summary: QI Residential - FY24-25

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Columbus Youth Academy
TrueCore Behavioral Solutions, LLC.
(Contract Provider )
9502 E Columbus Dr
Tampa, Florida 33619
Review Date(s): October 22-25, 2024
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Justin Terziu, Office of Accountability and Program Support, Lead Reviewer ( Standard 1)
Kara Brown, Office of Accountability and Program Support, Deputy Regional Supervisor (Co-
Lead-Standard 1)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Jeremy Curvan, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Cheryl Francis, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Tamara Mahl-Adkins, Office of Accountability and Program Support, Regional Monitor
(Standard 4)
Amanda Nelson, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Luis Rodriguez, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Sandra Thompson, Office of Accountability and Program Support, Regional Monitor
(Standard 1)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Columbus Youth Academy MQI Program Code: 1442
Provider Name: TrueCore Behavioral Solutions, LLC. Contract Number: 10476
Location: Hillsborough County / Circuit 13 Number of Beds: 50
Review Date(s): October 22-25, 2024 Lead Reviewer Code: 214
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 64 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Non-Applicable
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 64 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
* 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 64 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Satisfactory
3.19 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 64 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education 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 64 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Satisfactory
5.24 Controlled Observation Satisfactory
5.25 Controlled Observation Safety Checks and Release Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 64 (Revised September 2022)
Standard 6: Education Services
Residential Rating Profile
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Satisfactory
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Non-Applicable
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Non-Applicable
6.08 Florida Youth College (Post-Secondary Contract) 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 9 of 64 (Revised September 2022)
Program Overview
The Columbus Youth Academy is a fifty-bed program, for thirteen to eighteen year old males,
located in Tampa, Florida. The program is operated by TrueCore Behavioral Solutions, LLC.,
through a contract with the Department. The program provides services including Mental Health
Overlay Services (MHOS) and Substance Abuse Treatment Overlay Services (SAOS)
with a specialized emphasis on juvenile sexual offender (JSO) treatment services. In addition,
the program fosters each youth by providing Pathways, Skillstreaming the Adolescent,
Passport, Living in Balance, Coping with Depression, Coping with Stress: A Cognitive
Behavioral Therapy (CBT) Guide for Teens with Trauma, and Life Skills Training. Additional
treatment services provided include family/individual therapy, group therapy, and recreational
therapy. Program administration is comprised of a facility administrator (FA), assistant facility
administrator (AFA), designated mental health clinician authority (DMHCA), designated health
authority (DHA), director of nursing, director of case management, and a community liaison.
Case management services are provided by the director of case management, four case
managers, one transitional case manager, and one recreational therapist. Mental health staff at
the program include the clinical director, a licensed mental health counselor (LMHC) who serves
as the DMHCA, and five additional LMHCs. Medical services are offered Sunday to Saturday
from 7:00 a.m. to 5:00 p.m. and are provided by three full-time registered nurses (RNs), and one
RN providing services pro re nata (PRN). The layout of the program includes one building which
consists of administration, master control, three youth dormitories, three group rooms, three
classrooms, a kitchen area, and a game room. The program has sixty-six operating security
cameras providing coverage. At the time of the annual compliance review, the program had ten
vacant positions including seven youth care workers (YCWs), one HR coordinator, one shift
supervisor, and one recreational therapist.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 64 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures requiring all staff, volunteers, and contracted
personnel to undergo background screening before having contact with youth or accessing
youth records. During the annual compliance review period, the program did not have any
volunteers or interns who interacted with youth on an intermittent basis, defined as less than ten
hours a month. Seventeen new staff members were hired during the annual compliance review
period, and each received a background screening prior to hire. Additionally, six new volunteers
were onboarded, and all underwent background screening before having contact with youth or
accessing confidential records. A criminal history report was reviewed for each staff member
and volunteer, and all were added to the Clearinghouse employment roster. None of the staff or
volunteers required an exemption to work with youth. An Annual Affidavit of Compliance with
Level 2 Screening Standards was completed and submitted to the Department’s Background
Screening Unit on December 15, 2023. Teachers, paid by the school board, received their
annual screenings on December 1, 2023.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures in place requiring all staff and volunteers to receive a
background rescreening every five years from their hire date. A review of the staff roster found
there were three staff applicable for a five-year rescreening during the annual compliance
review period. All of the five year rescreens were completed on time and submitted to the
Clearinghouse at least ten business days prior to the five-year anniversary date.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 64 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures in place to promote an environment where youth,
staff, and others feel safe, secure, and free from any form of abuse or harassment. According to
the program’s policy, all staff must immediately report any knowledge or suspicion of abuse or
sexual harassment occurring within the program. They are also required to report any retaliation
against youth or staff who reported an incident, as well as any staff neglect or violation of
responsibilities which may have contributed to an incident or retaliation. Potential abuse must be
reported to the Florida Abuse Hotline. In addition to reporting to the Florida Abuse Hotline, the
program ensures notification is made to the provider’s corporate management team by the
incident reporting email group. The telephone numbers for the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC) are posted throughout the program.
Staff adhere to a code of conduct, which they agree to, sign, and document in their personnel
records. A review of seven staff personnel records confirmed each staff member signed the
code of conduct. The program had no incidents of alleged abuse during the annual compliance
review period. The facility administrator (FA) was interviewed and reported the code of conduct
outlines the actions to be taken if a staff violates policy.
The program has a dedicated champions team driving the Trauma Responsive and Caring
Environment (TRACE) initiatives. The team completed their self-assessment, surveys, and
action plan. Through targeted interventions, they focus on maintaining an environment which is
both physically and emotionally safe. From the moment a youth enters the program, they are
immersed in a trauma-responsive culture. Trauma-responsive practices are embedded in both
policies and procedures. Staff are made aware of Florida Abuse Hotline/CCC reporting
procedures during new hire training, in-service training, and general staff meetings. Youth are
also informed about the Florida Abuse Hotline/CCC during the orientation process and receive a
handbook containing this information. Seven youth were interviewed and all stated they feel
safe at the program. Additionally, none of the youth reported ever being stopped from reporting
abuse to the Florida Abuse Hotline. All seven youth confirmed they know where the telephone
number for the Florida Abuse Hotline is located, with each mentioning it is posted in the dorm.
Seven staff members were interviewed about whether they have ever heard another staff
member using profanity while speaking with youth. Six staff members stated they have never
heard profanity used, while one staff member mentioned it occurred when a staff member was
frustrated; however, noted it was not directed at a youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 64 (Revised September 2022)
1.04 Management Response to Allegations (Critical) Non-Applicable
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had no allegations of physical, psychological, or emotional abuse in the program
during the annual compliance review period; therefore, this indicator is rated non-applicable.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program maintains a policy and procedures to ensure the Department’s Central
Communications Center (CCC) is notified within two hours of an incident occurring, or within two
hours of program staff becoming aware of a reportable incident. Twelve incidents were reported
during the annual compliance review period, and five of those incidents were reviewed. Each
was reported within the required two-hour time frame and documented in the logbook. There
were no incidents during the annual compliance review period which should have been reported
to the CCC and were not. The program did not experience an increase in the number of
reportable incidents to the CCC during the annual compliance review period.
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program has a policy and procedures in place requiring a Right Interactions (RI) Report to
be completed whenever staff use a physical intervention technique. Two RI incidents occurred
during the annual compliance review period. Both RI Reports were completed by the end of the
staff member's workday and included statements from all staff involved. Both reports were
reviewed by the facility administrator (FA) or designee within seventy-two hours of the incident.
A copy of each report was placed in the program’s centralized file within forty-eight hours of
approval by the FA. Monthly summaries of RI incidents were maintained and submitted to the
Department by the fifteenth of each month. The program’s RI plan was updated on April 29,
2024, and approved by the Department on May 3, 2024. The FA was interviewed and indicated
the program continuously emphasizes the use of verbal de-escalation techniques when
managing escalated situations. Physical intervention is always a last resort. All RI-related
incidents are reviewed by the assistant facility administrator and/or the FA. A RI Review
Committee is convened following each RI incident. The staff and youth involved in the incident,
along with members of the treatment team, are present at the meeting. The purpose of the
meeting is to process the incident with the youth in an effort to avoid future RI-related incidents
with the same youth. Seven staff were interviewed about the process of using RI with youth. All
interviewed staff mentioned using verbal interventions and minimal force. Six staff emphasized
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Office of Accountability and Program Support Page 13 of 64 (Revised September 2022)
de-escalation and securing other youth before taking further action. Five staff noted using
physical intervention only when a youth is combative or offensive. Each staff completes their
own paperwork following the incident. Four staff mentioned using verbal de-escalation,
escorting youth away from the situation, and using a take-down as a last resort. Three staff
highlighted calling a code and following RI procedures to remove youth from the dorm. Two staff
mentioned assessing the level of threat to decide on intervention. One staff emphasized
avoiding physical contact and using verbal de-escalation.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has a policy and procedures outlining its pre-service training requirements, as
specified by Florida Administrative Code, which state pre-service training must be completed
within 180 days of hire. Supervisory direct care staff must complete sixteen hours of supervisory
training in addition to the required pre-service training. Seven staff training records were
reviewed for pre-service training. All instructors were qualified to deliver the trainings they
provided. Prior to implementation, the program submitted a pre-service training plan/calendar,
which was approved by the facility administrator and the assistant secretary for the
Department’s Office of Residential Services; however, the training plan was not approved by the
director of the Department’s Office of Talent, Leadership, and Culture. All seven reviewed staff
completed all required training in the Department’s Learning Management System (SkillPro)
within 180 days of hire. Each staff member completed the required essential skills training
before any contact with youth. No supervisory staff were applicable for review regarding pre-
service training. All completed trainings were documented in SkillPro.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a policy and procedures regarding in-service training. Seven staff training
records were reviewed. Each staff completed all required trainings. Three of the seven reviewed
staff were supervisory staff. Each supervisory staff completed at least eight hours of additional
training in the topics of coaching, leadership, and personal accountability. Each reviewed staff’s
trainings were documented in the Department’s Learning Management System (SkillPro). All in-
service trainers were qualified to deliver the trainings provided. The program provided an in-
service training calendar, which is updated as changes occur. The program provided an in-
service training plan/calendar which was approved by the facility administrator, the assistant
secretary for the Department’s Office of Residential Services, and the director of the
Department’s Office of Talent, Leadership, and Culture.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 64 (Revised September 2022)
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures outlining the training requirements for the grievance
process. The grievance process consists of an informal phase, a formal phase, and an appeal
phase. The informal phase encourages youth to resolve questions, disputes, and complaints
through informal communication with program staff, using a conference request form.
Documentation supported the program’s practice in alignment with its process. The program
maintained copies of all grievances during the annual compliance review period. The facility
administrator (FA) was interviewed and reported all youth have access to grievance forms in
their dorms and can submit them in the grievance boxes located on each dorm. The first phase
of the grievance process involves the youth filling out the grievance form. The second phase
includes the youth meeting with the facility grievance officer. The final phase involves a review
by the assistant facility administrator or a meeting with the youth and the FA if the youth is not
satisfied with the resolution proposed by the grievance officer. Three grievance forms were
reviewed for the annual compliance review period. All forms included the informal and formal
phases, as well as the appeal phase. According to the program’s policy and procedures,
responses were provided within the specified time frames as required. Seven youth were
interviewed and all confirmed they can request help filling out a grievance form if needed. Seven
staff members were interviewed regarding the program's youth grievance process. Five staff
stated grievance forms are placed throughout the program. Three stated youth can ask for
assistance in completed the form. Two stated a supervisor reviews the completed forms and
one stated the FA reviews the completed forms. Five further stated when a youth feels their
rights have been violated, they are given a grievance form to fill out. The completed form is then
placed in a grievance box for review. One staff also mentioned, in certain situations, they work
to de-escalate the issue before addressing the grievance.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
A review of the contractually required services, which are not primary services, revealed the
program was providing delinquency interventions as required. The program offers Thinking for a
Change. One staff member is assigned to facilitate this curricula, and their education and
experience were reviewed. The assigned staff member had the required years of experience
and education to facilitate these groups. The staff training record was reviewed, and training
within the specified curricula was confirmed for the applicable staff. A review of the program’s
posted activity schedule confirmed the program provides structured programming and activities
for at least sixty percent of youth awake hours, as required by the program’s contract. Groups
are being provided as outlined on the program’s daily schedule. The facility administrator (FA)
was interviewed and reported the program utilizes Pathways and Impact of Crime as evidence-
based delinquency intervention groups. These groups are held with fidelity and are monitored
for quality assurance and effectiveness, ensuring they meet the needs of youth as they
graduate from the group and earn their release from the program. The program provided
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Office of Accountability and Program Support Page 15 of 64 (Revised September 2022)
supplemental groups during the annual compliance review period, which were non-primary,
non-clinical groups.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures which emphasize social and life skills training for
youth. The program’s compliance manager indicated the program’s only life skills groups are
considered primary services. Seven youth were interviewed about the life skills groups and
activities they have participated in while at the program. Their responses highlighted a variety of
therapeutic and educational activities aimed at personal development. One youth mentioned
participation in treatment, Impact of Crime (IOC), and a substance abuse trauma group. An
additional youth described involvement in the Living in Balance substance abuse group, trauma
and mental health group, and open processing sessions. These groups focus on discussing
triggers, coping skills, and strategies to avoid negative situations, as well as processing
thoughts and learning how to respond positively. One youth reported engaging in various
groups, including Living in Balance, Financial Group, Therapy, Anger Management, Depression
Group, Sports, Academic Sports, Dog Therapy, and Thinking for a Change (T4C). Activities in
these groups involved practicing breathing exercises, learning coping strategies, and
understanding the effects of substance abuse. One youth highlighted participation in
Skillstreaming the Adolescent on Saturdays and Sundays, where different activities and role-
playing scenarios focus on developing social and pro-social skills. The facility administrator
indicated all youth participate in the Pathways group, a sexual offender specific group, as well
as other mental health and substance abuse groups. From admission to transition, staff treat
youth with dignity and model expected behaviors. Each youth receives orientation, treatment
planning, and family therapy tailored to their specific juvenile sexual offender (JSO) needs. As a
male population, they also receive health education focused on gender-specific issues.
Curriculums are carefully selected to address these needs. For youth identifying as LGBTQIA+,
their pronouns, clothing choices, and other preferences are respected. Staff are trained to
ensure all youth are treated with dignity and respect.
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 has established policies and procedures designed to offer activities and instruction
to enhance youth awareness of, and empathy for, crime victims and survivors. These initiatives
also emphasize the importance of personal accountability for the youth's criminal behavior and
the harm caused to others. The program offers Impact of Crime (IOC) for restorative justice,
which is a primary service; therefore, this group is not applicable for review. Restorative justice
activities could not be observed during the annual compliance review week. The facility
administrator (FA) was interviewed and reported the program provides community service
projects as restorative justice activities. Youth have participated in projects such as park clean-
ups, feeding the homeless, and a toy drive with donations going to youth in Department of
Children and Families (DCF) care. The program offers all youth the opportunity to participate in
off-campus community service projects, including assisting at an aquaponics farm and feeding
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the homeless. Youth aim to restore victims and communities by supporting programs in need of
volunteers. They want to help rebuild the community through maintaining public spaces and
donating time to community institutions in need. Seven youth were interviewed, and all
confirmed participation in the Impact of Crime (IOC) group Monday through Friday. The contract
requires the program to partner with community stakeholders, ensuring all aspects of the
program reflect the restorative justice philosophy. This includes case planning processes,
competency development, involvement in meaningful community service, restitution, conflict
resolution, and victim and community involvement. Documentation for three off-campus
community service projects was reviewed, confirming activities were conducted.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures outlining how alerts are identified, documented,
updated, and communicated to staff. The program’s policy requires all alerts to be entered into
the Department’s Juvenile Justice Information System (JJIS) and notated on the alert
communication board in the facility administrator’s (FA) office, as well as on the shift report
form. The program’s logbook is used to record suicide and mental health alerts, along with
instructions for staff. Seven youth records were reviewed, for a total of nineteen reviewed alerts.
All alerts were present in JJIS and on the program’s internal alert board and all matched. All
alerts were entered and removed by staff who are required to do so. Eighteen of the nineteen
alerts were entered late due to the Department-wide system outages during the annual
compliance review period. The remaining alert was not late. The FA was interviewed and
reported the program management team meets daily to discuss medical issues, with the
Director of Nursing or a medical representative present at these meetings. Additionally, the DHA
debriefs with the FA and director of nursing occurring on a weekly basis to provide updates on
the well-being and medical condition of the youth prior to exiting the facility. The confidential
alert board is available for staff to review during shift briefings. Alert logs and the alert board are
also maintained in master control and dietary. The clinical director, director of case
management, and director of nursing are responsible for entering and closing out JJIS alerts.
Alerts are reviewed during daily management meetings. The health services administrator
(HSA) was interviewed and reported all registered nurses (RNs) are responsible for updating
alerts. Seven staff were interviewed, and all were able to describe how they are notified of youth
alerts.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
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The program maintains an Individual Healthcare Record and a separate individual management
record. The individual management records contained the youth’s name, Department
identification number, date of birth, county of residence, and committing offense. The individual
management records contained legal information, demographics and chronological information,
correspondence, case management and treatment team activities, a miscellaneous section. All
youth records were labeled confidential and secured in a locked file cabinet.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a policy and procedures in place to ensure the program has a community
advisory board meeting at least every ninety to 120 days. Sign-in sheets were reviewed for the
advisory board meetings, and documentation confirmed board meetings were held every ninety
to 120 days as required. A review of the list of attendees, the board roster, and letters from the
program found the facility administrator (FA) solicited involvement from all required parties;
however, there were no documentation confirming solicited involvement from the LGBTQIA+
community. All advisory board meeting were scheduled quarterly as required. There were no
board members available for interview during the week of the annual compliance review.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures outlining their system for evaluating staff, at least
annually, based on established performance standards. The program completes performance
evaluations annually; however, they can be completed more often if deemed necessary. All new
staff receive an evaluation ninety-days after hire. Evaluations can be completed up to fourteen
days early. Six job descriptions were reviewed for performance standards, and staff
performance standards were clearly identified in each. Seven personnel records were reviewed
and confirmed evaluations were completed on each, annually, as outlined in policy. Twenty-four
job descriptions were reviewed for staff whose job functions include implementation of the
program’s behavior management system (BMS). Each job description included job functions
related to implementation of the BMS. The program’s contract was reviewed to ensure all
specific contractually required positions were maintained and performed, as outlined in contract.
The program had one key vacancy, a recreational therapist which has been vacant since
October 18, 2024. The program had one recreational therapist during the annual compliance
review period. The recreational therapist held a bachelor’s-level degree in liberal studies with a
concentration in physical education and education. The program provided a daily schedule of
recreational activities which were held during the annual compliance review period. The
program’s facility administrator (FA) was interviewed and indicated the program has
experienced slight turnover; however, they have not had any issues with staff morale. The FA
indicated vacancies are continuing to be filled for direct care positions. The FA stated incentives
are given to staff to show appreciation and reflect the commitment they display working with
youth. Staff surveys are completed on a quarterly basis to gauge staff morale and gather
feedback in an effort to better the program. The FA indicated annual performance evaluations
are completed for each staff. Supervisors are responsible for completing evaluations, which are
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reviewed and discussed with each staff individually. Seven staff were interviewed. Five staff
indicated they receive a formal evaluation annually, one stated they receive a formal evaluation
every six months, and the remaining staff indicated they receive a formal evaluation quarterly.
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 items and services which are negotiated or outlined in their contract
which are considered special contract conditions. The program has special contract conditions
relating to self-sufficiency planning, Alcoholics Anonymous (AA) and Narcotics Anonymous
(NA), community involvement, animal assisted therapy, a comprehensive monthly health
education program, and discharge and transition services. The program is required to assess
needs and strengths of youth with regards to independent living arrangements when youth and
family circumstances indicate independence and self-sufficiency are more realistic goals than
reunification with the family. The self-sufficiency process begins at admission for each youth.
During the transition phase, a transition services manager (TSM) works with each youth on
learning self-sufficiency skills related to money, banking, and employment. The program shall
provide youth with substance abuse issues the opportunity to participate in AA or NA while in
the program. The program provided documentation indicating they had been working to secure
an individual to assist with providing these services on-site at the program; however, due to
scheduling conflicts, they were unable to secure this individual. The program provided a list of
virtual meetings, as well as an email with a link for a meeting on Sundays at 7:00 p.m. The
program’s daily activity schedule, which is posted on each dormitory, indicates AA is held on
Sunday from 7:00 p.m. until 8:00 p.m. The program did not have documentation indicating any
youth had participated in a meeting during the annual compliance review period. The program’s
contract indicates youth may earn opportunities for community involvement including, but not
limited to, community service work hours or group community service projects. The program
provided documentation indicating youth are provided opportunities to go off-site for community
work projects and other community service outings. During the annual compliance review
period, youth have participated in community service outings with three agencies, as well as
three community outings to sporting events. Sign-in sheets were provided for each community
outing. A review of sign-in sheets found twenty-eight youth participated in a community outing
during the annual compliance review period. The program is required to establish animal
assisted therapy or an animal assisted activity. The program offers a Kids N’ Canines Dog
Therapy program. The program has volunteers who come in weekly on Tuesdays to run the
program with youth. A review of documentation found thirty-seven youth have participated in the
program during the annual compliance review period. The program’s contract indicates they will
provide a comprehensive monthly health education program in recurring cycles, so each youth
receives the benefit of each topic during their length of stay. Seven youth Individual Healthcare
Records were reviewed, and each record contained a Monthly Health Education Record
including a different healthcare topic they received each month. The program also provided a
monthly calendar indicating which topic they review with youth each month. The program’s
contract requires the program to provide transition services which require each TSM to be
qualified as indicated in contract, a transitional dormitory for each youth’s last sixty days in the
program, development of a Relapse Prevention Plan by each youth, and post-release services.
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The program has two TSMs. One has a bachelor's-level degree in criminal justice and the other
has a bachelor's-level degree in business administration. The program's youth handbook
indicates each youth may earn the privilege of a transition dorm room once they enter the
transition phase. There are five transition dorm rooms on dorm one, five rooms on dorm two,
and four rooms on dorm three. The program indicated each youth in transition receives a
transition room. Three closed youth case management records were reviewed, and each record
had a Relapse Prevention Plan completed by the youth. The three closed records were
reviewed for post-release services. The TSM made weekly post-release contact with each
youth, as required, with the exception of one week when the program was evacuated due to a
hurricane. The program’s facility administrator (FA) was interviewed and confirmed the program
had transition dorm rooms. The FA stated the program focuses on each youth’s self-sufficiency
with targeted interventions identified through admission assessments and transitional goals.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has practices in place to collect information about the program and share this
information with their staff and administration monthly. The program utilizes daily management
meetings, the Department’s Juvenile Justice Information System (JJIS), staff and youth surveys,
and electronic records system. The program gathers data from the morning management
meetings to evaluate for trend analysis and the information is shared with the administrative
management team during these meetings. Trend analysis is also shared with staff during daily
briefings and during general staff meetings. There was documentation of daily management
meetings, monthly staff meetings, youth and staff surveys, and the use of the internal
dashboard. The internal dashboard includes information from operations, mental health, health
services, support services, and human resources.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures ensuring each youth’s parent/guardian is contacted
by telephone within twenty-four hours, and in writing within forty-eight hours of the youth’s
admission to the program. The case manager also notifies the youth’s committing court,
assigned juvenile probation officer, and post-residential counselor, if applicable, within five
working days of the youth’s admission. Seven reviewed youth case management records
confirmed each youth’s parent/guardian was contacted by telephone within twenty-four hours of
admission, and each record contained documentation verifying the youth’s parent/guardian was
notified in writing within forty-eight hours of admission. Two of the seven reviewed youth were
applicable for Department of Children and Families (DCF) case manager notification. Both
reviewed records confirmed DCF notification was sent. All seven records had documentation
indicating the juvenile probation officer, committing court, and post-residential counselor, if
applicable, were notified of the youth’s admission. All notifications were sent on the day of
youth’s admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to provide youth orientation to the program’s rules,
expectations, goals, and services applicable to the youth on the day of youth’s admission into
the program. The policy indicates this will be initiated within two hours of the youth’s admission
by the transition services manager (TSM). The program uses an orientation checklist during the
process to ensure all required elements are addressed. Additionally, they provide a youth
handbook detailing all the required elements. Each youth’s parent/guardian is mailed a
parent/guardian handbook covering all required elements. During the annual compliance review
week, the program had a new admission. An observation of the orientation process confirmed
the program followed this practice. Seven youth case management records were reviewed.
Each record verified youth received an orientation to the program on the day of admission.
Orientation contained all required elements. Seven youth were interviewed. Each interviewed
youth confirmed they received an orientation within twenty-four hours of their admission and
were able to describe the orientation process.
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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 policy and procedures to obtain written consent of any youth eighteen years
of age or older for release of their confidential information to their parent/guardian. Seven youth
case management records were reviewed. One youth was applicable for requiring written
consent. Two additional applicable case management records were requested for a minimum
sample of three. All three applicable youth case management records contained written consent
signed by each youth.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a policy and procedures to utilize a classification system, in accordance with
Florida Administrative Code, promoting safety and security, as well as effective delivery of
treatment services. The program utilizes a classification system to promote safety and security
for which a youth’s classification is determined by their individual needs and identified risk
factors. A review of the program’s classification form validated the form included all required
elements. A review of seven youth case management records found documentation indicating
each record contained an admission classification form including all required elements outlined
by the Department’s policy. Each applicable youth was classified for the purpose of assignment
to a living area, sleeping room, and group. A review of the Department’s Juvenile Justice
Information System (JJIS) alerts list for any issues affecting classification was completed for
each youth and any identified risk were entered into JJIS. The program’s policy and procedures
also address reassessment and reclassification of youth prior to an increase of a youth’s
privileges or freedom of movement, participation on work projects or other activities which
involve the use of tools, or a youth’s participation in any off-campus activities. Two of the seven
reviewed youth case management records were applicable for a reassessment. One additional
record was requested for reassessments for a minimum sample of three records. All three youth
case management records included documentation for the reclassification of the youth prior to
being moved to another dorm. An interview with the facility administrator (FA) confirmed the
program’s practice.
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2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures for gathering any information on gangs or gang
involved youth and sharing this information with law enforcement. Seven youth case
management records were reviewed. One of the seven reviewed youth were applicable for gang
involvement. An additional record was provided for a total of two records. The program only had
two youth applicable for gang involvement during the annual compliance review period. The two
applicable case management records indicated upon identification, local law enforcement and
the youth’s home county law enforcement were notified of each youth’s suspected gang activity,
and this was completed prior to the seven-day notification from Monitoring and Quality
Improvement. Each youth had notifications to their juvenile probation officer and education
provider. One youth was applicable for the program needing to enter a gang alert into the
internal alert system and the Department’s Juvenile Justice System (JJIS) alerts. The remaining
youth was identified as a gang member prior to admission and the alert had already been
entered into JJIS. Neither of the two applicable youth required notification to a post-residential
counselor.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures to ensure the implementation and provision of gang
prevention and intervention strategies. The policy also includes providing youth the opportunity
to disaffiliate with a criminal street gang, if desired. Seven youth case management records
were reviewed. One youth was applicable for gang prevention and intervention services. An
additional record was provided for review. The program only had two applicable youth for gang
prevention and intervention services during the annual compliance review period. The two
applicable reviewed youth case management records reflected the program incorporated a
gang goal in each youth’s Individual Performance Plan (IPP) addressing the need for gang
awareness and intervention services. The program has a gang binder which maintains all
documented information and program activities completed with gang identified youth. The
program utilizes the GRADE: 50+ Stories of Fractured Lives curriculum as the selected gang
prevention and awareness curriculum. All program youth participate in Impact of Crime (IOC)
which also had a gang prevention component. The gang binder included all packets completed
by the identified youth and the sign-in sheet reflecting youth completed the gang prevention
segment of IOC. The facility administrator (FA) was interviewed and confirmed this practice. The
FA stated the program also provides youth education on the Racketeer Influenced and Corrupt
Organizations (RICO) Act and how this could impact them in the future.
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2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures ensuring each youth receives a Residential
Assessment for Youth (RAY) within thirty days of admission. The program maintains all
documentation of the initial RAY in the Department’s Juvenile Justice Information System
(JJIS). The program also maintains documentation of RAY Reassessments in the youth’s
record. The program’s policy also requires each youth to receive a RAY Reassessment within
ninety days of the initial RAY, or when deemed necessary by the intervention and
multidisciplinary treatment team. Seven youth case management records were reviewed. Each
reviewed youth had a RAY completed within thirty days of admission. One youth’s RAY was
entered into the Department’s Juvenile Justice Information System (JJIS). The remaining six
youth had handwritten RAYs completed, due to Department-wide system outages at the time of
completion. All seven reviewed youth were applicable for a RAY Reassessment. Five out of
seven youth had a RAY Reassessment completed within ninety days of the initial RAY. The
remaining two youth had their RAY Reassessments completed six days late. All RAY
Reassessments were maintained in each youth’s case management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures to ensure a Youth Needs Assessment Summary
(YNAS) of each youth is completed within thirty days of admission and maintains all
documentation of the initial assessment process in the Department’s Juvenile Justice
Information System (JJIS). Seven youth case management records were reviewed. Each youth
had a YNAS completed within thirty days of admission. Four of seven youth had their YNAS
documented in JJIS, as required. The remaining three youth had a handwritten YNAS
completed due Department-wide system outages.
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
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probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a policy and procedures regarding the development of the Individualized
Performance Plan (IPP) within thirty-days of a youth’s admission. Seven youth case
management records were reviewed for the development of the IPP within thirty-days of
admission. Six of seven reviewed youth records indicated all youth had an IPP developed within
thirty days of the youth’s admission, the remaining youth’s IPP was developed twelve days late.
All members of the treatment team were involved in the development of each youth’s IPP, and
all required signatures were documented. Five out of seven reviewed youth’s documentation
confirmed the parent/guardian was not present during the development of the IPP; however, the
signature page and copy of IPP were sent to parent/guardian. The remaining two youth were
foster care youth; therefore, their IPPs were sent to their Department of Children and Families
case manager. A review of documentation confirmed each youth had goals and the top three
criminogenic factors based on the youth’s needs assessment included on their IPP. All plans
included youth and program staff responsibilities and target dates for completion. Seven
reviewed records confirmed court-ordered sanctions were initiated/completed while in the
program and transition activities for the youth’s last sixty days were incorporated in the IPP. All
seven records confirmed within ten working days of completing the plan, a transmittal letter and
copy of the plan were sent to the committing court, juvenile probation officer, parent/guardian,
and DCF if applicable. Seven youth were interviewed. All interviewed youth stated they were
involved in the development of their IPP.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a policy and procedures to ensure performance plan reviews will result in
revisions when determined necessary by the intervention and treatment team. The youth’s
performance plan shall reference or incorporate the youth’s treatment or care plan. Seven youth
case management records were reviewed. Six of seven reviewed youth were applicable for plan
revisions. The remaining youth has not been in the program long enough to require a review or
revision. Revisions were completed based on Residential Assessment for Youth (RAY)
Reassessment results and progress youth made toward completing goals. One youth was
applicable for a plan revision to facilitate transition activities during the last sixty days of the
youth’s stay at the program. All seven reviewed youth were applicable for the incorporation of
treatment and academic plans. Documentation confirmed each youth had treatment and
academic goals incorporated into their performance plan. Two of the seven reviewed youth
were applicable for the incorporation of a Department of Children and Families (DCF) plan. The
program did not have any other youth applicable for a DCF plan or Agency for Persons with
Disabilities (APD) plan during the annual compliance review period. One of the two applicable
DCF youth did have a DCF plan goal incorporated into their performance plan. The remaining
youth did not have a DCF goal on their performance plan. Case management staff added a
DCF goal to the youth’s plan during the annual compliance review week.
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2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a policy and procedures to prepare a Performance Summary at minimum
every ninety days, or sooner if requested by the committing court, and prior to a youth’s release,
discharge, or transfer from the program. Seven youth case management records were
reviewed. Six of seven reviewed youth were applicable for the completion of a Performance
Summary. The remaining youth has not been in the program for ninety days. Five of the six
applicable youth had a Performance Summary completed within ninety days of the signing of
the initial performance plan. The remaining youth’s Performance Summary was fourteen days
late. One of the six applicable youth required a Performance Summary prepared prior to the
youth’s discharge. The Performance Summary was completed as required. A review of
documentation confirmed the Performance Summaries contained all required elements. The
reviewed records revealed the youth were afforded the opportunity to read and add comments
prior to signing the summary. Documentation confirmed each Performance Summary was
signed and dated by the youth, program director or designee, and treatment team leader or staff
member preparing the summary. Each record contained documentation reflecting the youth
were provided with a copy of their performance summary once this was sent to all required
parties. Original summaries were maintained in the case management record. A review of three
closed youth case management records found release summaries were completed, as required.
One of the three release summaries did not contain a justification for release. Each record
contained a release summary and Pre-Release Notification (PRN) sent at least ninety days prior
to the youth’s planned release. A signed copy of the PRN was maintained in each record. None
of the reviewed youth were applicable for the court objecting to the youth’s release. All three
youth were applicable to be referred to the sexually violent predator program (SVPP). None of
the youth were eligible for SVPP. Each youth’s juvenile probation officer was notified at least
ninety days prior to the youth’s release. Two of the three closed youth case management
records were applicable for requiring a Victim Notification of Release. The remaining youth’s
charges did not require victim notification. The program mailed a Victim Notification of Release
at least ten days prior to the youth’s release in each applicable record.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to encourage and facilitate parent/guardian
involvement in the case management process. Upon admission, each youth’s parent/guardian is
mailed a letter which includes information about the services offered at the program. Included in
the letter are the dates and times of the youth’s treatment team meetings. Parents/guardians
are encouraged to participate in person; however, if this cannot be arranged, parents/guardians
may participate by telephone. Seven youth case management records were reviewed. Each
record confirmed the program mailed the parent/guardian a letter with program services and
dates and times of each youth’s treatment team meeting on the day of admission. A treatment
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team meeting was observed during the annual compliance review week. The parent/guardian
participated by telephone and was an active participant in the treatment team meeting. The
parent/guardian was also made aware of the date and time of the next treatment team meeting.
An interview with the facility administrator confirmed parent/guardian involvement is encouraged
throughout the youth’s stay at the program. Seven youth were interviewed. All seven youth
reported their parents/guardians are contacted by telephone by the case manager or therapist
for family days, treatment team, weekly telephone calls, therapy sessions, and any updates on
the youth.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a policy and procedures establishing the treatment team members and bi-
weekly formal or informal treatment team meetings. Seven youth case management records
were reviewed, and documentation confirmed each youth had a formal treatment team meeting
held at least every thirty days. Documentation confirmed attendance of all required treatment
team members including the youth, case manager, a representative from education, a mental
health therapist, the youth’s parent/guardian, assigned juvenile probation officer (JPO), medical
staff, a representative from the living unit, and a representative from the program’s
administration. If staff from education or the medical department were unable to attend, they
provided a written progress report to be shared with the treatment team. Documentation for
each of the formal treatment team review meetings included the youth’s name, date of review,
comments from treatment team members, a brief synopsis of the youth’s progress, performance
plan revisions, positive and negative behaviors, behaviors resulting in physical interventions,
treatment progress, and Residential Assessment for Youth (RAY) Reassessment results. All
information was included in each formal treatment team review; however, the performance plan
revision for one youth was not addressed during the reviewed meetings. Each record confirmed
formal and informal treatment team meetings are held bi-weekly. Documentation for each of the
informal treatment team review meetings included the youth’s name, date of review, comments
from treatment team members, a brief synopsis of the youth’s progress, positive and negative
behaviors, behaviors resulting in physical interventions, and treatment progress. Documentation
for each of the informal treatment team reviews included RAY Reassessment results and
performance plan revisions for applicable youth. All information was included in each formal
treatment team review; however, the performance plan revision for one youth was not
addressed during the reviewed meetings. Documentation confirmed each youth’s JPO, and
parent/guardian were invited and encouraged to participate in treatment team meetings. A
treatment team meeting was observed during the annual compliance review week and all
required members were in attendance. Seven youth were interviewed. All seven youth
confirmed the program discusses youth’s performance to include progress on performance plan
goals, positive and negative behavior, and treatment progress. All seven youth confirmed the
program gives youth opportunity to demonstrate the skills they have learned in the program. All
seven youth stated the case manager and therapist ask youth questions during treatment team
meetings to determine what youth needs, what goals they are working on, what the youth have
learned, and their progress in the treatment.
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2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a policy and procedures to ensure the intervention and treatment team is
planning for the youth’s successful transition to the community upon release from the program.
Three closed youth case management records were reviewed for transition planning,
conferences, and Community Re-Entry Team (CRT) meetings. Two of three youth’s transition
conferences were held at least sixty days prior to the youth’s targeted release date, with one
youth’s transition conference being conducted one day late. Each transition conference included
a review of transition activities on the youth’s performance plan, targeted completion dates,
persons responsible for completion, and other pertinent transition activities. Documentation
reflected all required transition conference attendees were invited/encouraged to participate.
Each record confirmed all required treatment team members attended/participated in the
transition conference and signed/dated the transition conference forms. Each of the three youth
records confirmed CRT meetings were conducted prior to the youth’s release from the program
with invitations for participation being sent out by the juvenile probation officer. Chronological
notes reflected each youth and case manager participated in the CRT meeting as well as
education, mental health staff, parent/guardian, and program administration.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures to ensure the program assembles an exit portfolio for
each youth to assist the youth once they are released back into the community. Three closed
youth case management records were reviewed. A review of each record confirmed the exit
portfolio was discussed and initiated for each youth during the transition conference. Each exit
portfolio contained the required items to include state-issued identification card, copy of youth’s
transition plan, calendar with all dates, times, and locations of upcoming community
appointments, birth certificate, education/vocational certificates earned in the program,
education records, school transcripts, résumé, and sample employment application. One record
did not contain a Social Security card in the exit portfolio; however, documentation confirmed
the program made multiple attempts to obtain a copy of the Social Security card from the
parent/guardian. The remaining two exit portfolios contained a copy of the Social Security card.
Each record confirmed the exit portfolio was verified during the exit conference. A copy of the
exit portfolio was given to each youth upon release and forwarded to each youth’s juvenile
probation officer. The program’s contract does not include any special conditions for the exit
portfolio.
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2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures to ensure a meeting is conducted to review the status
of goals developed at the transition conference and finalize release plans. Three closed youth
case management records were reviewed. Documentation confirmed the exit conference was
conducted for each youth after the program notified the juvenile probation officer (JPO) of the
release and at least fourteen days prior to youth’s release. Each record contained the date of
the exit conference, signatures of all required parties, and a summary of pending transition
goals. The admission and release dates in the Department’s Juvenile Justice Information
System (JJIS) matched the dates in each youth record. The exit conference form for each youth
reflected the status of transition activities established at the transition conference and plans
finalized for the youth’s release reviewed, provisions for continued education and/or
employment, and documentation the parent/guardian and JPO are aware of the youth’s
vocational plan. Documentation in each youth record confirmed the case manager and
parent/guardian were aware of the plan, documents, and post-release discharge plans. All
required individuals participated in the exit conference for each youth. All records documented
the exit conference was conducted separately from the transition conference and Community
Re-Entry Team meetings.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to provide a formal process for youth to provide
constructive input to the program. A review of meeting sign-in sheets and agendas found
evidence the program hosts weekly community meetings and monthly Youth Advisory Board
(YAB) meetings. The program provides Conference Request forms to allow youth to share
ideas, needs, concerns, or to formally speak with program staff. The forms are available on the
living units. In addition, the program conducts quarterly surveys for youth and
parents/guardians. A review of survey documentation for the annual compliance review period
confirmed this practice. The program also completes the Trauma Responsive and Caring
Environment (TRACE) assessment and develops an action plan based on youth responses.
Documentation confirmed the program completed the yearly TRACE assessment and action
plan. An interview with the facility administrator (FA) confirmed the program has weekly
community meetings and monthly YAB meetings which allows the program to solicit input from
youth to improve the program. The FA stated youth can also submit a Conference Request form
to provide input and program surveys. Seven youth were interviewed about how youth can
provide input to the program. Four youth stated they can use the Conference Request form.
One youth stated they had never provided input; however, they would speak to staff if they
wanted to provide input in the future. The remaining two youth stated they would speak to staff
to provide input.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program has a policy and procedures requiring a single licensed mental health professional
to be the designated mental health clinician authority (DMHCA). The program’s clinical director
(CD) is a licensed clinical social worker with an active license which expires on March 31, 2025.
The CD is a full-time staff who works forty hours a week on-site with a juvenile sex offender
certification. The CD is responsible for coordinating and overseeing mental health/substance
abuse services. The assistant CD acts as the back-up when required. The assistant CD is a
licensed mental health counselor with an active license expiring March 31, 2025. The CD
interview indicated the role of the CD is to provide continuing supervision and both formal and
informal assistance to all staff. The CD ensures the services are being fulfilled, conducts fidelity
checks of group services, conducts chart audits, and reviews the weekly progress notes. The
CD conducts monthly treatment plan reviews to ensure the clinical team is working on identified
goals with the youth. The CD also provides annual training to all staff pertaining to suicide
training, effective communication, Prison Rape Elimination Act (PREA) needs, and how to work
with traumatized youth. The CD meets daily with the management team to ensure all
departments are working together to address any needs as they arise or help prevent any
potential complications.
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.
Since the last annual compliance review, the program had six licensed mental health and
substance abuse clinical staff responsible for the coordination and implementation of services.
The designated mental health clinician authority (DMHCA) ensured the licensed clinical staff
working under their supervision were performing services which they are qualified to provide
based on education, training and experience as outlined in the review of the job description. A
review of the program’s contract confirmed the licensed mental health and substance abuse
clinical staff are in accordance as required. At the time of the annual compliance review, the
program had five licensed mental health and substance abuse clinical staff providing services.
The center has had three licensed mental health counselors (LMHCs) and two licensed clinical
social workers (LCSWs), since the last annual compliance review, working under the direction of
the DMHCA, who is also a LCSW. Both LMHCs and the LCSWs had clear and active licenses in
the State of Florida with expiration dates of March 31, 2025.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures requiring the facility administrator to ensure mental
health and substance abuse services are provided by individuals with appropriate qualifications.
The program has two non-licensed therapists and one provisional licensed mental health
counselor. The two non-licensed therapists hold a master’s-level degree from an accredited
university or college in the field of counseling, social work, psychology, or related human
services field. Both non-licensed therapists conducted Assessments of Suicide Risk (ASRs) and
completed twenty hours of training and supervised experience in assessing suicide risk, mental
health crisis intervention, and emergency mental health services. The one provisional mental
health counselor held an out of state license and was pending a Florida license. The provisional
therapist has not completed any ASRs during the annual compliance review period.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a policy and procedures addressing a standardized process for the screening
and referral of youth identified as in need of further mental health and/or substance abuse
evaluation, staff training in mental health and substance abuse issues, as well as administration
of the Massachusetts Youth Screening Instrument, Second Version (MAYSI-2). The program’s
policy states all newly admitted youth receive an Assessment of Suicide Risk (ASR) and
comprehensive evaluation, no matter the risk factors. The program staff were not able to access
the Department’s Juvenile Justice Information System (JJIS) from March of 2024 until July of
2024 due to Department-wide system outages. In all seven reviewed mental health and
substance abuse records, the screener reviewed all available information, including the
commitment packet, and reports and/or records for existing documentation of mental health,
substance abuse problems, or history of human trafficking. One youth was screened with the
MAYSI-2 in JJIS on the day of admission in a confidential manner by one of the trained
therapists. The six remaining youth were screened during the time frame JJIS was down. Each
of the seven MAYSI-2 screenings were completed in full, indicating further assessment was
required with a referral being completed to alert the clinical director and the facility administrator
(FA)/designee. Six of the seven referrals indicated a need for a comprehensive evaluation, and
one was not applicable. Only three of the seven referrals required an Assessment of Suicide
Risk (ASR); all documented the reason for the referral. The FA interview indicated a
classification meeting is conducted for all youth on the day of admission as a part of the intake
process. The intake process includes a review of the findings of the MAYSI-2 screening, records
review, Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB), ASR, and the
initial interview. The classification team identifies needs for comprehensive evaluations,
placement on precautionary observation when indicated, and mental health/substance abuse
alert status. If youth behavior warrants, either program staff or the treatment team may complete
a Mental Health/Substance Abuse Referral form requesting a comprehensive evaluation be
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conducted, which is forwarded to the therapist. The comprehensive evaluation is completed
within thirty days of referral.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a policy and procedures requiring they conduct comprehensive mental health
and substance abuse evaluations on all youth admitted to the program. All seven mental health
and substance abuse records maintained a new combined mental health and substance abuse
evaluation completed within thirty days of admission by a licensed clinical staff. Each of the
seven youth provided consent for substance abuse services. Only two of the seven youth
evaluations were completed by a non-licensed substance abuse clinical staff. Both youth
evaluations indicated they were reviewed by a licensed mental health professional or a qualified
professional. The seven combined mental health and substance abuse evaluations included
identifying information, reason for evaluation, relevant background information, Mental Status
Examination, administered interview/procedures, diagnostic/clinical impression with Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition diagnosis, patterns of alcohol and other
drug abuse, impact of alcohol and other drug abuse on major life areas, risk factors of continued
alcohol and other drug abuse, and recommendations.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures in place requiring an Initial or Individualized Mental
Health or Substance Abuse Treatment Plan for youth determined to have a serious mental
disorder or substance abuse impairment and are receiving mental health or substance abuse
treatment. In all seven reviewed mental health and substance abuse records an initial treatment
plan was developed within seven days of treatment initiation on a form which contained all
elements of the Department’s Initial Mental Health/Substance Abuse Treatment Plan form. All
seven initial treatment plans were signed by the licensed clinical staff completing the form, as
well as all treatment team members who participated in the development of the plan, each
youth, and parent/guardian, where applicable. In three of seven, the initial treatment plan
included each youth’s psychiatric needs, as well as medication and frequency of monitoring by
the psychiatrist. The remaining five youth did not take psychotropic medications. Each of the
seven mental health and substance abuse records an individualized treatment plan which was
developed within thirty days of admission on a form which contained all elements of the
Department’s Individualized Mental Health/Substance Abuse Treatment Plan form. All seven
individualized treatment plans were signed by the licensed clinical staff completing the form, as
well as all treatment team members who participated in the development of the plan, and each
youth. In each of the seven, the parent/guardian participated telephonically; however, they did
not sign the plan. Each record contained a letter which was sent to the parent/guardian with the
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plan to return with signature. Only two of the seven youth received psychotropic medications
and the individualized treatment plan included psychiatric services, as well as psychotropic
medication and frequency of monitoring by the psychiatrist. In all seven records the
individualized treatment plan reviews were completed on a form which contained all elements of
the Department’s Individualized Mental Health/Substance Abuse Treatment Plan Review form.
All seven individualized treatment plan reviews were conducted every thirty days. In all seven
records the goals and objectives were individualized for each youth. Video observation was
conducted for this annual compliance review period for mental health groups. A total of three
mental health groups were viewed for three randomly selected days. Each group adhered to the
daily activity schedule and adhered to the duration time in accordance with the contract. All
groups were documented in the program logbook.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program has a policy and procedures governing treatment and discharge planning. In all
seven reviewed mental health and substance abuse records, each youth was assigned to a
treatment team upon admission. A review of treatment team documentation indicated each of
the seven reviewed records showed all youth participated in treatment team meetings. Each of
the seven records showed the residential living unit participated in all treatment teams and all
indicated education staff participated and provided input in one treatment team meeting. Only
three of the seven reviewed records indicated the youth required substance abuse treatment,
which included individual, group, and/or family counseling provided by a qualified professional in
accordance with each youth’s initial or individualized substance abuse treatment plan. All seven
records contained a signed Department’s Youth Consent for Substance Abuse Treatment and a
Youth Consent for Release of Substance Abuse Treatment Records form. Each of the seven
youth records contained an Authority for Evaluation and Treatment. In all seven records, the
mental health and substance abuse treatment notes were documented on a form which
contained all elements of the Department’s Counseling/Therapy Progress Notes form. All seven
youth received individual counseling and psychosocial skills training. All seven records
determined individual counseling sessions were documented, as well as group sessions and
monthly counseling sessions; however, progress notes from three of the seven reviewed
records could not confirm if youth received services as stipulated on each treatment plan and
the remaining four did. In all three closed mental health and substance abuse records the
discharge plan was documented on the Department’s Mental Health/Substance Abuse
Treatment Discharge Summary form which included the services needed for daily maintenance
of the positive improvement in behavioral, emotional, and social skills made by each youth
during treatment. All three closed records indicated the discharge plan was discussed with each
youth, parent/guardian where applicable, and the juvenile probation officer during the exit
conference, and a copy of the plan was provided. Only one of the three records reviewed did
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not indicate future services were discussed with the youth. None of the youth were released
while on suicide alert/precautions.
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 provides sex offender services as well as specialized treatment services. The
designated mental health clinician authority (DMHCA) is on-site for forty hours each week and
the clinical staff are on-site seven days each week. A review of the therapist to youth caseload
documentation confirmed each therapist was assigned to nine youth at the time of the annual
compliance review. Each non-licensed clinical staff held a master’s-level degree. The program
provided individual therapy at least once weekly and family therapy at least twice a month. The
psychiatrist provided services weekly on-site as documented by sign-in sheets. The DMHCA,
who is a licensed clinical social worker (LCSW), ensures coordination of services provided to
youth. The program provided four groups each week which included three juvenile sex offender
(JSO) groups. The program met the requirements for practicing Sexual Offender Therapy
according to Florida Administrative Code. In addition, the program sent all staff names to the
Department’s Office of Health Services (OHS) to confirm approval as a JSO therapist. None of
the youth reviewed missed services due to being on medical quarantine during the annual
compliance review period. According to the contract, the program’s clinical groups are
Pathways: A Guided Workbook for Youth Beginning Treatment, Skillstreaming the Adolescent,
Living In Balance, and Impact of Crime. Each of the seven interviewed youth reported
participating in family and individual counseling. All seven youth reported having individual
therapy once a week and family therapy at least twice a month. During interviews with seven
staff, they indicated direct care staff do not facilitate any mental health or substance abuse
groups. The facility administrator (FA) reported the program utilizes Pathways curriculum for
specialized treatment groups which focuses on sex offending behaviors and is an evidence-
based treatment intervention. The DMHCA reported youth are provided individual, group, and
family therapy. The program offers behavior management services, medication management,
skills training, and life skills training.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a psychiatrist with an active and clear license under Chapter 459, with the
State of Florida, which expires on January 31, 2026. The psychiatrist is available for emergency
consultation twenty-four hours a day, seven days a week. A review of sign-in/out logs confirmed
the psychiatrist was on-site at least two hours a week as required. There was documentation
the psychiatrist communicates with the treatment team regarding the psychiatric status of youth
receiving psychiatric services who are scheduled for treatment team reviews. The psychiatric
evaluation and recommendations for youth were incorporated into the mental health clinical
staff’s evaluations and individualized mental health and/or substance abuse treatment plans. A
review of medication management reviews confirmed the psychiatrist actively participates in,
manages, and supervises psychotropic medication services in the program. The program did
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not utilize an advanced practice registered nurse (APRN) during this annual compliance review
period. The program has a back-up psychiatrist, with an active and clear license, with the State
of Florida, which expires on January 31, 2026; however, the back-up psychiatrist was not
utilized during the annual compliance review period. The contract was reviewed for tele-
psychiatry inclusion; however, this was not utilized during the annual compliance review period.
During the interview with the psychiatrist, the psychiatrist confirmed responsibilities of
communicating with clinical staff, conducting medication management reviews, and psychiatric
evaluations for youth upon admission. The designated mental health clinician authority
(DMHCA) reported the clinical staff and case management team meet with the psychiatrist on a
weekly basis to discuss youth needs. Three of the seven youth reviewed were applicable for
entering the program on psychotropic medications. The remaining youth did not enter the
program on psychotropic medication. Each of the applicable youth were referred for a
psychiatric interview and received a diagnostic interview within fourteen days of admission as
required. Each initial diagnostic psychiatric interview included all required elements. Each of the
applicable youth had medication management reviews every thirty days as required with the
psychiatrist. None of the youth had any medication modifications or a psychiatric evaluation
completed within six months of their admission. Page three of the Clinical Psychotropic
Progress Note (CPPN) included all required elements for each youth. Each CPPN included the
signature of the psychiatrist and date. Monitoring for Tardive Dyskinesia was documented on a
monthly basis as indicated on the CPPN by the psychiatrist for each applicable youth.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a suicide prevention plan in place which received an annual review by the
facility administrator and designated mental health clinician authority (DMHCA) October 2, 2024.
The plan included procedures for identification and assessment of youth at risk of suicide, staff
training, suicide precautions, levels of supervision, referral, communication, notification,
documentation, immediate staff response, and a review process. The review process included
all required elements.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
The program has a practice in place for suicide precautions. Seven youth records were
reviewed for any youth exhibiting suicide risk behaviors. Two of the seven reviewed youth
records were applicable; therefore, the program provided one additional youth record for review.
Two of the three applicable youth were determined to be at risk and placed on precautionary
observation (PO) due to staff observation and one youth was during admission. When each
applicable youth was placed on PO, there was documentation in the facility logbook indicating
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instructions related to the suicide risk. In addition, it was noted each applicable youth was
allowed to participate in selected activities with other youth in designated safe
housing/observation areas of the facility. Each of the applicable youth had a referral for an
Assessment of Suicide Risk (ASR) and the ASR was completed on the Department’s form.
Upon each of the applicable youth being placed on PO, the parent/guardian was notified of the
potential suicide risk. The parent/guardian and juvenile probation officer notification was
documented on the ASR for each applicable youth. It was documented the clinical staff provided
supportive services for each applicable youth. Each of the ASRs were completed by a licensed
clinical staff. Each ASR was completed within twenty-four hours of screening/concerns and the
discontinuation of close supervision was documented in the facility logbook. Discontinuation of
suicide precautions did not occur until the licensed mental health professional and the facility
administrator (FA) communicated for each applicable youth. The date and time the clinician
conferred with the FA was documented on the ASR for each applicable youth. None of the
applicable youth were in crisis. Two of the applicable youth required a Follow-Up ASR prior to
removal from PO. The Follow-Up ASR was documented on the Department’s form. The youth
was maintained on suicide precaution with one being placed on one-to-one and the other youth
placed on constant supervision until the Follow-Up ASR indicated suicide precautions could be
discontinued. Upon the decision to discontinue suicide precautions, each youth was stepped
down to close supervision prior to transitioning to normal routine and standard supervision. Both
youth were maintained on close supervision until the licensed mental health professional
deemed it no longer necessary. After review of the program’s suicide prevention plan, it was
confirmed the discontinuation of close supervision was documented in accordance with the plan
for each applicable youth. A review of the Department’s Juvenile Justice Information System
(JJIS) confirmed each applicable youth had a suicide alert entered and closed following the
recommendations of the ASR and/or Follow-Up ASR. During the annual compliance review
week, video observation of one youth was conducted over a period of three days. It was
confirmed the youth was being supervised as required.
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program’s Suicide Prevention Plan requires staff to maintain one-to-one or constant
supervision for youth placed on suicide precautions. Seven youth mental health and substance
abuse records were reviewed, and three were applicable for youth who were placed on
precautionary observation (PO). The three applicable youth records contained the Suicide
Precaution Observation Log form documenting the appropriate level of supervision and
observations of the youth’s behavior in real time, not exceeding thirty-minute intervals. There
were no warning signs indicated for any of the three youth’s Suicide Precaution Observation
Logs. Each Suicide Precaution Observation Log was reviewed and signed by each shift
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supervisor and mental health clinical staff and documented safe housing requirements. All three
Suicide Precaution Observation Logs documented safe housing requirements as required.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a policy and procedures outlining suicide prevention training. A review of
seven pre-service and seven in-service staff training records confirmed completion of suicide
prevention training. The program has five suicide response kits which are co-located with first-
aid kits. The suicide kits are located in master control, medical, and each of the three dorms.
A review of “mock” suicide drills and medical drills since the last annual compliance review was
conducted. The mock suicide drills were held quarterly on each shift, for all staff who come in
contact with youth including kitchen and maintenance staff. Video observations of two “mock”
suicide drills confirmed they were simulated, as required. Each mock mental health drill was in
response to a simulated suicide attempt and/or incident of serious self-injury. The program did
not use youth during drill simulations related to mental health or substance abuse care. The
program provided semi-annual training on emergency response procedures which include
“mock” training, emergency response to a suicide attempt or incident of serious self-inflicted
injury using cardiopulmonary resuscitation (CPR) for the second shift. A review of medical drills
confirmed the use of CPR for the first and third shift, meeting the requirement. Staff who were
not present during a quarterly drill have the opportunity to review each drill scenario and
procedures in an effort to understand the process and receive necessary training to respond to
an incident of a suicide attempt or incident of serious self-inflicted injury in the facility. The
facility administrator reported drills are conducted monthly on each shift. Seven staff were
interviewed and each indicated when youth express suicidal ideation, they are to notify mental
health staff. Five staff reported they place youth on constant sight and sound supervision and
three reported they document supervision. Four staff reported they would notify the supervisor.
Six of the seven staff reported medical and suicide drills are conducted once a month and one
staff reported quarterly.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a crisis intervention plan which was reviewed annually by the facility
administrator and designated mental health clinician authority (DMHCA) on October 2, 2024.
The plan included notification, an alert system, means of referral including youth self-referral,
communication, supervision, documentation, and review.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
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working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a policy and procedures outlining Crisis Assessments. None of the youth
reviewed were applicable; therefore, the program provided two additional youth for review. The
program did not have any additional examples for review. Each applicable youth was
determined to be in crisis and a Crisis Assessment was completed within twenty-four hours of
the youth needs. Each Crisis Assessment included all required elements. One of the applicable
youth had documentation the parent/guardian was notified of follow-up treatment; the remaining
youth had no recommendation of follow-up treatment; therefore, notification was not required.
Each of the applicable Crisis Assessments were conducted by a licensed mental health
professional. Neither applicable youth posed a safety and security risk, and a mental health alert
was not applicable. Both applicable Crisis Assessments were Prison Rape Elimination Act
(PREA) related. One of the applicable youth was in the presence of the therapist; therefore, a
referral was not required. The second youth had a Mental Health and Substance Abuse Referral
Summary for a Crisis Assessment. As a result of the alleged PREA event, each applicable
youth was offered ongoing mental health treatment services.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has an emergency mental health and substance abuse services plan separate
from the crisis intervention plan in place. The plan includes immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health or substance abuse services including Baker Act and Marchman Act, documentation,
training including mock drills, and review. The plan was reviewed annually by the facility
administrator and designated mental health clinician authority (DMHCA) October 2, 2024.
3.18 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.
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3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedures regarding the safety planning process for youth. Each
of seven youth had safety plans including all required elements. The safety plans were
completed within fourteen days of admission for each youth. Each of the seven safety plans had
clear documentation showing the plan was jointly prepared by the youth, the program’s clinical
staff, and behavioral specialist. None of the safety plans had documentation input from the
parent/guardian during the safety planning process. There was no indication an attempt was
made to call the parent/guardian at the time the safety plan was being developed. Each of the
seven safety plans incorporated recommendations from previous or current clinical
assessment/screening instruments and incorporated trauma responsive practices. Each of the
seven safety plans were reviewed and/or updated at least every thirty days. None of the seven
youth required a review or update as a result of any significant behavioral or mental health
event identified by the youth’s intervention and treatment team. All safety plans are located in
master control for staff to review. Each of the seven interviewed youth reported contributing to
their safety plans. The facility administrator reported safety plans are updated monthly at
minimum.
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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 designated health authority (DHA) who is a licensed physician (MD) holding
an unrestricted license and meeting all requirements for independent and unsupervised practice
in the State of Florida. The DHA’s license expires on January 31, 2025, and there were no
disciplinary cases/public complaints on record. The DHA’s specialty training is in internal
medicine. The program does not utilize a physician assistant or advanced practice registered
nurse. A review of the DHA sign-in and out logs for the annual compliance review period
indicated the DHA was on-site once a week for up to four hours as contractually required. The
DHA was not on vacation or absent during the annual compliance review period; however, the
program does have a back-up DHA with equal licensure expiring on January 31, 2026, with
specialty training in family and internal medicine. The program does not utilize tele-medicine.
The DHA interview indicated the role of the DHA is to provide on-site clinical services, perform
Comprehensive Physical Assessments, conduct periodic evaluations, make referrals to a
specialist if needed, and conduct sick calls when on-site. The DHA develops the policy and
procedures, collaborates with the interdisciplinary team regarding each youth's ongoing medical
care, writes physician orders, and administers medical treatment as needed. The DHA is on-call
twenty-four hours a day, seven days a week, as well as on-site weekly for two hours. The health
services administrator (HSA) provides updates to the program staff through telephone and
physician orders. The off-site care documentation is placed in the youth’s Individual Healthcare
Record, as well as the DHA folder to be reviewed weekly and signed off.
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 had three registered nurses (RNs) providing on-site nursing coverage. All three
RNs had clear and active licenses, two expiring July 31, 2026, and the remaining one on April
30, 2025. The three RNs had current cardiopulmonary resuscitation (CPR) certifications; one
expiring November 2024, one February 2025, and the third October 2025. The program’s
contract requires 100 hours of nursing coverage a week, for ten hours a day, with a minimum of
one RN serving as the health service administrator (HSA) for forty hours a week, and the
remaining sixty hours a week being covered by one and a half RN positions. The program had
three full-time RNs, one serving as the HSA, providing the contractually required on-site nursing
coverage.
The program had three registered nurses (RN) providing on-site nursing coverage. All
three RNs had clear and active licenses, two expiring July 31, 2026, and the remaining
one on April 30, 2025. The three RNs had current cardiopulmonary resuscitation (CPR)
certifications; one expiring November 2024, one February 2025 and the third October 15,
2025. The program’s contract requires 100 hours of nursing coverage a week, for ten
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The designated health authority (DHA), the facility administrator (FA), and the psychiatrist
signed and dated all respective treatment facility operating procedures (FOPs). The DHA and
FA signed on July 1, 2024, and the psychiatrist on July 2, 2024, acknowledging an annual
review of the FOPs and protocols. The nursing staff reviewed, signed, and dated a cover page
on which all FOPs, healthcare protocols, and other procedures were listed. Signature dates for
the three RNs were February 1, 2023, February 3, 2023, and February 15, 2024, respectively.
All new policies or changes in policies made during the year were reviewed, signed, and dated
by each nurse on a signature page added with the specific policy listed, date of revision, and
signatures. The program had hired one new RN since the last annual compliance review. The
RN received a comprehensive clinical orientation to the Department’s healthcare policies and
procedures, given by a RN. The approval of treatment protocols or standing procedures was
written and authorized by the DHA.
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 policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) authorizing treatment of youth in the program’s custody. A
review of seven youth Individual Healthcare Records (IHCR) found all with a signature and a
date. Five of the youth had the original AET form filed in the youth’s IHCR, and two youth were
not applicable. Four youth had a parent/guardian signature on the AET form. A court order was
obtained for two youth records, which were filed in the IHCR. One youth was not applicable
because he was nineteen years of age. All AET forms were signed by a Department
representative. Five AET forms were valid, and the AET is valid for as long as the youth is in the
program or until the youth’s eighteenth birthday. Two youth had a valid court order in lieu of an
AET form. One youth record reviewed indicated the youth was eighteen years of age or older,
and there was documentation of the release of information in the IHCR. Two youth were in the
care of the Department of Children and Families (DCF). An interview with the registered nurse
confirmed when the youth arrive to the program, the nurse reviews the intake information in the
Department’s Juvenile Justice Information System (JJIS) and validates the AET. If a new AET is
needed, the juvenile probation officer (JPO) is contacted through case management to obtain a
new AET. The policy for documenting consent for youth who are eighteen years of age or older
occurs during intake or when the youth turns eighteen years of age while in the program. A
release of information is completed and filed on top of the AET.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is notified of any
changes in the youth’s condition and to document informed consent for youth healthcare. A
review of seven youth Individual Healthcare Records (IHCRs) found two applicable for
parental/guardian notifications for over-the-counter (OTC) medications beyond those covered by
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the Authority for Evaluation and Treatment (AET). Documentation confirmed consent was
provided by the parent/guardian for both youth. Four of the applicable IHCRs included
documentation of attempted contact with the parent/guardian in the progress notes when a new
medication was ordered. Four applicable IHCRs contained written notifications documented on
the Department’s Parental Notification of Health-Related Care: General or Parental Notification
of Health-Related Care: Medications forms. Three of the seven youth were taking prescribed
psychotropic medications at the time of admission, and staff witnessed all telephone call
attempts and conversations for psychotropic medications. None of the youth were applicable for
new psychotropic medications, a significant change in dosage, or discontinuation of medication.
Two youth in the care of the Department of Children and Families (DCF) had a valid court order
authorizing all treatment and procedures or indicated all treatments were approved. In all seven
IHCRs, vaccinations were verified within thirty days of each youth’s admission. An interview with
the registered nurse (RN) confirmed parental/guardian notifications are made verbally and are
followed by a written notification for all medications and treatments. The process to ensure
timely parental/guardian notifications occurs within twenty-four hours of admission, and verbal
consent is obtained as soon as possible after an order is written by the physician. The nursing
staff interview confirmed the parent/guardian is contacted if the youth is taken to the emergency
room, when the youth returns to the program, and if the injury or illness requires emergency
medical services. Written notifications are also completed after the return from the emergency
visit. The procedures for informing the parent/ guardian and obtaining consent for new
psychotropic medications, discontinuances, or psychotropic medication adjustments consists of
the program witnessing verbal consent to initiate the new medication. Furthermore, a copy of
page three from the Clinical Psychotropic Progress Note (CPPN) is mailed to the parent/
guardian. If there is a significant dosage change or an order to discontinue a medication, the
notification is mailed within twenty-four hours. Vaccinations are provided by the Department of
Health (DOH) on-site, and immunization records are obtained through the Florida Certification of
Immunizations upon the youth’s admission. The youth medical records are reviewed prior to
admission and again upon admission. If a youth is exempt from immunizations, the
parent/guardian must provide the appropriate forms from the DOH. After submitting the forms,
the DOH will provide the program with a copy. The form is immediately filed in the youth’s IHCR.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures regarding youth healthcare admission screening and
rescreening each time the physical custody of the youth changes. Seven youth Individual
Healthcare Records (IHCRs) were reviewed for a Facility Entry Physical Health Screening
(FEPHS) form. All seven FEPHS forms were completed by the registered nurse (RN) on the
date of each youth’s admission. None of the youth were outside the physical custody of the
Department. The interview with the RN confirmed the nursing assessment is completed
following the initial search, and within ten to fifteen minutes of arrival. Medical is notified by the
case management director by email prior to any youth being admitted. If the admission
screening is completed by direct care staff the nurse/healthcare staff reviews the form within
twenty-four hours.
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4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures ensuring all youth admitted to the program are
provided an orientation to healthcare services. A review of seven youth Individual Healthcare
Records (IHCRs) confirmed all youth were provided a general care orientation upon admission
to the program. The Health Education form in all seven IHCRs included access to medical care,
sick call, what constitutes an emergency, medication process, right to refuse care, what to do in
the case of a sexual assault or attempted sexual assault, the role of non-disciplinary healthcare
providers, and Standard Universal Precautions, which were discussed with the youth as
evidenced by their signature. Youth receive health education monthly throughout their stay at
the program. The program’s health education topics included all those required by Florida
Administrative Code.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to notify the designated health authority (DHA) or
designee, by telephone or verbally, of each youth’s arrival at the program and provide
immediate notification when any youth admitted to the program requires emergency care. The
program’s practice is to notify the DHA of all youth admissions, including youth with chronic
conditions, medical concerns, or any youth admitted on psychotropic medications. Seven youth
Individual Healthcare Records (IHCRs) were reviewed. Four youth were admitted with a known
or suspected chronic condition or required a referral to the DHA. None of the youth were
identified as in need of an emergency response upon admission. All seven IHCRs documented
the DHA notification in each youth’s Chronological Progress Notes and the Chronic Conditions
Log was updated after the notification. All seven IHCRs documented the DHA was notified
within twelve hours of admission. Three youth were taking psychotropic medication upon
admission, and notification to the psychiatrist was documented for each youth. According to an
interview with the registered nurse (RN), the DHA is notified of all new admissions and any
chronic conditions on the day of admission, and all youth are added to the DHA appointment list
and medical tracker. The DHA notification is filed in the IHCR in the chronological note section.
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 policy and procedures ensuring the Department’s Health-Related History
(HRH) form is completed prior to the Comprehensive Physical Assessment (CPA) and
healthcare needs are identified. A review of seven youth Individual Healthcare Records (IHCRs)
found each HRH was completed on the day of admission. All seven IHCRs indicated the HRH
form was completed prior to the CPA as indicated by the date and signatures. In all seven
IHCRs, the designated health authority (DHA) reviewed the HRH form as evidenced by a
checkbox on the CPA and a focused note in the admission documentation. An interview with the
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registered nurse (RN) confirmed a new HRH is completed on the day of admission for all new
youth by the RN.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the acute and chronic healthcare needs of
the youth are addressed by completing a Comprehensive Physical Assessment (CPA) within
seven days of youth admission. A review of seven Individual Healthcare Records (IHCRs)
confirmed the program utilized the Department’s CPA form. Seven reviewed IHCRs confirmed
the CPAs were completed by the designated health authority (DHA) within seven days of each
youth’s admission to the program. Seven youth records included documentation of the youth’s
Medical Grade on the CPA. The program completed a new CPA for all seven youth, no prior
CPAs were utilized. All sections of the seven youth’s CPAs were completed in full utilizing “O” or
“X” markings. The Department’s Problem List was updated for each youth, when applicable.
The CPA in all seven records included documentation of the most recent verified Tuberculosis
Skin Test (TST) which was administered within the last year to determine exposure to
tuberculosis (TB). The results of the TST were documented on each youth’s CPA and matched
the documentation on the Department’s Infectious and Communicable Disease (ICD) forms. An
interview with the registered nurse (RN) confirmed a new CPA is completed within seven days
of arrival and renewed yearly. The Department’s Juvenile Justice Information System (JJIS)
youth records are reviewed for TST status prior to admission and upon arrival of the youth. A TB
screening is completed by the nurse during the initial assessment, and a medical tracker is
maintained to monitor TST due dates. There are no female youth at 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 policy and procedures to ensure all youth admitted to the program are
screened, evaluated, and treated, if applicable, for sexually transmitted infections (STIs) and
human immunodeficiency virus (HIV). A review of seven Individual Healthcare Records (IHCRs)
found all youth were clinically screened and evaluated for STIs on the date of admission. None
of the reviewed youth were applicable for further evaluation, which was documented on the
Department’s STI form. None of the reviewed youth were applicable for further testing. No youth
records reviewed were out of the Department’s physical custody; therefore, a rescreening was
not applicable. All reviewed youth records documented evidence the youth were offered
counseling, testing, and treatment for HIV. None of the reviewed youth received HIV testing.
The program’s policy ensures the youth’s HIV test results are only disclosed to the youth’s
legally authorized representative, healthcare providers during treatment, the Department of
Health for purposes of reporting, health facility staff committees conducting facility monitoring,
medical personnel who have been subject to significant exposure, and healthcare facility
personnel or agents for healthcare providers who have a need to know during patient care. Pre
and post-test counseling services are provided by a local agency. Seven youth were
interviewed, and all indicated they can request HIV testing. An interview with the registered
nurse (RN) confirmed all youth are screened at admission and results are provided to the
designated health authority (DHA). STI results are filed in the lab section of each youth’s record.
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Testing documentation is entered on ICD forms. Results of HIV testing are placed in a sealed
envelope marked “Confidential” and placed under the lab section of the youth’s 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 policy and procedures addressing when there is not a licensed nurse on-site
the shift supervisor reviews all Sick Call Request forms, as soon as possible and within two
hours after the request is submitted. A review of seven Individual Healthcare Records (IHCRs)
indicated three were not applicable for sick call. None of the four applicable IHCRs had youth
present with similar sick call complaints three or more times within a two-week period, no sick
call was completed by a licensed practical nurse (LPN), and none of the youth were in restricted
housing. All four IHCRs contained Sick Call Request forms completed by each youth and the
RN, were documented in accordance with Florida Administrative Code, and were filed in each
IHCR in reverse chronological order. All sick calls were documented on the Sick Call Referral
Log. Three of four IHCRs had all sick calls documented on the Sick Call Index. The remaining
record had one sick call which was not documented on the Sick Call Index. The program
indicated it was missing due to human error. A review of the daily posted schedule, and the
nursing interview confirmed sick call is conducted twice daily, pursuant to contract requirements.
It should be noted the contract specifies scheduled hours, which differ from the hours on the
daily schedule, posted schedule, and the nursing interview. Observations indicated the sick call
hours were posted outside of the clinic doors, Sick Call Request forms were available in each
dormitory, and the clinic has an exam table and equipment to perform sick call. The RNs
conduct sick call unless the DHA is on-site. An observation of a sick call event could not be
conducted due to the program not having any sick call events during the annual compliance
review week. Five of seven youth interviews indicated they will see a nurse within one day of
making a sick call request. One stated immediately, and another one was not sure since they
never had requested a sick call. The nursing interview indicated youth can submit a sick call at
any time placing the completed Sick Call Request form in the sick call box, which is monitored
by the nurses at least twice each shift, and the youth are seen within twenty-four hours in the
clinic by a RN or the DHA if on-site. If a youth presents with similar sick call complaints three
times or more within fourteen days or if the treatment protocols seem to be ineffective, a referral
is made to the DHA. The DHA approves the treatment protocols. The nurse indicated the
program does not utilize room restriction; however, if a youth is placed in medical isolation,
healthcare staff visit the youth and document daily health status/complaints on a Nursing
Progress Note.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures addressing episodic and emergency care, including a
process for ensuring contents of first-aid kits are maintained and stored to prevent expiration or
deterioration and are replenished as needed. The program’s policy also encompasses the use,
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access, and inventory of Narcan. A review of seven Individual Healthcare Records (IHCRs)
indicated six were not applicable for episodic care. The program was only able to provide one
more example of a youth with episodic care. The two applicable IHCRs had youth who required
on-site first-aid or episodic care. Each on-site care was provided by a registered nurse (RN) in
problem-oriented charting. The program has one first-aid kit in each dormitory, master control,
kitchen, maintenance, front desk, and two more in master control for youth transportation. A
review of first-aid kit checks for the annual compliance review period indicated all kits were
checked weekly as required by policy. Observations of three first-aid kits, one each in dormitory
three, master control, and for van one, indicated all were stocked with designated health
authority (DHA) approved contents, and within their expiration date. The program has one
automated external defibrillator (AED) maintained in master control with the AED procedures.
The nurses ensure the batteries and pads are operable by conducting weekly checks. A review
of AED checks for the annual compliance review period indicated the AED was checked weekly
as required. The AED batteries expire on September 30, 2028, and the pads on December 15,
2025. The batteries were last changed June 21, 2023, and the pads on March 20, 2024.
Observations during the annual compliance review week indicated the AED light was green, and
the AED was in working order. A list of emergency numbers is kept in the clinic, master control,
and front office accessible to staff and inaccessible to youth. A review of training documentation
indicated the authorized direct care staff were appropriately trained on the administration of the
epinephrine auto-injector, as well as how and when to use Narcan. All seven pre and seven in-
service training records showed all fourteen staff were trained in episodic, first-aid, and
emergency care. A review of emergency medical drills for the annual compliance review period
for announced or unannounced emergency medical drills indicated they were conducted at least
monthly on each shift and simulated an episodic care event which called for immediate first-aid
and/or administration of cardiopulmonary resuscitation (CPR) techniques and the initiation of the
emergency procedures to follow when a life-threatening emergency does occur. All applicable
direct care staff participated in at least one drill which included the use of CPR annually or had
the opportunity to review each scenario in an effort to understand the process and required
response. A video review of three emergency medical drills indicated the nurses showed the
staff what to do and the staff did not practice the skills. The program indicated this was not the
normal process and usually the staff practice the skills and not just observe. An observation of
an episodic care event could not be conducted due to the program not having any first-aid
events during the annual compliance review week. All seven staff interviews indicated they can
personally call 9-1-1 if a youth has a medical emergency. All seven youth interviews indicated
they can see the doctor and the dentist if needed. The nursing interview corroborated the
number of first-aid kits, and their location in the facility, as well as the AED. The nursing
interview stated nursing progress notes reflect when episodic care has been provided. If non-
licensed staff provide first-aid the required Department form is completed, and the nurses are
notified upon return to the program to conduct a follow-up assessment. Youth who are sent off-
site for emergency care are tracked on the Episodic Care Log. The nursing interview indicated
emergency medical drills are conducted monthly on each shift, the nurses utilize a drill calendar,
and plan accordingly to include the use of CPR in an emergency medical drill quarterly.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
Four of the seven Individual Healthcare Records (IHCRs) reviewed were not applicable for off-
site care. The three applicable IHCRs had youth who required off-site care and for each event
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the Summary of Off-Site Care Consultation Report form was utilized and filed in each IHCR. All
off-site care was documented on the Episodic Care Log and the designated health authority
(DHA) reviewed and signed/initialed all off-site care findings, instructions, and information. Two
of the three IHCRs had documentation parental/guardian notifications were attempted. The
remaining one record did not require parental/guardian notification due to the youth being
nineteen years old. One of the three youth required a follow-up appointment which was tracked,
and the youth received the appropriate, timely follow-up care, as needed. The nursing interview
indicated nursing staff, and the DHA are notified of all off-site medical care and events are
tracked on the healthcare tracker. All hospital orders are reviewed with the DHA when on-site.
The off-site care findings are placed in the DHA folder, as well as being flagged in the youth’s
IHCR.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure any youth admitted to the program who
have chronic conditions receive regularly scheduled evaluations and as-needed follow-up care.
A review of seven youth Individual Healthcare Records (IHCRs) found four youth were identified
on the Department’s Facility Entry Physical Health Screening (FEPHS) form with a chronic
condition at admission. None of the youth were identified as having a communicable disease.
Two of the youth were taking prescribed medication on an on-going basis. Four youth were
undergoing treatment for a physical health condition. Two youth were classified with a Medical
Grade of two to four. Four youth were placed on the program’s Chronic Illness List and received
periodic evaluations at least every ninety days. None of the youth were applicable for taking
anti-tuberculosis medications. The program does not have any pregnant youth. Two youth were
applicable for having periodic evaluations conducted prior to renewing a prescription medication
which expired. None of the youth had an evaluation conducted off-site. There was no evidence
of any lapses in care or missed periodic evaluations. The Department’s Problem List was
updated for each youth. An interview with the facility administrator (FA) confirmed the program
management team meets on a daily basis to discuss medical issues, and the director of nursing
is present. These meetings take place on a weekly basis. The designated health authority
(DHA) interview confirmed chronic conditions are tracked using an excel spreadsheet.
Furthermore, periodic evaluations are completed every sixty days for youth with chronic medical
conditions.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
Two of seven Individual Healthcare Records (IHCRs) reviewed were not applicable for
medication management. Three of the five applicable IHCRs indicated each youth was admitted
with medication and this was documented in the progress notes and the Facility Entry Physical
Health Screening (FEPHS) form. The three IHCRs documented in the Chronological Progress
Note and the Prescription Medication Verification Checklist form the medication was verified
prior to each youth being admitted to the program. The designed health authority (DHA) and,
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when applicable, the psychiatrist were contacted to obtain the order to resume the specified
medications prescribed prior to admission. The remaining two youth were admitted without
medication. The five applicable youth had all medication administered pursuant to a current
prescription and all medication had a current, valid order. If current medications were continued,
discontinued, changed, or new ones were ordered, the DHA placed an order on the Practitioner
Order form. None of the youth were in restricted housing. Two of the five youth received over-
the-counter medication not listed on the Authority for Evaluation and Treatment (AET) form and
they were administered according to approved protocols or the practitioner order. All five IHCRs
utilized pre-printed pharmacy Medication Administration Records (MARs) to document all
medication and treatment and included all information required by the Department MAR. All
reviewed MARs clearly indicated medication start and stop dates, and each administered
medication entry was initialed by the nurse. None of the medication was administered by non-
healthcare staff, none of the youth refused any medication, and none received parenteral
medication. None of the five youth had any undocumented explanations for lapses or errors in
medication administration. The nursing staff documented weekly side-effect monitoring on all
reviewed MARs. All five IHCRs contained MARs including youth name, Department
identification number, date of birth, youth allergies, precautions, Medical Grade, medical alerts,
and a youth picture was next to the MAR. Three of the youth had a prescribed psychotropic
medication upon admission. In all three IHCRs the DHA and psychiatrist were notified, and an
initial diagnostic psychiatric interview was conducted within fourteen days. One of the remaining
two youth without medication was referred to the psychiatrist upon admission and received an
initial diagnostic psychiatric interview within fourteen days. All four youth who received an initial
diagnostic psychiatric interview received a medication monitoring/review every thirty days as
required. The program did not have any standing orders, emergency treatment orders, or pro re
nata (PRN) orders for psychotropic medications. Observations of medication administration for
three youth were conducted during the annual compliance review week. The medication
delivery was the sole responsibility of the nurse during the time of administration. Each youth
was escorted to the clinic for medication administration by a youth care worker and approached
the nurse individually. The nurse identified themself and the youth stated why they were there.
The nurse verified the alerts and allergies of each youth, what medication the youth was taking,
and removed the medication out of the bubble pack after confirmation it was the correct one.
Each medication administration was initialed by the nurse. The nurse provided water to each
youth to swallow the medication, had each youth cough and show their tongue, as well as
repeat the cough and show their open mouth to the youth care worker to ensure the medication
was swallowed. The Six Rights of Medication Delivery/Administration were verified for all three
youth. Four of the seven interviewed youth indicated the nurse conducts medication
administration and described the process. The remaining three stated they do not take
medications. The nursing interview indicated the nurses conduct youth admission including
medication verification with parent/guardian during the intake period. The nurse stated the
program maintains a list of non-healthcare staff which have been trained in providing medication
by a registered nurse. Medication pass times are daily at 7:00 a.m., 12:00 p.m., 4:00 p.m., and
8:00 p.m. if needed. The program utilizes a psychiatrist who is on-site weekly for medication
management, initial evaluation, and referrals.
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.
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The program has a policy and procedures addressing the destruction and disposal or return of
expired or discontinued medications and reporting criteria and procedures regarding inventory
discrepancies. Observations of the clinic indicated the sharps and stock medications are stored
in locked cabinets which have labels to identify what is maintained within and are inaccessible
to youth. The stock medication cabinet contained ten doses of Narcan. The sharps are
inventoried utilizing a routine perpetual inventory with descending count as each sharp is
utilized and disposed, as well as a weekly count. A review of the sharp inventory for the annual
compliance review period indicated the inventories were conducted as required. The medication
cart was observed as locked, organized, and clean with injectables, topicals, drops, liquids, two
doses of Narcan, and youth-specific medication all kept separated. The medication cart had a
lock box which contained all youth-specific controlled medications. The clinic has a locked
medication refrigerator which contained only insulin during the annual compliance review week.
A review of the five applicable Individual Healthcare Records (IHCRs) of youth with controlled
substances indicated all controlled medications had a shift-to-shift inventory count documented
on each youth’s Individualized Controlled Medication Inventory Record. A review of nine stock
over-the-counter (OTC) medication inventories for the annual compliance review period
indicated a perpetual and weekly count was conducted; however, three medications had a total
of four incorrect documentations of weekly counts, and there was missing documentation when
medication was removed from stock. A review of training for supervisory-level, non-healthcare
staff in the delivery and oversight of medication self-administration indicated the training was
conducted by a registered nurse (RN). Observations of a nurse completing counts for three
controlled medications, three sharps, and three OTC medications indicated all counts matched
the ending inventory numbers. The nursing interview indicated class II medications are
destroyed on-site with the pharmacist, a nurse, and the facility administrator (FA), and other
medications are returned to the pharmacy for destruction. The pharmacist is on-site once a
month to complete medication inventories, inspect the medication cart, and complete controlled
medication destruction. Controlled medications are maintained behind a double locking
mechanism, a locked box within the locked medication cart. The controlled medication is
counted shift-to-shift at least twice a day. Medications are inventoried with a perpetual and
weekly count. All medication is stored within the clinic behind locked doors.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a policy and procedures addressing needle stick post-exposure evaluation.
The program has infection control procedures in place including prevention, containment,
treatment, and reporting requirements related to infectious diseases, in accordance with the
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Occupational Safety and Health Administration (OSHA) federal regulations and the Center for
Disease Control and Prevention (CDC) guidelines. The procedures were reviewed by the
designated health authority (DHA), the facility administrator (FA), and others on January 31,
2023. The program’s infection control procedures include common, infectious diseases of
childhood, self-limiting, episodic contagious illnesses, viral or bacterial infectious diseases,
tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus (HIV), infectious diseases
caused by bloodborne pathogens, other outbreaks or epidemics caused by any other infectious
agent, whether spread directly or indirectly, outbreaks of pediculosis and/or scabies, Methicillin-
Resistant Staphylococcus Aureus (MRSA) and other emerging antibiotic-resistant micro-
organisms, foodborne illnesses, bio-terrorist agents, as well as chemical exposures in the
workplace, Hepatitis B immunizations being available for staff, and staff having access to
protective equipment. The program did not have any instances in which the local county health
department, CDC, and/or the Department’s Central Communications Center (CCC) should have
been notified of an infectious disease nor did they have three or more cases of any reportable
infectious diseases which needed to be reported to the local county health department and/or
CDC during the annual compliance review period. The FA has established a separate file to
contain all documents for youth and staff who have experienced a facility/occupational
exposure. The program’s exposure control plan was written in accordance with OSHA
standards and is available to all staff. The plan was reviewed and signed annually by the
administration of the program on January 31, 2023. The FA interview indicated the exposure
control plan is located in the FA office and the clinic. The health service administrator (HSA)
reviews the plan with all new hires and annually with all other staff. The nursing interview
indicated the exposure control plan is located in the clinic. Infection control training for staff is
provided by a registered nurse during pre-service training, as well as annually. Training is also
provided to the youth during the admission process and as part of the monthly health education
groups throughout the year.
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 policy and procedures stating how they will maintain active
supervision of youth at all times. Observations of staff during the annual compliance review
week found staff supervising youth appropriately during all observed activities. According to the
policy and procedures provided to the annual compliance review team, staff-to-youth ratios are
one staff to eight youth during awake hours, one to ten during sleep hours, and one to five for
off-site activities. Observed activities during the four-day annual compliance review included
supervision of youth during school hours, activities in the multi-purpose room of each dormitory,
educational activities, and youth movement through the facility. The daily schedules were
posted in the dormitories and cafeteria. At no time during the annual compliance review were
youth observed wandering freely about the program. Each of the seven interviewed staff
confirmed their understanding of the procedures when there is a discrepancy with the count. All
the staff indicated the count is reconducted until the count is reconciled and all movement is
stopped. Observations found the counts were conducted at scheduled and unscheduled times
and the shift supervisor was able to give an accurate count when asked. Informal interviews
with three staff found they were aware of the number of youth under their supervision
immediately without having to stop and count.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program maintains a policy and procedures to address the behavior management system
(BMS) or positive performance system (PPS). The PPS fosters accountability for behavior and
compliance with the residential community’s rules and expectations. The PPS was observed to
be posted in the dormitories. The PPS is clearly explained in the youth handbook, which is
accessible to youth, as a copy is provided to the youth upon intake. The program’s PPS details
the rules and the positive and negative consequences for actions. Seven pre-service staff
training records and seven in-service staff training records were reviewed and indicated all staff
training records contained PPS training. Staff are provided feedback from supervisory staff on
their implementation of the PPS during the shift or as needed. The agreement between
education and the program states the staff will address youth behaviors while in class and the
teachers can address the youth behaviors as well. The assistant facility administrator (AFA)
provided training to the teachers on the program’s BMS. A review of seven staff position
descriptions found the responsibility for implementation of the PPS as part of the staff’s job
function. Seven staff were interviewed and confirmed training and understanding of the PPS. All
seven staff stated the PPS is a point system to earn rewards and levels. All seven staff stated
the PPS levels and points earned are updated daily and the information is posted on the
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dormitories. The program uses an Excel spreadsheet which consists of each youth by
dormitory, daily behavior, phase levels, and daily and weekly points earned. There are four
phase levels youth must apply for and achieve to complete the program. Each phase level has a
phase packet youth must complete to show what skills they have learned and how they were
able to display these skills. Each phase level has a required number of days the youth must
meet in order to complete the level and phase packet. The treatment teams meet to review the
youth behavioral infractions, earned points, and consequences which are administered through
the PPS system as a result of program rule violations by the youth. The orientation checklist
documents the PPS is reviewed with the youth. All seven reviewed youth case management
records contained a complete orientation checklist. The PPS promotes youth rights, positive and
negative consequences, constructive disciplinary action, opportunities for reinforcement,
recognition of accomplishments and positive behaviors at a four to one ratio, peaceful
resolutions, as well as provides youth with prosocial acceptable alternative behavior. Youth
have an opportunity to explain their behavior during treatment teams and special treatment
teams. The special treatment team discusses reasonable reparations for harm caused to others,
alternate behaviors the youth could utilize, promotes peaceful and positive dialog towards a
resolution, and keeps separations of youth from the population at a minimum. The PPS is
connected to each youth’s individual performance and treatment plan goals. The PPS includes
a variety of rewards including daily snacks, meals, canteen, fun days, movies, verbal praise,
and special privilege activities. The facility administrator (FA) stated the program maintains a
spreadsheet which is monitored daily and updated on a weekly basis. It displays the daily
behavior write-ups, if any, on all youth which shows whether the youth gained or lost a particular
day. The positive reward for earning days consists of; caught being good canteen points, weekly
Monday/Thursday incentive, weekly canteen on Fridays, monthly meal day, monthly movie
night, Dormitory of the Month, monthly community service outings, and special events. The
phase level three and four youth are able to earn a privilege telephone call in addition to the
weekly telephone call. The youth advisory board has input into the incentives they would like to
see applied. The consequence within the PPS program is losing the ability to attend and/or earn
one of the above listed positive rewards. Consequences/punishers are monitored through
meetings focusing on discussing behavioral program infractions. During these meetings,
members of the treatment team discuss all youth program infractions and discuss
consequences for each. Seven youth were interviewed and indicated they receive prompts from
staff prior to receiving a write-up for their actions and youth can earn a minor, moderate, or
major rule violation for their negative behaviors or points for positive behaviors. All seven youth
stated they earn snacks or meals, recreation time, canteen, television time, daily incentives,
weekly incentives, and monthly incentives for positive behaviors.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract state the program does not use restricted housing
including confinement, seclusion, room restriction, or secure observation; therefore, this
indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has sixty-six cameras. All cameras were operational at the time of the annual
compliance review. The video coverage is stored for thirty days. The program’s practice is to
conduct checks of youth in their rooms every five minutes. Ten-minute check sheets were
reviewed for the three dorms from October 2023 to October 2024 finding no more than ten
minutes passed without the staff actively observing each youth. Staff completing the checks
initialed the check sheet. Video review of three dorms for thirty-minute intervals on nine different
days and shifts found no more than ten minutes passed without staff actively observing youth.
Seven staff were interviewed; all staff indicated room checks are completed every five minutes.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program maintains a policy and procedures which address population census, counts, and
tracking of youth. The program’s policy indicates headcounts will occur and shall be
documented at a minimum of six times within a twenty-four-hour period. The program has
adapted to counts being completed formally and informally every thirty minutes, at the beginning
and end of each shift, and during every movement. The program utilizes the master control
logbook to document youth counts and movements. Logbooks were reviewed from October
2023 to October 2024. The logbook is utilized to maintain a chronological record of events as
they occur. The program headcounts are conducted by the shift supervisor at the beginning of
each shift to verify accuracy and document counts in the program’s logbook. Counts are
conducted at the beginning of shift, after outdoor activities, and after emergency situations. The
logbook also tracks youth intakes, releases, and movements outside of the facility. The program
utilizes alert boards to track the daily count of all youth in and out of the program. Staff were
aware of all youth locations and could provide accurate counts to the annual compliance review
team members during the annual compliance review week. Seven staff were interviewed, and
each was aware of count procedures, as required by program policy, including what to do in the
case of an unsuccessful count.
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5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a policy and procedures addressing logbook entries. The program does
not use shift reports. The program maintains a chronological record of events, incidents, and
activities in a logbook as outlined by Florida Administrative Code. Logbooks utilized by the
program during the last eleven months were reviewed. Each reviewed logbook was bound with
numbered pages and entries were made in ink with no white-outs or missing or removed
entries. Logbook entries are to include emergency situation, incidents, including the use of
mechanical restraints which are not applicable at this program, special instructions for
supervision and monitoring of youth, population counts at the beginning and end of each shift,
and any other population counts conducted during a shift, perimeter security checks and other
security checks conducted by direct care staff, transports away from the facility, including the
names of the staff, youth involved, and the destination, requests by law enforcement to access
any youth, removal of any youth from the mainstream population, controlled observation,
admission 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.
Oncoming staff members participate in a shift briefing and sign the logbook acknowledging they
are aware of all information from the last two shifts and alert changes. Each reviewed logbook
entry was legible and included the time and date of the entry, printed name, and the signature of
the staff member making the entry.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a written policy and procedures in place for key control and security which
includes assignment, inventory, tracking, and storage of keys. The policy also includes
procedures addressing missing or lost keys and reporting and replacement of damaged keys.
During observations made throughout the annual compliance review week, all staff and visitors
surrendered their personal keys to master control upon entering the program. Keys were then
stored in a locked cabinet in master control. Program keys are in a locked box in master control.
When entering the program, staff sign the key logbook, write the date, key ring number, and
time the program keys were taken. When leaving the program, staff write the time and sign the
key logbook indicating the keys were returned. A review of key logbooks for the annual
compliance review period verified this practice. The program has a list of staff who are assigned
permanent keys authorized by the facility administrator (FA). Permanent keys are issued, and
staff signed an acknowledgment form indicating a key identification number and the number of
keys on the ring. If keys are damaged or need to be replaced it is reported to the shift supervisor
and a maintenance request form is completed. The damaged keys are given to the physical
plant manager and the staff are given new keys. There were no incidents reported to the
Department’s Central Communications Center (CCC) or Program Monitoring and Management
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(PMM) deficiencies related to key control concerns. Informal interviews were conducted with the
master control operator who stated when a staff wants to sign out a key, they verify the key with
the master key inventory to make sure it’s not a restricted key. The master key inventory is color
coded to show which keys are assigned to which staff. After the key is verified, it is released to
the staff. Each of the three informally interviewed staff knew how many keys were on their
personal key ring and the function of each key. Their responses were compared to the key
inventory and there were no discrepancies. Seven staff were interviewed, and each was able to
explain the key control process.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a system to prevent the introduction of contraband and identifying contraband
items and materials through searches of the physical plant, facility grounds, and youth, which is
also clearly explained in the youth handbook. The policy also states any staff found to be in
possession of contraband at the program will be subject to disciplinary action up to, and
including, dismissal, as well as procedures regarding notification of law enforcement for items
considered illegal as defined in Florida Statutes. At the time of the annual compliance review,
the program had not disposed of any contraband or notified the Department’s Central
Communications Center (CCC). The program’s policy and procedures and the youth handbook
define items and materials considered contraband when found in the possession of youth,
provides youth with a list of contraband which meets the indicator requirements, and informs
youth of the consequences if found with contraband. The prohibited list includes personal
cellular telephones and/or equipment and/or electronic devices capable of taking pictures and/or
audio/video recordings. The list also includes unauthorized articles of clothing and food,
controlled substances, prescriptions or non-prescription drugs, and any firearm or explosive
device. The program policy and the youth handbook also explain the searching of the physical
plant, facility grounds, youth and staff, and incoming and outgoing mail. The program maintains
room search forms which document any contraband findings and staff document these findings
in the program logbook. A review of contraband forms from October 2023 to October 2024 was
completed. No illegal contraband was found. Items not considered illegal contraband were
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documented on the contraband search form as along with the disposition of the item. Any item
not considered illegal contraband will be sent to the youth’s home or retained at the program
until the youth’s release. Seven interviewed staff were able to explain the process for youth
room searches during interviews. Five staff stated searches are completed weekly and two staff
stated monthly. The contraband notice is posted, and states law enforcement will be contacted
for anyone bringing in contraband and a criminal report will be filed. This practice was confirmed
through an interview with the facility administrator. The visitor’s log and outside contractor’s
sign-in form include the contraband attestation statement. Seventeen new staff were hired since
the last annual compliance review; personnel records were reviewed and all had a signed copy
of the contraband attestation. The facility administrator stated in the event illegal contraband
items are discovered, the facility will immediately contact local law enforcement and the CCC.
All instances of contraband items and their disposal are documented appropriately after being
discarded or turned over to local law enforcement or investigating agency.
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 policy and procedures addressing searches and full body visual
searches. The program conducts searches as a method to prevent the introduction of
contraband and unauthorized items into the facility. Policy indicates searches of youth are
conducted after off-site transports, after visitation, before moving youth from an outside area
into the building, and prior to moving youth from the building to an outside area. The program
conducted one off-site transport during the week of the annual compliance review. The review
team observed properly conducted searches and full visual searches before and after the
transport. The annual compliance review team also observed several youth searches during the
week of the annual compliance review including transition to school, to group, to recreation, and
back to the dorm. No youth were observed to be using a tool except for a mop and a broom.
Search procedures and expectations were properly explained to all youth before searches were
conducted. Searches were conducted by staff of the same gender as the youth, while a second
and third staff member assisted with supervision. Searches were thorough and done in a
manner which did not degrade the youth. All searches were documented in the program’s
logbook. The review team was electronically searched and frisked search every day of the
annual compliance review. A video review of staff searches was conducted and found all staff
entering the facility were electronically searched as well as frisk searched. Seven staff were
interviewed, and two of the seven stated searches occur once a week. Five of the seven staff
stated youth are searched following any movement. Seven youth were interviewed, and one
stated they are searched when returning from off campus, one youth stated after an outdoor
activity, one youth stated when an item is missing, one youth stated they are searched after
visitation, one youth stated they are searched after meals, and one stated they are searched
after work detail.
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Office of Accountability and Program Support Page 56 of 64 (Revised September 2022)
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a policy and procedures addressing vehicles and maintenance. The
program utilizes one vehicle, a van, for youth transports. The van passed inspections during this
annual compliance review period. The vehicle is also inspected weekly by the plant manager.
Results of weekly inspections are documented and stored in the program’s vehicle maintenance
log/binder. A member of the annual compliance review team inspected the vehicle, and all
required equipment was observed, which included a seatbelt cutter, window punch, and fire
extinguisher. The first-aid kits are not stored in the van to preserve the items inside of the kit.
Staff check out a first-aid kit prior to a transport and return the kit to the program upon return. All
seatbelts in the van were in proper working condition. A random check of personal vehicles and
the van was conducted during the annual compliance review week and all were found to be
locked. A transport was observed during the annual compliance review week and transport staff
were found to abide by the transport policy and procedures. Seven youth interviews indicated
they are never secured to the vehicle during transports and all seven have never seen
contraband being placed in the vehicle. Seven staff were interviewed, and six stated youth must
wear seatbelts, five stated youth wear handcuffs, four staff stated youth wear shackles, and one
staff never participated in a transport. Six of the seven staff stated they can use the program
transport telephone and one stated they never participated in a transport. Six of seven staff
stated they take a first-aid kit on transports, one stated the suicide kit, six stated the fire
extinguisher, and two stated the seatbelt cutter are taken on transports. All seven staff stated
they cannot use personal vehicles to transport youth and the van is searched prior to and after a
transport. In the event of an accident or transport emergency three staff stated they call 9-1-1,
three have not participated in a transport, one stated they would call the supervisor and await
instructions, and three stated they would call the facility administrator (FA). One staff stated they
would call the FA, let the facility know of the situation, notify corporate, and check to see if
everyone is unharmed.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a policy and procedures addressing transportation of youth, outlining
staff to youth ratio during transports as one to five; however, if there are five or fewer youth, a
minimum of two staff are needed to perform all transports. No youth may operate the vehicle at
any time. The program’s transport vehicle was inspected by an annual compliance review team
member and the vehicle was found to be in working order. The program has an approved
transport list which is updated monthly to ensure staff driver’s licenses are valid. This approved
driver’s list is located in the administrative area. An annual compliance review team member
observed the facility transporter conduct a routine check of the program’s transport vehicle. The
vehicle was found locked and secured. The team was able to observe a transport and the staff
to youth ratio was two to one, staff and youth wore seatbelts, and the youth was not attached to
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Office of Accountability and Program Support Page 57 of 64 (Revised September 2022)
the vehicle. Staff interviews confirmed they are issued a cellular telephone before transport and
staff do not conduct transports in personal vehicles. Vehicles are checked before and after
transports. All seven youth stated they had not seen staff place contraband inside the vehicle.
All seven youth stated they feel safe during transports.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The policy and procedures designate the assistant facility administrator (AFA) or the unit
manager as the person responsible for conducting the weekly safety and security audits. The
weekly safety audits are kept in a binder, which was reviewed weekly during the safety
committee meeting held on Fridays. This committee consists of the facility administrator,
assistant facility administrator, unit manager, the physical plant manager, and another member
of the management team. Findings are discussed and a corrective action plan is implemented to
fix any deficiency noted. During the annual compliance review period, there were no inspections
missing. The forms documented safety and maintenance repairs needed and the date and time
the repairs were completed, or due to be completed. All forms were reviewed and signed by the
facility administrator. The forms cover radios, cameras, keys, telephones, mechanical restraints,
the generator, flashlights, fire safety equipment, alarms, ensuring no anchor points, youth
rooms, recreation area, grounds, correction action needed, and corrective action completed.
The interview with the facility administrator confirmed the weekly safety audits are conducted in
accordance with program policy and procedures.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures to address tool inventory and management.
The policy addresses the issuance, inventory, and control of equipment and tools. The policy
also states all Class A tools are maintained in the maintenance shed. Youth only have access to
Class B tools which are brooms, mops, and scrub brushes. Tools such as machetes, bowie
knives, and other long-blade knives are prohibited by policy. The program has identified their
plant manager as the program’s tool control manager. The policy classifies tools into two
categories as Class A tools and Class B tools. Class A tools are hazardous with sharp edges or
points and have a high potential to be used as a weapon to inflict serious bodily harm, such as
knives, hammers, screwdrivers, and electric drills. Class B tools do not have sharp edges or
points such as brooms, mops, and scrub brushes. The plant manager inventories the tools daily
at the beginning of shift and at the end of shift except when not in use or assigned days off. The
plant manager completes a sign-in and out sheet when a tool is used. Class B tools are
inventoried monthly. Staff must sign in and out the Class B tool being used. A review of the
inventory and verification of ten tools found two ladders recently purchased not on the inventory.
They were added immediately. The plant manager stated there were no tools which were
damaged or out of use.
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Office of Accountability and Program Support Page 58 of 64 (Revised September 2022)
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures addressing youth tool handling and
supervision. The policy outlines proper procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries to youth and staff. Youth do not have access to
Class A tools, only Class B tools which consist of a broom, mop, and scrub brush and must be
signed out by staff from the secure closet located in the dorm. The program completes Risk
Assessments which determine youth risk to self and others. Seven youth case management
records were reviewed, and all indicated youth have been trained on the proper usage of Class
B tools during their orientation process. All seven youth signed an acknowledgement of tool
training during the orientation process for Class B tools. The signed acknowledgement form was
filed in each youth’s record. Although each youth receives a risk assessment monthly, youth do
not participate in work projects. The program maintains a ratio of one staff to five youth for
vocational training; however, does not offer vocational training which may include tools. There
were no work projects to observe during the annual compliance review week. Youth were
observed to be cleaning their rooms and dorm using Class B tools. Seven youth interviews
confirmed youth are only allowed to use a scrub brush, mop, and a broom. Seven staff
interviews revealed youth are allowed to use Class B tools.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a policy and procedures which address outside contractors. The
program has established guidelines for outside contractors including information regarding tool
control and restrictions. The program has a form to be signed by outside contractors addressing
how tools will be checked upon arrival to and departure from the program, restrictions to youth
work area access, immediate reporting of missing tools, restriction of personal cellular
telephones and/or equipment capable of taking pictures and/or recording audio/video in secure
areas, and the contraband attestation statement. The form also requires contractors to list each
tool brought into the facility. This list is reviewed by the plant manager or designee before the
contractor has access to a secure area. This list is again reviewed before the contractor exits
the program. The contractor’s failure to sign this form prohibits access to work within the
program. Outside contractors are escorted and supervised by the plant manager or designee at
any time they are within the facility. The review team was not able to observe this process
during the annual compliance review week. Five program invoices were cross checked to
ensure outside contractor agreements were signed on the date of service. All invoices and
contractor agreements matched and there were no discrepancies found.
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Office of Accountability and Program Support Page 59 of 64 (Revised September 2022)
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 policy and procedures to provide for the safety and security of both
staff and youth. All drills conducted during the annual compliance review period were provided
for review. The documentation showed drills were consistent with the Continuity of Operations
Plan (COOP). All reviewed drills contained the type of drill, date, time, participants, and a brief
scenario, including findings and recommendations. Fire drills were conducted monthly from
October 2023 to October 2024 on each shift with no exceptions being noted. There were thirty-
three fire drills required and all thirty-three drills were completed. Emergency drills were also
conducted monthly from October 2023 to October 2024 on each shift with no exceptions. There
were thirty-three drills required and all thirty-three were completed. The types of drills included
disaster, bomb threat, gang, riot, chemical, tornado, evacuation, and hostage. Escape and Right
Interactions (RI) drills were held semi-annually. Evacuation and egress routes were posted
throughout the facility, and all thirteen fire extinguishers were inspected annually. The facility
administrator reported fire drills, mental health drills, and medical drills are conducted monthly.
Seven staff were interviewed and reported they participated in drills. Seven interviewed youth
reported they have been instructed on what do in case of a fire. Seven of the youth reported
they have participated in a drill.
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 policy and procedures addressing the Continuity of Operations Plan
(COOP). The policy states the COOP is located in the master control room, the facility
administrator’s office, and the staff lounge. The plan addresses alternative housing plans
approved by the applicable Department regional director/designee. The COOP was last
approved on May 15, 2024. The COOP addresses fire prevention and evacuation, severe
weather, disturbances or riots, bomb threats, hostage situations, chemical spills, flooding,
terrorist threats or acts, staff roles and 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 has
food and necessary supplies on-site readily available in case of emergency evacuation.
Equipment included bedding, pillows, extra clothing and undergarments, shoes, hygiene items,
and copies of group materials. Seven youth records confirmed the program maintains an
administrative hard copy on youth in case of emergency with all required information, which are
located in the case management office and master control. The facility administrator reported
the COOP is located in master control and facility administrator office.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 64 (Revised September 2022)
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains a policy and procedures addressing storage and inventory of flammable,
poisonous, and toxic items and materials. The policy and procedures also address chemical
spills and clean-up of chemical spills. This process is also captured in the Continuity of
Operations Plan (COOP). The program’s flammable, poisonous, and toxic materials are stored
in a flame-resistant cabinet located outside the facility near the maintenance shed. The program
maintains proper inventory of these items. The program’s plant manager is the only individual
authorized to handle flammable, poisonous, and toxic items within the maintenance shed. A
binder is stored in the secured closet located on each dorm containing the Safety Data Sheets
(SDSs) for the items located in the cabinet as well as cleaning supplies. The cleaning supplies
are maintained in a locked closet located on each dorm and can only be accessed by the plant
manager, supervisors, and facility management. Staff sign these items in and out with each use.
The program maintains a policy and procedures addressing disposal of all flammable, toxic,
caustic, and poisonous items. The policy prohibits chemicals from being poured on the ground
or being disposed of by any method other than what is outlined by the biohazard guidelines. The
facility administrator interview stated all flammable, toxic, caustic, and poisonous items are
disposed of by the maintenance director at the county waste management site. The program’s
plant manager was interviewed on the proper procedures of disposing chemicals and stated all
items for disposal are collected by the county waste disposal. The plant manager further stated
the program has not needed to dispose of any chemicals since the last annual compliance
review and a review of the disposal log confirmed this. Kitchen staff dispose of kitchen waste by
use of the plumbing drains. Kitchen grease is disposed of monthly by a contracted grease
disposal company. A review of seven flammable, toxic, caustic, and poisonous items being
maintained on-site was conducted, confirming all seven items were accounted for. An interview
with the facility administrator validated this practice.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedures addressing youth handling and supervision of
flammable, poisonous, and toxic materials. The policy prohibits youth from using flammable,
poisonous, and toxic items and materials. These materials are stored in a storage locker located
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 64 (Revised September 2022)
outside the building in the maintenance shed. Youth do not have access to these items and are
supervised by staff during daily cleaning. Youth were observed participating in facility clean-up
by video and found the staff spray the cleaning chemical and youth wiping the area. Six of
seven youth interviews indicated they are prohibited from using chemicals/cleaning products,
one youth said they can use laundry soap.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a policy and procedures to allow visitation and communication for youth
while in the program. The visitation procedures are posted on the wall in the lobby and in the
dormitories. The visitation and communication procedures are covered in the youth handbook,
parent/guardian handbook, and included on the orientation checklist. The program utilizes staff
translators or the interpret line with live translators if necessary. Seven youth and staff
interviews indicated they can make weekly calls to the parents/guardian. The visitation schedule
was posted in the lobby. Visitation documentation indicated visitation is being offered on the
weekends as required by policy; if the parent/guardian requests an alternative visitation
arrangement, the program will attempt to comply with the request. The visitation, telephone, and
correspondence logs were reviewed. The logs showed youth have contact with only approved
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Office of Accountability and Program Support Page 62 of 64 (Revised September 2022)
persons. Incoming and outgoing mail is searched and recorded in the correspondence logs,
then given to the youth’s case manager who delivers the mail to the youth and has them open
the mail in front of them. There were no youth applicable for a history of human trafficking;
therefore, the program is not required to request clarification from the youth’s juvenile probation
officer (JPO) about any parent/guardian past or current human trafficking investigation
involvement. The facility administrator stated the program has staff members who are bi-lingual
with English, Spanish, and Creole to assist youth whose primary language is not English.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a policy and procedures stating recreation activities shall be provided for
a minimum of one hour a day. The policy requires a schedule including a selection of activities
for youth to choose from. The youth have a variety of recreation and leisure activities. The
program’s schedule has structured indoor and outdoor recreation and leisure activities which
includes large muscle activity for a minimum of one hour each day. A review of the logbook from
October 2023 through October 2024 indicated recreation was conducted as scheduled. The
program’s contract requires a recreation therapist. At the time of the annual compliance review
this position was vacant and had been since October 18, 2024. A review of seven youth case
management records confirmed each youth record contained a wellness plan, including
recreational therapy, and goals on their individualized treatment plan. Seven youth were
interviewed and stated the program allows the opportunity to exercise, play outside, read a
book, play a board game, arts and crafts, sports, or physical fitness activities. Seven youth also
stated physical activities are provided for at least one hour. Seven staff were interviewed and
confirmed recreation was occurring and included activities such as football, basketball, tug of
war, pickleball, board games, and playing video games.
5.23 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program maintains a policy and procedures for searching and inspecting the controlled
observation rooms. No youth have been placed in controlled observation since the last annual
compliance review.
5.24 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program maintains a policy and procedures for searching and inspecting the controlled
observation rooms. No youth have been placed in controlled observation since the last annual
compliance review.
5.25 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
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Office of Accountability and Program Support Page 63 of 64 (Revised September 2022)
The program maintains a policy and procedures for searching and inspecting the controlled
observation rooms. No youth have been placed in controlled observation since the last annual
compliance review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 64 (Revised September 2022)

report_type: QI Residential

program_name_raw: Columbus Youth Academy