Log stored in the nursing office. The health services
administrator (HSA) stated the DHA provides the pre and post-test counseling. The youth’s
confidentiality was protected and there was no indication the youth results were documented in
the program alerts. The program maintains a written policy and procedures ensuring all youth at
risk for HIV infection are offered counseling, testing, education, prevention counseling, and a
referral for medical treatment. The programs policy confirmed the practice. Five interviewed
youth stated they can receive an HIV test. The interviewed nurse stated all youth admitted to the
program are screened for possible STIs by completing the Sexually Transmitted Infections
Screening form. If a youth screening indicates a need for further evaluation the youth will be
referred to the DHA to receive a physician order for testing. When all youth testing has been
provided and results are received, the youth results are stored in the youths IHCR in the
laboratory section of the record.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a written policy and procedures ensuring all youth shall be able to make sick
call requests and have their complaints treated appropriately through the sick call system. The
program’s sick call hours are Monday through Friday from 9:10 a.m. to 9:40 a.m. and 5:00 p.m.
to 5:30 p.m., and on weekends from 8:30 a.m. to 9:30 a.m. and 3:00 p.m. to 5:00 p.m. The sick
call hours are posted in the dayroom hallway. A review of the program’s contract and the activity
schedule found the program is following the sick call hours. Sick call forms were observed in the
dayroom hallway accessible to youth. A locked sick call box was observed in the dayroom hall
next to the sick call forms. A review of five youth Individual Healthcare Records (IHCRs)
reflected none of the five youth were applicable for presenting with a similar sick call complaint
three of more times within a two-week period. Four of the five youth were applicable for
completing a sick call request form. One youth was applicable for a licensed practical nurse
(LPN) conducting the sick call and there was documentation the sick call was reviewed by the
programs registered nurse (RN). All sick calls were documented on the Department’s Sick Call
Index, Sick Call Referral Log, and filed within the youth’s IHCR in reverse chronological order.
None of the five youth were applicable for being in restricted housing. The program does not
utilize restricted housing of any kind. During the annual compliance review week there was no
sick call observation conducted due the program not having any sick calls while the annual
compliance review team was on-site. The interviewed nurse stated the program has two staff
trained to conduct sick calls when there is not a licensed nurse on-site. The nurses stated youth
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can submit a sick call at any time and place the form in the sick call box. The box is checked at
least every two hours throughout the day by nursing staff. Youth are seen within twenty-four
hours. Five staff were interviewed all five staff stated the nurse reviews sick calls. Five staff
stated the nurse conducts sick calls and two stated the doctor conducts sick calls. Five youth
were interviewed, and one youth stated they can see the nurse immediately when a sick call
request is made, and four youth stated they can see the nurse within one day.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a written policy and procedures regarding the provision of episodic and
emergency care. A review of five youth Individual Healthcare Records (IHCRs) reflected two
youth were applicable for episodic care encounters. The program provided one additional youth
record to meet the sample size of three. Each of the three episodic care events were conducted
by a registered nurse (RN) and documented in subjective, objective, assessment, and plan
(SOAP) form. None of the episodic or first-aid care was provided by non-healthcare staff. None
of the applicable youth were sent off-site for emergency care. Each applicable youth episodic
care event was documented in the progress chronological notes and tracked on the Episodic
Care Log. The program has six first-aid kits located in areas throughout the program. The kits
are located in conference room, the kitchen, the classroom, and the laundry room. Two first-aid-
kits are for the program’s two vans, and both first-aid kits are kept in the front office until ready
to be used. The program has a specific content list for each first-aid kit. The list is maintained in
each first-aid kit and has each item noted with an expiration date. Documentation showed the
nurse checks the first-aid kits weekly. Observation of three first-aid kits was conducted and each
kit had the required items. The program had one automated external defibrillator (AED) located
in the dayroom hallway. The AED procedures are located with the AED. Documentation showed
the AED is checked by the nursing staff once a month. Reviewed documentation confirmed the
AED batteries expire on October 31, 2027, and the pads expire on June 9, 2025. The batteries
and pads were last changed in July 2023. Observation of a self-test of the AED showed the
AED was operating correctly and there were no issues. The program has three shifts. A review
of the program’s mock emergency medical drills documentation showed a drill was conducted
on each shift monthly for the last twelve months. Emergency medical drills included the
demonstration of cardiopulmonary resuscitation (CPR) and AED at a minimum of annually. The
emergency medical drills consisted of both announced and unannounced drills and were
conducted on each shift as required. Each drill was shown to simulate an episodic care event
which called for immediate first-aid and/or administration of CPR techniques and the initiation of
the emergency procedures to follow when a life-threatening emergency does occur. All drills
were stored in a binder documented as drills. A review of five staff training records
documentation confirmed all five staff had current CPR/first-aid and AED certifications. The
program has a list of emergency numbers posted in the front entrance of the program and in the
nurse’s office accessible for non-licensed and licensed staff. Emergency phone numbers were
inaccessible to youth. An observation of an episodic care event was conducted. The medical
staff was able to maintain the youth’s privacy. The direct care staff was located by the door of
the nurse’s station. The program has a written policy and procedure which steps out the use,
access, and inventory of NARCAN®. The nurse secures the NARCAN® in the locked medical
cart. The nurse reported all medical staff are trained and identified program staff have been
trained on how and when to use NARCAN®. The nurse stated NARCAN® is inventoried when
conducting the medication count along with all other medications. An interview with five staff
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stated they are personally allowed to call 9-1-1 if a youth has a medical emergency. Five
interviewed youth stated they can see the dentist and the doctor if needed.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a written policy and procedures for the provision of off-site emergency and
non-emergency referrals for medical care and treatment. A review of five youth Individual
Healthcare Records (IHCRs) reflected two youth were applicable for receiving off-site care. The
program provided one additional record. One youth was applicable for having emergency care
documented on the Episodic Care Log. Two youth were taken off-site for a dental appointment.
Documentation showed each youth’s parent/guardian was notified of the youth’s off-site care
event. Each of the three youth IHCRs had a Summary of Off-Site Care Consultation Report
which was filed in the IHCR with any applicable additional documents. The designated health
authority (DHA) reviewed and signed all forms as required. All three youth required a follow-up
appointment, and documentation showed each youth received the follow-up appointment in a
timely manner. An interview with the nurse stated the DHA signs off on all off-site summary
forms, when the youth return from the off-site visit, and if a follow-up appointment is needed the
nurse documents the appointment on the nursing tracking calendar.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a written policy and procedures ensuring youth who have chronic illnesses
receive regularly scheduled evaluations with the required follow-up. A review of five youth
Individual Healthcare Records (IHCRs) reflected two youth were applicable for having a chronic
condition. The program provided one additional youth to meet the sample size of three. None of
the youth were documented as having a communicable disease. Two of the three youth were
taking medication on an ongoing basis. Two youth were undergoing treatment for a physical
health condition. Each youth was placed on the chronic illness list and periodic evaluations were
conducted when applicable, at least every ninety days. The program maintains a tracking log for
youth with chronic conditions and evaluation dates. The tracking log indicated each youth’s next
scheduled appointment. None of the youth were applicable for taking anti-tuberculosis
medications. Periodic evaluations were conducted prior to a prescription renewal, change, or
expiration, when applicable. None of the reviewed youth were applicable for an off-site
evaluation. There were no documented lapses in care or missed periodic evaluations in each of
the reviewed records. The Department’s Problem List for each youth was updated in
accordance with policy. An interview with the facility administrator (FA) stated medical issues
are discussed daily during morning meetings and management meetings. An interview with the
nursing staff and the designated health authority (DHA) confirmed the process for the
completion of periodic evaluations.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a written policy and procedures which outline the process of how medications
are to be received, stored, inventoried, and administered in a safe and effective manner. A
review of five youth Individual Healthcare Records (IHCRs) reflected three youth were
applicable for being on medication. Two youth were on medication prior to admission, and one
was prescribed medication after admission. For the two youth admitted on medication the
medication was verified prior to being admitted into the program. Both youth prescription
verifications were included in the chronological progress notes. There was documentation the
designated health authority (DHA) and psychiatrist were contacted to obtain orders to resume
medications. All three youth medications had a current, valid order, and were administered
pursuant to a current order. Each youth had a Practitioner Order form filed in their IHCR for
continued medication or new medication. Documentation showed each youth had a standard
Department Medication Administration Record (MAR) to document all medication and treatment.
A review of the MAR for all three youth reflected no instances where a non-healthcare staff
assisted in the delivery of medication. In each record there was documentation medical staff
initialed each medication entry, along with documented weekly side-effect monitoring. One of
the three records was applicable for the youth refusing the medication. There was clear
documentation on the MAR along with a signed Refusal of Treatment form. Each reviewed MAR
documented all required elements. None of the three youth were applicable for parenteral
medication. Documentation showed each applicable youth received an initial diagnostic
psychiatric interview within the required fourteen days of admission. All three youth received
medication monitoring every thirty days as required. There was no sign of any type of standing
orders for psychotropic medications. There were no signs of any emergency treatment orders
for psychotropic medications. There was no sign of any pro re nata (PRN) orders for
psychotropic medications. One medication pass was observed during the annual compliance
review week with no noted issues. The youth was escorted to medical by direct care staff. The
Six Rights of Medication Administration were verified by the nurse. The nurse administered the
medication as required and did not pre-pour any of the medications. Five youth were
interviewed, and three youth stated the nurse gives medication and two youth stated they do not
take medication. Five staff were interviewed, and five staff stated the nurse dispenses
medication and two staff stated the doctor does. An interview with the nurse confirmed the
process for nursing staff verifying youth medications. The nurse stated only nurses are to
complete admissions in the program. All medications are verified with the records sent with the
youth from the juvenile detention center. Medications are also verified with the youth’s
parent/guardian during the intake process.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a written policy and procedures regarding the requirements for the storage
and inventory of medications and sharps ensuring all medication is inaccessible to youth at the
program. Observations of the medication cart showed it was clean and organized, with stock
items separate from youth specific medications. An observation of the medication cart found all
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medications were stored in the locked cart which is kept in the locked medical office. All non-
controlled medications were stored in a separate, secure, locked medication cart. Narcotics and
other controlled medications are securely stored and double locked within the medication cart.
Observations found all medications were securely stored in the medical clinic inaccessible to
youth. The program had no medication requiring refrigeration during the annual compliance
review week; however, the program has a refrigerator which is used only for medication, if
needed. A review of documentation showed the program’s over-the-counter (OTC) medications
are inventoried using a perpetual inventory daily. An interview with the nurse confirmed the
programs practice. Perpetual inventories with running balances are maintained on all controlled
substances with a shift-to-shift inventories conducted by the nurses. Syringes and sharps are
counted through a perpetual inventory and are verified weekly. An observation of counts was
conducted with the nurse. The program had one youth prescribed two narcotic or controlled
medications and the reviewed inventories were accurate. Three OTC medications were
reviewed, and the inventories were accurate. Three sharps were reviewed, and inventories were
accurate. An interview with the nurse stated the disposal of medication is to destroy the
medication on-site with the pharmacist. Medications can also be returned to the pharmacy for
destruction.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a written policy and procedures for infection control which includes an
Exposure Control Plan and is written in accordance with Occupational Safety and Health
Administration (OSHA) and the Centers for Disease Control and Prevention (CDC) guidelines.
The policy for infection control was signed by the facility administrator (FA) July 17, 2023, and
the designated health authority (DHA) July 18, 2023. The plan included common infectious
diseases of childhood, self-limiting, episodic contagious illnesses, viral or bacterial infectious
diseases, tuberculosis, Hepatitis A, B, and C, Human Immunodeficiency Virus (HIV), infectious
diseases caused by blood-borne pathogens, other outbreaks or epidemics caused by any other
infectious agent, outbreaks of lice or scabies, Methicillin-Resistant Staphylococcus Aureus
(MRSA) and other anti-biotic resistant micro-organisms, food-borne illnesses, bio-terrorist
agents, and chemical exposures. The program also has Hepatitis B immunizations available to
staff along with access to protective equipment. An interview with the program’s compliance
manager confirmed since the last annual compliance review there were no instances where the
local county health department, CDC, and/or the Department’s Central Communications Center
(CCC) needed to be notified of any infectious disease; however, the program has a separate file
containing documents for youth and staff who have experienced an occupational exposure. The
plan includes a process for needle stick post-exposure evaluation. The program has a separate
file containing documents for youth and staff who have experienced an occupational exposure.
There also were no instances involving quarantining or hospitalization since the last annual
compliance review. An interview with the FA stated the infection control and exposure plans are
located in master control and are reviewed with youth twice a year. An interview with the nurse
stated infection control and exposure control training for staff is conducted by the health service
administrator (HSA), and the training for youth is provided during the youth admission process.
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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 written policy and procedures to ensure all program staff promote
safety and security by maintaining active supervision of youth to include interacting positively
with youth, engaging youth in a full schedule of constructive activities, closely observing
behavior of youth, and consistently applying the program’s behavioral management system
(BMS). The program’s staff-to-youth contract required ratio of daytime activities is one staff to
eight youth and nighttime/sleep ratio is one staff to twelve youth. There were staff observed
during daily activities to include school, recreation, breaks, and line movement, on Tuesday
through Friday during the annual compliance review week. All staff were observed in ratio, and
searches were conducted before and after movement. During the observations, each youth
called out line numbers from the back to the front for the accuracy of count. All youth were
conducting themselves positively with other youth and staff. Five staff were interviewed, and
each staff was aware of the number of youth they were supervising for physical sight and sound
presence. During a program tour, there were daily schedules posted and available to each
youth within their living units. Each youth was actively involved in their daily education during
the annual compliance review week. Video surveillance revealed staff were checking each
youth room during sleeping hours consistently with no issues or concerns. Five staff were
interviewed, and each staff stated if a youth count cannot be reconciled, staff will stop all
movement, conduct an emergency head count until the youth is located, the supervisor will
search the entire program and call a code green over the radio, and if the youth has not been
located the program will call 9-1-1/law enforcement.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program has a written policy and procedures to ensure the implementation and training of
the program’s behavior management system (BMS) which is approved by the facility
administrator (FA) and has not changed since the last annual compliance review. The program
has a written BMS which is a multi-level point system designed to maintain respect, promote
safety, fairness, protection of rights within the program, order, security, teach youth alternative
pro-social methods of dealing with issues, and foster compliance with program rules. A review
of documentation revealed the appropriate parties are involved in the development and on-
going maintenance of the BMS. The policy and procedures include a protocol where staff are
provided feedback regarding the implementation of the BMS. The facility trainer provides the
education to staff while jointly combining the BMS plan to include the use of the BMS during
school. Five youth records were reviewed and confirmed youth orientation included a review of
the program’s BMS. A review of five staff records indicated each staff position description
included implementation of the BMS. A review of the program’s pre-service staff trainings
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reflected five staff completed training in BMS. During a program tour there were observations of
the BMS posters, located throughout the program in the common areas which included the rules
governing conduct and positive and negative consequences. Documentation in the youth
handbook indicated the agreement from each youth on the expectations on the BMS. The BMS
had not been changed since the last annual compliance review and still includes promoting
safety, respect, fairness, promoting and protecting youth rights, positive and negative
consequences, constructive disciplinary actions/non-punitive, opportunities for positive
reinforcement, recognition of accomplishments and positive behaviors at a four to one ratio,
promoting socially acceptable means for youth to meet their needs, a process for explaining to
youth the reasons for any sanctions imposed, youth having the opportunity to explain his/her
behavior, opportunities for staff and youth to discuss the impact of behavior on others,
reasonable reparations for harm caused to others, discussions of alternate behaviors, promoting
positive dialogue and peaceful conflict resolution, and separation of youth from the population is
minimized. An observation of staff and youth interactions confirmed adherence to elements of
the BMS, including rewards and negative consequences, which are in direct relation to the
severity or seriousness of inappropriate behavior exhibited. An interview with five staff indicated
each staff was aware of requirements given, based on the youth’s level points each day. All staff
use the BMS to reinforce positive and decrease negative behaviors, and youth are given the
opportunity to correct their behaviors when needed. An interview with five youth indicated each
youth is familiar and agrees with the BMS. Three youth stated staff are fair and two youth stated
staff are good with the implementation of the BMS. Each youth confirmed the incentives given
for good behavior and stated there will be a level drop for bad behavior; however, youth are
given the opportunity to correct their behavior before a level drop. An interview with the FA
indicated rewards and incentives consists of canteen, movies, holiday parties, University of
Miami game day tickets, and outside food such as chicken, smoothies, ice-cream, and pizza.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program’s practice, policy, and procedures, confirm the program does not use the use of
room restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a written policy and procedures to ensure the program conducts and
documents ten-minute checks during sleep hours, or at other times, such as during an illness.
The program has a total of twenty-four video cameras, which are all operational and can store
thirty days of footage. An interview with the facility administrator (FA) indicated the program’s
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best practice during the annual compliance review period had been eight-minute checks.
Observations of ten-minute checks reflected checks were conducted in the required
frequencies, in real time, and ensured the checks were met with fidelity. An observation of ten-
minute check video and logs for five different dates indicated each staff completed the ten-
minute checks with a signature while the youth were sleeping on each shift. This documentation
validated ten-minute checks were done accurately and logged in the program’s logbook in
correlation with the video. An interview with five staff stated ten-minute checks are completed
every eight minutes and logged in the program’s logbook daily.
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 ensure youth are always accounted
for through a system of physically counting youth at various times throughout each day. The
program’s policy states all counts are conducted after disruptions which may occur, escapes,
riots, and during power outages. The program’s policy and procedures and/or Continuity of
Operations Plan (COOP) regarding the youth census, count(s), and tracking is for the program
to conduct six counts within each twenty-four-hour period/time frame. Informal, emergency, and
regular counts are documented in the shift logbooks. A review of randomly selected dates and
times in the program’s logbook for the past twelve months validated the correct head count and
movement was documented at the beginning and ending of each shift, after outdoor and indoor
activities, during drills, and emergency situations. Each logbook also included all releases, new
admissions, and transfers, as well as youth temporarily away from the program for
appointments. An interview with five staff verified the program’s practice is to conduct formal
youth counts twice for each shift, safety and security checks every thirty minutes, as well as
before all youth movement.
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 to ensure the maintenance of a
chronological record of events, incidents, and activities in a central logbook. The program
maintains a bound logbook called the shift report logbook with numbered pages for each month.
All entries are made in ink with no erasures or white-out areas and none of the reviewed
logbooks were destroyed. Any errors made within the logbook were struck through with a single
line and initialed by the staff correcting the error. Each of the entries included the dates and
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times of the 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. Reviewed documentation
and a review of the activity schedule showed minimal interference of educational instruction and
a review of the logbook indicated education classes were conducted, as scheduled. Additionally,
a review of the logbook reflect youth arrived and departed school on time, and the logbook
indicated recreation is conducted, as scheduled. The program does not maintain a logbook at
each living unit; therefore, reviewed shift reports summarize the events, incidents, and activities
documented and logged within the program’s central logbook. The incoming staff sign and date
the shift reports for the previous shift to document they reviewed or were verbally briefed about
its contents. An observation of the shift briefing confirmed the supervisor verbally briefed
incoming staff about the contents of the shift report or incoming staff reviewed the shift report.
There is a copy of the shift report maintained at each living area for forty-eight hours and the
program documents events, incidents, and activities in a central logbook maintained in master
control. These entries include emergency situations, incidents, including the use of mechanical
restraints, special instructions for supervision and monitoring of youth, population counts at the
beginning and end of each shift, any other population counts conducted during a shift, perimeter
security checks, other security checks conducted by direct care, transports away from the
program, including the names of the staff, youth involved, and the destination, requests by law
enforcement to access any youth, removal of any youth from the mainstream population,
admissions and releases, including the name, date, and time of anticipated arrival or departure
and mode of transportation, and information relating to escapes or attempted escape incidents.
In addition, documentation revealed each logbook included internal incidents reported to the
Florida Abuse Hotline and/or the Department’s Central Communications Center (CCC).
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program maintains a written policy and procedures to ensure key control and security which
includes assignment, inventory, tracking, and storage of keys. Observations made indicated the
program has a system in place for the usage of keys at the program. A review of the center’s
policy and procedures on key control determined it includes the control and use of keys
including key assignment and usage, 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’s staff turn in their personal keys and receive a
program key. This key is updated in the logbook to reflect the key with the tag number given to
staff. An interview with the facility administrator (FA) stated the key inventory is reviewed daily to
ensure the inventory matches the actual key rings in use. The FA’s permanent keys matched up
with the permanent key log during the annual compliance review week. There was an
observation of the key storage area and the program’s keys were kept in a secure storage box
with a secured lock. The program’s process for permanent key assignment is keys are
authorized in writing by the FA. The program staff sign a permanent key assignment
acknowledgment form to receive the keys, and proper procedures for controlled keys. An
interview with the FA revealed the restricted keys are stored and secured in the restricted key
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box located in the admissions hallway, separated from the other keys at the program. The FA
stated the process for reporting and the replacement of keys is for a work order to be completed
and maintenance to replace the keys no later than the next day. Observations found the key box
was not easily accessible while it was locked and confirmed the FA’s process for restricting
usage of keys by having two secure locked boxes. The key box housed active keys and the
restricted medical keys were stored in a secured locked box in the medical clinic. An
observation of the sampling of key rings of three randomly selected staff, which were compared
to the inventory and key log, showed there were no discrepancies noted. An interview with five
staff indicated each staff confirmed there aren’t any youth at the program with access to the
program keys. If keys are missing, the FA is notified, the program and youth are searched for
the missing keys, and maintenance will replace keys, if needed. A review of the Department’s
Central Communications Center (CCC) reports and an informal interview with the assistant
facility administrator (AFA) verified there were no instances of lost/missing keys in the last
twelve months.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a written policy and procedures to identify materials considered to be
contraband, to prevent contraband from entering the program, and consequences when found
in the possession of youth in the program. The program has a system in place to prevent
contraband from entering the program, which includes the defining of items/material considered
to be contraband, as well as exemptions, and providing youth with a list of contraband. This list
includes and is not limited to sharps, escape paraphernalia, tobacco products, lighters or
matches, electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive substance,
non-program issued electronic equipment or devices to include smartwatches, metals, personal
non-program issued cellular devices, unauthorized currency or coin(s), and non-program issued
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keys. The program ensures this process by informing the youth of consequences, the searching
of the physical plant and grounds, and searching incoming and outgoing mail to and from youth.
The program’s mandatory requirement includes the addressing of any staff who is found in
possession of contraband in the program. The staff will be subject to disciplinary action up to,
and including dismissal, and law enforcement will be contacted if any found item would be
considered illegal as defined in Florida Statutes, or if there is evidence of any type of unlawful
activity. The program clearly delineates those items considered contraband, to include, but not
limited to, the objects stated above. The program’s logbooks and incident reports were reviewed
to determine frequency and quality of searches and the results of each search with no
discrepancies noted. The program’s policy and procedures, including orientation training
provided to all new staff, stipulates staff found in possession of contraband will be subject to
disciplinary action up to and including dismissal. All instances involving confiscation of illegal
contraband require the program to turn the item over to local law enforcement authorities and
file a criminal report. The review of the Department’s Central Communications Center (CCC)
incidents indicated there were no reports of illegal contraband found in the program since the
last annual compliance review. An interview with the facility administrator (FA) indicated when
entering the program, all staff and visitors are wand searched to prevent any contraband from
entering the program. In the entry way of the program there were signs posted to reflect the
notice of the Florida Statute regarding contraband and a list of items identified as contraband.
The list is also included in the parent/guardian and youth handbook, as well as in the employee
handbook for staff.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a written policy and procedures to ensure searches and full body visual
searches are conducted according to Florida Administrative Code (FAC) at the time of
admission, after off-campus activities, and visitation. During the intake process, at the time of
the youth’s admission, the youth is searched before entering the program. The parent/guardian
is also informed each youth will be searched before and after movement, which may include
during a transport, admission, visitation, off-campus activities, and readmission. An interview
with the facility administrator (FA) revealed each youth is treated with dignity and respect to
minimize the youth’s stress and embarrassment during searches. An observation of a search
was conducted by the appropriate number of staff of the same gender. Each search was
observed to be thorough. The observations revealed the staff gave instructions and the overall
demeanor of the staff was appropriate when explaining the reason and extent of the search.
Each observed youth search was conducted as required by the Protective Action
Response/Right Interactions training manual. An interview with five staff indicated each staff is
aware of a proper search to include staff of the same gender to complete a search during all
movement, before and after in and outdoor activities, before and after visitation, before and after
meals, before and after work details, new admissions, and as well as off-campus returns. An
interview with five youth revealed searches are conducted when returning from off campus, after
outdoor activities, after visitation, after meals, and after work detail. Additionally, one of the five
youth stated a search is conducted when items are missing.
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5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a written policy and procedures to ensure vehicles used to transport
youth are properly maintained and in working order. At the time of the annual compliance review
the program only utilized two transport vehicles. An inspection of both vehicles verified the
vehicles were locked while not in use, all the seatbelts were checked and working, and all
passenger doors were without handles in the inside; therefore, could not be opened. Both
transport vehicles had documented annual safety inspections on the vehicle log, maintenance
records, and observed transport vehicles were secured when not in use. Each transport vehicle
contained one fire extinguisher, one approved first-aid kit, one seatbelt cutter, one window
punch, and the appropriate number of seatbelts. A check of nine staff vehicles during the annual
compliance review week in the program’s parking lot verified all vehicles were locked. An
interview of five staff stated there is a minimum of two staff during transports, and the youth’s
level will determine if the youth will need to be handcuffed during transport. All five staff reported
youth wear a seatbelt during transports. An interview of five youth indicated two youth have
never been transported, and three youth stated they always have on a seatbelt while two staff
transport 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 to ensure the safety and security of
youth and the community when youth are transported outside of the program. The program’s
policy and procedures were reviewed to ensure compliance of all requirements outlined relating
to transportation of youth and driver eligibility with no issues noted. The interviewed facility
administrator (FA) stated a program issued cellular telephone and radios are issued, by the
program’s FA, to use during transports. The staff-to-youth ratio of one staff to five youth, not
including the driver, is used during all transports. A review of documentation showed all staff
operating the vehicles had a current and valid driver’s license. No youth are permitted at any
time to drive any of the program’s transport vehicles. An interview with five staff indicated they
are allowed a company cellphone and a radio when transporting any youth. Three of the five
staff stated a first-aid kit and a fire extinguisher are in the transport vehicle. The other two staff
stated a first-aid kit is present during a transport. None of the five staff are allowed to use their
personal vehicles to transport any youth at the program. Five staff were interviewed regarding
transport vehicle searches. All five staff stated the transport vehicles are searched for
contraband prior to and after transport. Five staff explained the program’s emergency response
process during vehicle transports is to notify the FA of the emergency and maintain sight and
sound supervision over each youth during transport. An interview with five youth stated they
have never seen anyone place contraband in a transport vehicle. Each youth stated they feel
safe while being transported to and from the program.
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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 to ensure a safe and secure physical
plant, grounds, and perimeter are maintained, and for weekly safety and security audits to be
conducted. The program has developed a policy and procedures outlining the audit/inspection
process. An interview with the facility administrator (FA) stated audits were conducted by the
assistant facility administrator (AFA) until September 12, 2023. Since then, the FA has been
conducting the audits. The policy includes the development and implementation of corrective
action warranted as a result of safety and security deficiencies found during any internal or
external review, audit, or inspection; however, at the time of the annual compliance review the
program did not have any corrective actions warranted. The program has an internal system to
verify the deficiencies are corrected and existing systems are improved, or new systems are
instituted as needed to maintain compliance. Weekly safety and security audits were completed
every week during the annual compliance review period with no concerns or issues. The
program’s Preventive Maintenance Checklist was reviewed to ensure maintenance schedules
and repairs were conducted in accordance with contract language, with no exceptions. At the
time of the annual compliance review the program had a part-time maintenance worker;
therefore, the FA assisted with weekly safety and security audits. A review of documentation
confirmed all findings were documented on the weekly safety inspection report and reviewed. If
the final report identified any issues, the program tracks the corrective action plan for any
deficiencies. The FA stated if any deficiencies arise there will be immediate efforts made to
correct in a timely manner.
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 ensure the program has a tool
management system which ensures youth do not use tools or equipment as weapons or for
security breaches. The policy addresses the issuance, inventory, and control of equipment and
tools. A review of the tool storage shed located outside of the program, inventory, and inventory
logs verified tools are securely stored when not in use. Each item is easily marked and
inventoried prior to and following work activities. Documentation confirmed the policy addressed
the issuance, inventory, and control of equipment and tools. An interview with the facility
administrator (FA) confirmed all tools are inventoried prior to being issued for work, all tools are
inventoried following work activities, all tools are inventoried daily such as sharp-edged or
pointed tools, and there is a monthly inventory of tools which do not have sharp edges.
Additionally, any machetes, bowie knives, or other long blade knives are prohibited. A review of
documentation revealed the procedures for missing/lost tools; however, since the last annual
compliance review the program did not have any missing/lost tools. The FA stated when this
occurs, tools are searched for throughout the program and if it cannot be located the
Department’s Central Communications Center (CCC) is contacted. If a tool is broken, it will be
discarded and replaced. Observations of the tool storage area found it was well organized and
secure. Class B tools in the maintenance tool shed included mops, brooms, blowers, weed
eaters, and screwdrivers. A review of the items and inventories showed they were accurate.
These items are maintained in a locked closet which is inaccessible to the youth. Additional
items located in the maintenance tools shed consisted of drills, grinders, saws, jack stands, and
bolt cutters. A review of these items and the corresponding inventories showed they were
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accurate. An interview with five randomly selected staff stated youth can only use brooms,
mops, dustpans, and scrub brushes with supervision.
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 to ensure youth use tools safely and are
supervised appropriately to prevent injuries. Reviewed documentation confirmed all staff are
required to always complete a sign-in and sign-out log when any of the documented Class B
tools are taken and returned from use to the maintenance storage room. Youth permitted to use
the Class B tools must be always supervised while they are in use. An interview with the facility
administrator (FA) confirmed the issuing of tools to youth and staff must include a Youth Risk
Assessment to determine a youth’s risk to self and/or others. An established ratio is required in
order to distribute tools, and a search is conducted by staff supervising during work projects.
During activities involving tool use by the youth there is a ratio of one staff to every five youth,
as stated in the program’s contract. Reviewed documentation noted a vocational ratio of one
staff to every five youth. A video observation was conducted and the staff-to-youth ratio when
youth were using a mop was appropriate. Observed ratios were also appropriate during search
procedures, tool distribution, and collection during a work project. Observations showed the
youth were also searched by a same gender staff after the work project concluded.
Documentation revealed youth were deemed appropriate due to a Youth Risk Assessment and
were trained on the intended and safe use of Class B tools. A review of five youth records
confirmed youth who have used tools received a risk assessment prior to the use of tools. An
interview was conducted with five youth regarding the use of tools. Four youth stated they use
mops and brooms based on their level, and the other youth had never used any tools.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a written policy and procedures to ensure the establishing of guidelines
for outside contractors who come on-site to complete repairs. An interview with the facility
administrator (FA) and reviewed documentation revealed the program’s procedures regarding
outside contractors is for the physical plant manager or designee to inspect all tools and
equipment at arrival and departure for accuracy. All outside tools must be removed from the
program upon exit after the workday, each day. Sign-in sheets and instruction sheets were
reviewed for outside contractors with no discrepancies or concerns. The guidelines for
repairman/external worker tools include the requirement for all tools to be checked upon daily
arrival and departure, tool restrictions while in the program, the restriction of youth from any of
the working areas, and if there are any missing tools, there is an immediate follow-up
conducted. A review of three project invoices submitted to the program by the vendor were
compared and accurate with sign-in and out times. Each contractor completed a Prison Rape
Elimination Act (PREA) acknowledgement form. The FA documented an inventory check for
tools and other equipment upon arrival and at exit. The program’s policy and procedures outline
who is responsible for providing approval/permissions if electronic items are required, and at the
time of the annual compliance review this was the responsibility of the FA.
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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 Continuity of Operations Plan (COOP) which was reviewed on
February 10, 2023, updated on February 13, 2023, and approved by the Department on August
25, 2023, and a policy and procedures to ensure drills are consistent with the program’s COOP.
The COOP requires the program to conduct unannounced fire drills quarterly for each shift. A
review of documentation confirmed fire drills were conducted on each of the three shifts each
month and exceeded the requirement. In addition, the program conducted monthly emergency
drills on each shift to include fire drills, severe weather, disturbances/riots, flooding, bomb
threats, tornado, hurricane, escape drills, and lightning drills on a monthly basis. Reviewed
documentation confirmed all drills documented the type of drill, date, time, participants, brief
scenario, findings, and recommendations, as needed. During the program tour the fire
evacuation routes and egress plans were observed to be posted throughout the program. It was
also noted the program’s fourteen fire extinguishers were inspected annually. The program
reviews and debriefs staff on how well drills were conducted during the monthly all staff
meetings. Each drill is reviewed monthly in the general staff meeting. An interview with five staff
indicated they had participated in fire, weather, bomb threat, escape, and medical drills since
the last annual compliance review. All drills included the date and time, a brief scenario
description, type of drill, deficiencies identified during the drill, participants, and if applicable
corrective action plans. Five youth interviews were conducted, and each youth stated fire drills
are conducted monthly, and they had participated in fire drills, with instructions as to what to do
in the event of a fire. An interview with the facility administrator (FA) stated COOP drills are
completed monthly, on each shift. These drills include fire drills, severe weather,
disturbances/riots, flooding, bomb threats, tornado, hurricane, escape drill, and lightning drills.
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 written policy and procedures to ensure the Department approved
disaster and Continuity of Operations Plan (COOP) is available for all staff to review. An
interview with the facility administrator (FA) confirmed the COOP is available to staff and located
in administration and in the FA’s office. The plan was reviewed on February 10, 2023, updated
on February 13, 2023, and approved by the Department on August 25, 2023. The plan
addresses alternative relocation sites approved by the applicable Department regional
director/designee. The program’s Emergency Disaster Preparedness Plan and COOP is a
single combined plan. There was equipment and supplies required for continuous operation and
services during emergency or disaster situations, located in the kitchen and the FA’s office.
Observed supplies consisted of batteries, flashlights, and water. The COOP which has been
approved and updated annually, included the delegation of authority, new cooperative
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agreements, vendor contact list, emergency and staff contact numbers, and a county
cooperation checklist. The COOP also included fire and fire prevention, evacuation, severe
weather, disturbances or riots, bomb threats, hostage situations, chemical spills, flooding,
terrorist threats or acts, staff roles and responsibilities, any equipment and supplies needed,
information about youth which may be needed, alternative housing arrangements, provisions for
continuity of care and custody of youth, and provisions for public protection. The program’s
practice is to take youth records with them in the case of an emergency. A review of five youth
records confirmed the youth’s name, Department identification number, admission date, date of
birth, gender and race, name of parent/guardian, address, and parent/guardian contact
information was documented. An interview with the FA revealed the program has a separate
binder, which included the admission card and the youth face sheet in the case manager’s
office. The youth’s address, telephone number of the person with whom the youth resides and
their relationship to the youth, person(s) to notify in case of an emergency, the youth’s assigned
juvenile probation officer (JPO), committing judge, state attorney, public defender, victim
notification contact information, physical description of the youth, overall health status, personal
physician, and photograph of the youth were also maintained within the records.
5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program maintains a policy and procedures to ensure youth do not handle toxic,
combustible, or harmful chemicals and materials. An interview with the program’s facility
administrator (FA) indicated the FA and maintenance manager maintain a monitoring system to
ensure compliance with poisonous, toxic, and flammable items. All flammable materials are
stored in a metal fireproof container, which is safety locked in a shed located outside of the
program, inaccessible to youth. All items are inventoried on the Flammable Inventory Log. All
toxic materials are stored in a locked shed located outside the program and inventoried on the
Chemical Inventory Log. The Safety Data Sheets (SDSs) were compared with the inventory to
determine if the program had af SDS maintained on-site for all materials with no noted issues. A
SDS binder is located inside the locked storage shed outside of the program area with a picture
of each material corresponding to the SDS. The program maintains chemicals used daily in a
locked storage area outside of the program. An inventory was compared to the actual items at
the program to determine if there were any items missing or additional items not on the
inventory and there were no discrepancies noted. Inventories of four unique items were
compared to actual items stored in the shed and it was verified the data in the chemical logs
matched physical inventory. The FA stated the program maintains a list of all staff who are
authorized to handle the materials which includes the FA, therapists, medical staff, maintenance
staff, and youth specialists. Documentation revealed chemical inventory sign-in and out logs
track all toxic materials when in use by authorized staff. An observation was conducted of the
storage area, and confirmed items were clearly marked, securely locked, and had a posted list
of authorized staff.
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Office of Accountability and Program Support Page 66 of 70 (Revised September 2022)
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 prohibiting youth from handling any
flammable, poisonous, and/or toxic items or materials. Youth are strictly prohibited from the
maintenance area where toxic items and chemicals are stored. The program maintains strict
control of flammable, poisonous, and toxic items and materials. Youth are not permitted to use,
handle, or clean-up any dangerous or hazardous chemicals, youth are not permitted to clean,
handle, or dispose of any person’s bio-hazardous material, bodily fluids, or human waste. The
program restricts youth access to any areas where these items are used or stored. During the
annual compliance review week, a video observation was conducted of one youth during the
daily cleaning activities, and the youth was observed sweeping and moping during lunch time,
with assistance from one staff. No youth were observed handling flammable, poisonous, and/or
toxic materials. An interview conducted with five youth confirmed none of the youth have ever
used any chemicals or cleaning products at the program.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a written policy and procedures to ensure the disposal of flammable, toxic,
caustic, and poisonous items. An interview with the facility administrator (FA) revealed the FA
and the program’s maintenance manager are responsible for disposing of unused flammable,
toxic, caustic, and poisonous materials to a local household hazardous waste drop-off site, as
needed. There is a list of positions, titles, and functions authorized to dispose of these items.
The program’s policy and procedures to dispose of these items were created in accordance with
Occupational Safety and Health Administration (OSHA) standards. All hazardous chemicals
which are outdated or no longer in use are disposed by sending the items to a waste center or
back to the issuing vender in accordance with the Safety Data Sheets (SDSs). A review of the
Chemical Disposal Logs indicated the chemical disposed, staff disposing the chemical, date,
and time were documented. An interview with the FA confirmed the maintenance staff is the
only staff who uses all chemicals. If there are any chemicals in need of disposal, the staff is
required to fill out the Chemical Disposal Log and drop off the chemicals at the bio-hazardous
waste station, located outside of the program’s premises. All hazardous liquid waste was stored
in a hazardous materials storage area and liquid waste from work detail is disposed of in the
plumbing drains. Additionally, the kitchen liquid waste is disposed of in the kitchen; however, the
grease is discarded in a separate container and taken outside of the program and placed in a
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 70 (Revised September 2022)
grease trap. The program follows a procedure in the event of a chemical spill. If a chemical spill
occurs, the shift supervisor is notified. The shift supervisor then shuts down the ventilation
systems air handlers and closes all windows and doors at the direction of the FA. An interview
with the FA confirmed upon becoming aware of a chemical spill, staff shall notify master control
of the location, the shift supervisor/master control shall direct the shut-down of all air handlers
and ventilation systems and close all windows and doors at the direction of the on-site
supervisor or FA. Assistance from outside the program shall be contacted, as necessary, and
consistent with emergency procedures.
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 70 (Revised September 2022)
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a written policy and procedures to ensure youth are provided the
opportunity to receive visitation and communication with approved family members. During the
program tour observations, visitation posters were seen in the dayroom and the facility
administrator’s (FA) office. An interview with staff revealed the visiting hours are sent home with
parents/guardians during admission. Visiting hours are 1:00 p.m. through 3:00 p.m. weekly on
every Saturday and Sunday. The program’s policy and procedures related to visitation, youth
mail correspondence, and use of telephone ensures youth can maintain constant
communication with their family members to discuss the youth’s transition. All outgoing mail is
searched by the case manager before being processed. Youth may also receive incoming calls
from officials as needed. The program maintains a copy of all approved visitors for each youth.
A review of the program visitation log and schedule confirmed adherence to weekly Saturday
and Sunday visitations from 1:00 p.m. to 3:00 p.m. A review of the program’s telephone log and
schedule confirmed the youth are given a telephone call one time each week and their level is
used to determine the length of the telephone call. A review of the mail correspondence log and
schedule confirmed all mail is reviewed by the case management unit, outgoing mail is sent
every Wednesday, and incoming mail is given on Tuesdays and Thursdays. An interview with
the FA confirmed an alternative visitation arrangement with parents/guardians is available and
all youth are given an opportunity to communicate with family members by mail and to
communicate with family members by telephone. Additionally, the program requests clarification
from the assigned juvenile probation officer (JPO) to verify the youth’s parent/guardian and
other family members are not under current or past investigation for human trafficking related
charges for youth with a history of human trafficking. The program maintains a list of
interpreters, utilizes the language line, and has an agreement with a third-party language
service entity as needed for youth with a language barrier. An interview with five youth
confirmed they can make a telephone call or send a letter to a parent/guardian. An interview
with five staff confirmed the program has services in place for youth whose primary language is
not English, such as a list of staff who speak the language, a list of websites to help with the
understanding of the English language, and language help telephone numbers.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The activity schedule documented a range of supervised and structured indoor and outdoor
recreation and leisure activities for the youth for at least one hour daily. An observation of the
daily activity schedule confirmed these practices. The program provides the youth with indoor
and outdoor large muscle activities. These activities are provided by a recreation therapist and
promote social and cognitive skill development, creativity, teamwork, healthy competition,
mental stimulation, and physical fitness. An observation of a recreation activity ensured the
program takes precautionary measures to prevent overexertion, heat stress, dehydration,
frostbite, hypothermia, and exacerbation of existing illness or physical injury. The program’s
staffing roster was reviewed, as well as the therapist’s credentials, schedule, and services
provided to youth. At the time of the annual compliance review the program had a recreation
therapist. The recreation therapist is responsible for facilitating structured and organized
physical activities to restore motor, social, and cognitive functioning, build confidence, develop
coping skills, and promote wellness and pro-social activities. This position reports to the
designated mental health clinician authority (DMHCA) and works closely with the therapists to
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 70 (Revised September 2022)
integrate physical and mental health wellness goals into the youths’ individualized treatment
plans. The recreation therapist has a bachelor’s degree in physical education. Five youth
records documentation were reviewed and confirmed recreation therapy is included in each
youth’s individualized performance and/or treatment plan. An interview with five youth confirmed
the program allows youth the opportunity to exercise, play outside, or have down time to read a
book, or play a board game. Additionally, physical activities such as basketball, football, soccer,
recreation time, and workouts are provided for at least one hour daily. An interview with five staff
revealed types of indoor and outdoor activities, such as board games, large muscle activities,
football, basketball, and appropriate card games are provided to the youth for an hour daily.
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.26 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 70 (Revised September 2022)

report_type: QI Residential

file_name: Miami Youth Academy-FINAL-FY2324.pdf

program_name_raw: Miami Youth Academy

rule: Indicator 1.15

excerpt: Advisory Board

rating: Failed Compliance