summary: QI Residential - FY24-25

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Broward Youth Treatment Center
Youth Opportunity Investment, LLC
(Contract Provider)
8301 South Palm Drive, Building #2
Pembroke Pines, Florida 33025
Review Date(s): November 12-15, 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:
Rondarrell George, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Acasha Pressley, Office of Accountability and Program Support, Regional Monitor (Standard 1&
Interviews)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Damarcus Richardson, Office of Accountability and Program Support, Prioritization and
Planning (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Shakela Minns, Office of Accountability and Program Support, Regional Monitor (Standard 3 &
4)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Kieara Swan, Office of Accountability and Program Support, Prioritization and Planning
(Standard 5)
Sharon Wong, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Program Name: Broward Youth Treatment Center MQI Program Code: 1269
Provider Name: Youth Opportunity Investments, LLC Contract Number: 10553
Location: Broward County / Circuit 17 Number of Beds: 40
Review Date(s): November 12-15, 2024 Lead Reviewer Code: 179
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
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 64 (Revised September 2022)
A ll in d ic a to rs h a v e b e e n ra te d
O
S
v e ra
a tis fa
ll R a
c to ry
tin
a n
g S
d n o
u m
c o
m
rre
a
c
ry
tiv e a c tio n is n e e d e d a t th is tim e .
Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 64 (Revised September 2022)
In d ic a t o r R a t in g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t * 1 .0 3
M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 4
In c id e n t R e p o rtin g (C C C ) * 1 .0 5
P ro te c tiv e A c tio n R e s p o n s e (P A R ) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 6
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 7
In -S e rv ic e T ra in in g 1 .0 8
G rie v a n c e P ro c e s s 1 .0 9
In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .1 0
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 1
R e s to ra tiv e J u s tic e A w a re n e s s fo r Y o u th 1 .1 2
In te rn a l A le rts S y s te m a n d A le rts (J J IS )* 1 .1 3
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 4
Y o u th In p u t 1 .1 5
A d v is o ry B o a rd 1 .1 6
S ta ff P e rfo rm a n c e 1 .1 7
R e c re a tio n a n d L e is u re A c tiv itie s 1 .1 8
S p e c ia l C o n tra c t C o n d itio n s 1 .1 9
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s 1 .2 0
D a ta T re n d A n a ly s is 1 .2 1
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
a re a (d e te n tio n ,
ryryryryryryryryryryryryryryryryryryryryry
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 64 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 64 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 64 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Satisfactory
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Non-Applicable
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
5.25 Controlled Observation Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 64 (Revised September 2022)
Program Overview
Broward Youth Treatment Center is a forty-bed program, for thirteen to eighteen-year-old males,
located in Pembroke Pines, Florida. The program is operated by Youth Opportunity
Investments, LLC, through a contract with the Department. The program provides Substance
Abuse Treatment Overlay Services (SAOS), to include substance abuse assessments,
evaluations, individualized substance abuse treatment planning, daily substance abuse services
which include individual, group, and family substance abuse treatment planning, daily substance
abuse counseling, crisis intervention therapy, suicide prevention services, mental health and
substance abuse treatment for youth with co-occurring mental health disorders, twenty-four hour
response capability, routine and random urinalysis, psychopharmacological therapy, and
psychiatric and psychological services. In addition, the program fosters each youth by providing
weekly group therapy services to include the Living in Balance substance abuse group, and the
Men’s Trauma Recovery and Empowerment Model. The program has Mindfulness for Addiction,
Stop the Chaos, and Trauma Focused Cognitive Behavioral Therapy curricula available to
provide as supplemental services based on identified needs. Program administration is
comprised of a facility administrator (FA), one assistant facility administrator (AFA), a clinical
director, a human resources/business manager, and two administrative assistants. Case
management services are provided by a director of case management, three case managers,
and one transition services manager. Mental health and substance abuse staff at the program
include a designated mental health clinician authority (DMHCA) who supervises three non-
licensed therapists. In addition, the program contracts with a licensed psychiatrist for the
provision of psychiatric services to all applicable youth. Medical services are offered seven days
a week and are provided by a licensed medical doctor who serves as the designated health
authority (DHA), one registered nurse (RN) who serves as the health service administrator
(HSA), and two additional RNs. Educational services, including vocational training courses, are
overseen by the Florida Scholars Academy and provided by Florida Virtual School. The layout
of the program includes one main building with hallways on each wing of the program. Youth
rooms are located on the east wing and the west wing of the program. Staff offices are in areas
which are secured and inaccessible to youth. All meals are prepared on-site. The program has
seventy security cameras providing coverage with the capability to store video for up to thirty-
days. All cameras were operational at the time of the annual compliance review. At the time of
the annual compliance review, the program had three vacant positions including one kitchen
staff, one safety and security specialist, and one shift supervisor.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 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 written policies and procedures to ensure background screenings are
conducted for all staff, volunteers, and mentors. The program’s policy requires all staff,
contracted providers, grant recipient staff, volunteers, mentors, and interns with access to youth
and confidential youth records to have an initial background screening completed. Volunteers,
mentors, and interns who work with youth less than ten hours a month do not require a
background screening if they are under constant and direct supervision of screened program
staff. The program submitted an Annual Affidavit of Compliance with Level 2 Screening
Standards form to the Department’s Background Screening Unit (BSU)/Clearinghouse on
January 19, 2024, meeting the annual requirement. Nineteen staff have been hired since the
last annual compliance review. Reviewed documentation supported each staff had a
background screening and a criminal history report review completed prior to hire. No staff were
applicable for a break in service, and no staff were ineligible during their background screening;
therefore, no exemptions were necessary prior to working with youth. The program uses a pre-
employment suitability assessment prior to hiring all direct care applicants. Each reviewed staff
had a passing score on record and each staff was added to the Department’s Clearinghouse
roster, as required.
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 written policies and procedures for conducting a background screening every
five years. A background rescreening/resubmission is conducted for all staff, volunteers, and
mentors with access to youth and confidential youth records. The program had one staff
applicable for a five-year rescreening since the last annual compliance review. Reviewed
documentation of the rescreening showed it was submitted to the Department’s Background
Screening Unit (BSU)/Clearinghouse at least ten business days prior to the retained prints
expiration date, as required.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 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 written policies and procedures to ensure each youth’s rights, staff’s rights,
and others’ rights include the right to feel safe, secure, and not threatened by any form of abuse
or harassment. The program’s policy is to promote an environment of physical, psychological,
and emotional safety. Abuse is not tolerated within the program. Staff shall immediately report
all allegations of abuse, neglect, or sexual harassment. Any incident or suspected incident of
retaliation against youth or staff who reported an allegation of abuse must be reported
immediately. Staff are required to report any alleged neglect or violation of responsibilities which
may have contributed to an incident or retaliation. All staff, volunteers, interns, and contracted
staff who have knowledge or reasonable cause to suspect a youth is being abused or
neglected, shall report the information to the Florida Abuse Hotline or the Department’s Central
Communications Center (CCC), if the youth is eighteen years of age or older. Once the call has
been completed, staff must notify the facility administrator (FA) or supervisor on duty as soon as
possible. The FA or supervisor shall then begin an immediate review. The program had two
CCC allegations or incidents related to physical, psychological, and/or emotional abuse during
the annual compliance review period. There were no human trafficking victims, sexual
exploitation, or labor trafficking reported by the program. A review of seven staff records found
each record contained a signed code of conduct form, which was signed during orientation. A
tour of the program confirmed the Florida Abuse Hotline and the CCC telephone numbers were
observed to be posted throughout the program. The program’s steps for reporting abuse include
a youth requesting to make a call, and staff will provide the youth with telephone access in a
controlled observed area to make a confidential call. Youth and staff have unhindered access to
report alleged abuse to the Florida Abuse Hotline. Staff shall provide the youth with timely
telephone access to report allegations of abuse. The shift supervisor must be notified
immediately of the youth’s request. The shift supervisor must immediately notify administration
of the youth's request. Staff shall assist the youth with placing the abuse call, recording the
date, time, and the operator's name and badge number. Staff shall give youth the opportunity to
speak freely while maintaining sight of the youth. In the event the youth change their mind, a call
refusal shall be documented on an internal incident report. The FA shall complete appropriate
notification to the CCC and the Department’s regional director. All documentation and
notifications shall be included on the internal incident form. The program completed the Trauma
Responsive and Caring Environment (TRACE) self-assessment on August 8, 2024. A review of
all incidents since the last annual compliance review found there were two incidents which
involved complaints related to physical, psychological, or emotional abuse, and each was
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 64 (Revised September 2022)
closed as substantiated. Seven staff were interviewed. Each staff stated they would allow the
youth to make the call, one staff stated notification to the supervisor would be made, one stated
notification to the regional director would be made, one staff stated the supervisor will make the
call, and five stated they allow the youth to make the call. All interviewed staff reported they
never observed another staff telling a youth they could not call the Florida Abuse Hotline. Each
staff reported they never heard another staff use profanity while speaking with youth. Seven
youth were interviewed, and each stated they feel safe in the program, have never been
stopped from reporting abuse to the Florida Abuse Hotline or the CCC, know the number to the
Florida Abuse Hotline, and have never exchanged emails, telephone numbers, or social media
contact with staff. Six out of the seven youth stated they never heard staff use profanity when
speaking to them or other youth. One youth stated they heard staff use profanity occasionally.
An interview with the FA revealed the program’s staff code of conduct is outlined within the staff
handbook. It specifically addresses issues such as physical abuse, threats, and profanity
towards youth. These examples of rule infractions or misconduct may result in disciplinary
action, including termination of employment.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program has written policies and procedures to ensure the program takes immediate action
to address incidents of physical, psychological, and emotional abuse. The program had two
allegations related to physical, psychological, or emotional abuse involving a staff since the last
annual compliance review, both of which were thoroughly reviewed. A review of documentation
revealed management took immediate action regarding the staff involved in each incident by
initiating an investigation for all cases. In one incident, the staff failed to properly supervise
youth and violated policy, a written/oral reprimand was given, and the staff received a coaching
session. Documentation indicated the second staff resigned immediately on the same day of the
incident. At the time of the annual compliance review, there were no abuse allegations which
were pending an internal investigation. An interview with the facility administrator (FA) indicated
upon intake, youth are advised of their rights and procedures for reporting abuse by their case
manager. Youth have unimpeded access to a direct dial Florida Abuse Hotline telephone. The
FA is responsible for ensuring all staff completed their abuse training. All staff, volunteers,
interns, or contracted staff are trained as mandatory reporters for allegations of abuse. The shift
supervisor must be notified immediately of a youth’s request to make a report. The shift
supervisor must immediately notify administration of the youth's request.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a written policy and procedures to ensure incidents are reported to the
Department’s Central Communications Center (CCC) within two hours of the incident. The
program had twenty incidents reported to the CCC since the last annual compliance review. A
review of ten CCC reports confirmed each incident documented the incident date, time, CCC
number, and the time the program became aware of the incident as required. Each incident was
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 64 (Revised September 2022)
reported to the CCC within the required two-hour time frame and documented in the program’s
incident report logbook and shift reports, as required. There were no incidents reported late. A
review of the program’s internal incident reports and youth grievances reflected no additional
incidents which should have been reported to the CCC. The program maintains a separate file
for all incident reports and has an established system to track all incidents. The program did
experience a decrease in the number of reportable incidents to the CCC in comparison to the
previous 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 written policies and procedures to ensure the proper use of Right Interactions
(RI) and physical intervention techniques by staff. The program had fifty-four RI incident reports
since the last annual compliance review. Reviewed documentation confirmed monthly
summaries maintained by the program of all RI incidents were submitted to the Department’s
regional office by the fifteenth of each month, during the annual compliance review period. The
program’s RI Plan was approved by the Department on December 22, 2023. The program’s RI
rate during the previous quarter was 4.12, which is above the statewide Residential RI rate of
1.71. An interview with the FA reported RI incidents are tracked using incident report trackers
and monthly RI Reports. Video footage is reviewed to ensure the use of force aligned according
to the RI Response Matrix. If there are any deviations from the matrix, staff are either re-trained
or provided a coaching notification. Once a month, the RI incident tracker is reviewed with the
corporate office to determine if there is a rise of incidents. If so, corrective action plans are
developed to prevent further incidents. Seven staff were interviewed regarding the process of
using RI. Two out of the seven staff indicated they are not familiar with the process. The
information from the interview was reported to the program and they stated they will follow up
with training. Four staff indicated they are familiar with the process and mentioned they use RI
for accountability, de-escalation techniques, redirecting the youth, giving verbal warnings before
interventions, and the proper way to restrain a youth. One staff was not direct care and did not
have to be RI trained. A review of ten RI incident reports confirmed each report was completed
by the end of the staff’s workday and included written statements from each staff involved.
Mechanical restraints were not used in any of the reviewed RI incidents. All required reviews
were conducted and documented by the supervisor on duty at the time of the incident and by a
RI certified instructor within the required time frames. None of the ten RI Reports were
applicable for medical attention or abuse allegations. All ten RI Reports were reviewed by a
supervisor or designee. Each RI incident report was reviewed by the administrator or designee
within seventy-two hours of the incident.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 64 (Revised September 2022)
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 written policies and procedures which state the program staff shall satisfy pre-
service/certification requirements as outlined by Florida Administrative Code within 180 days of
hire. The program’s policy requires all full-time and part-time staff and volunteers to receive a
minimum of 120 hours of pre-service training during their first 180 days of employment.
Volunteers receive training appropriate to their assignments. All supervisors, the facility
administrator (FA), the assistant facility administrator (AFA), and any other staff in management
positions shall complete sixteen additional hours of supervisor specific pre-service training
within ninety-days of employment. Only supervisors and direct care staff are counted in the
youth-to-staff ratio. An informal interview with the FA reported case managers, therapists, the
AFA, maintenance staff, kitchen staff, and operations managers can supervise youth; however,
maintenance staff and kitchen staff are not considered to be direct care staff and are not
counted in the staff-to-youth ratio. The program reported every staff in the building is Right
Interactions (RI) certified. All instructors are qualified to deliver trainings and the program
submitted the pre-service training plans on December 20, 2023. The program’s pre-service
training plan and calendar was approved by the FA, the assistant secretary for residential
services, and the director of Talent, Leadership, and Culture. A review of seven staff training
records provided evidence each staff completed their required training within 180 days of hire. A
review of the staff records showed four were direct care staff. Each direct care staff training
record confirmed the staff completed the required training to have contact with youth and
records; however, the hours for some trainings in the Department’s Learning Management
System (SkillPro) could not be verified due to Department-wide system outages. The program
provided copies of completed trainings for review. Each direct care staff met the required
training requirements to include abuse recognition, reporting, and prevention, cardiopulmonary
resuscitation (CPR) certification, first-aid certification, automated external defibrillator (AED),
emergency procedures, program operating procedures, Prison Rape Elimination Act (PREA),
professionalism, interpersonal communication, ethics including standards of conduct, RI model
training, and suicide awareness and prevention training. Additional trainings completed within
the 180 days of hire, after having contact with youth, were active shooter preparedness,
adolescent development and behavior, balanced approach to restorative justice, the
Department’s Central Communications Center incident reporting, civil rights, communication,
confidentiality/Health Insurance Portability and Accountability Act (HIPAA), Department of
Juvenile Justice (DJJ) legacy/history, equal employment opportunity, gang awareness, human
trafficking, infection control, information security awareness, the Department’s Juvenile Justice
Information System (JJIS), mental health and substance abuse, Motivational Interviewing,
quality report writing, safety, security, and supervision of youth, sexual harassment, effective
and respectful treatment of youth, and trauma responsive practices. All seven staff completed
training in the grievance process, infection control, the Exposure Control Plan, behavior
management system, the intent and safe use of tools as required by the program’s manual, and
specialized services training. Additionally, training included Mental Health Overlay Services and
Substance Abuse Treatment Overlay Services. A review of one applicable pre-service
supervisory training and one therapist training record reflected each completed the required
sixteen hours of supervisory training.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 64 (Revised September 2022)
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has written policies and procedures to ensure staff complete in-service training. A
review of seven staff, which included three supervisors was completed. Each staff was certified
in cardiopulmonary resuscitation (CPR) and first-aid certified. Each staff exceeded the required
twenty-four hours of annual in-service training. A review of the in-service training plans, and
staff records confirmed all staff met the training requirements. Completed annual trainings
included active shooter preparedness, CPR, automated external defibrillator (AED), first-aid,
human trafficking, information security awareness, mental health and substance abuse, Prison
Rape Elimination Act (PREA), sexual harassment, Right Interactions (RI), professionalism,
interpersonal communication, ethics, suicide awareness and prevention, trauma responsive
practices, emergency response and emergency drills, infection control, blood-borne pathogens,
the Exposure Control Plan, Mental Health Overlay Services, and Substance Abuse Treatment
Overlay Services. A review of three supervisor training records reflected each staff exceeded
the eight hours of management/supervisory training in the areas of coaching, leadership, and
personal accountability. The program has a training calendar which is updated as changes
occur. All trainings were delivered by qualified trainers and were documented in the
Department’s Learning Management System (SkillPro). The program maintains a written in-
service training plan and calendar which was approved by the FA, assistant secretary for
residential services, and the director of Talent, Leadership, and Culture.
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 maintains a written policy and procedures regarding youth filing formal grievances.
The process is outlined with specific timelines for review and responses. Each reviewed
grievance included informal, formal, and appeal process instructions. Informal grievances
provide youth the opportunity to speak directly to staff members using verbal communication or
a Speak Out form. Seven interviewed youth indicated they knew the process for grievances and
the location of forms. In addition, each youth verified the timely review of grievances stating
administration responded within twenty-four hours unless completed over the weekend. All
seven interviewed staff and the facility administrator (FA) confirmed youth may ask for
assistance with grievances if necessary and attempt a resolution with staff as needed. All five
reviewed grievances confirmed all timelines were met for review and resolution, with a
turnaround of twenty-four hours on weekdays. All weekend grievances are reviewed the
following Monday. The FA was interviewed and stated when a concern arises, the youth shall
be encouraged to make all efforts to reach a resolution of the problem or complaint. The youth
may present an informal grievance to any staff member.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 64 (Revised September 2022)
1.10 Interventions and Facilitator Training Non-applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a written policy and procedures for instructions focusing on developing
life and social skill competencies in youth. The program’s practice is to provide evidence-based
interventions. The life and social skills should include communication, interpersonal
relationships, non-violent resolution, anger management, critical thinking, and targeted activities
specific to the program’s male population. Reviewed sign-in sheets verified the required life and
social skills services curricula Living in Balance and Seeking Safety were facilitated by a trained
professional. Seven interviewed youth confirmed participation in life skills activities during group
including coping skills, comprehensive sexuality education, environmental factors, anger
management, and different communication interventions. The designated mental health clinician
authority (DMHCA) and facility administrator interviews confirmed the facilitation of Living in
Balance and Seeking Safety groups which are held weekly.
1.12 Restorative Justice Awareness for Youth Non-Applicable
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.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at the program. For details related specific to IOC service delivery, please refer
to the annual SPEP report.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 16 of 64 (Revised September 2022)
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program maintains a written policy and procedures to determine how new alerts are
identified, updated, and communicated to staff members. The program shall maintain and use
an internal system easily accessible to program staff and keep staff informed on youth medical,
security, or safety risks. Examples of such risks are dietary, allergies, violent behaviors, escape,
suicide, or mental health risks. Youth are placed on an alert when special risk factors or special
needs are identified during or after the classification process which occurs during admission. It
is the program’s practice for staff to immediately update the internal program alert information
and the Department’s Juvenile Justice Information System (JJIS). Only appropriate staff may
recommend downgrading or discontinuing a youth’s internal alert status or JJIS alert status.
Licensed mental health staff and non-licensed mental health staff are responsible for updating
the system after verification. Seven youth records were reviewed, and all alerts were entered
into the internal alerts system and JJIS. Each reviewed JJIS alert was late due to Department-
wide system outages; however, matched the internal alerts system and logbook. The facility
administrator confirmed internal alerts are addressed in the daily management meeting and
communicated to the staff during briefing meetings and through the logbook. The department
heads are to ensure alerts correlate and are updated in JJIS. An interview with the nurse
revealed medical staff update the alert system and if non-licensed staff update the system, the
medical staff will verify the information. Seven interviewed staff verified the notification of alerts
through briefings, alert boards, administrative staff, and logbooks.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains a written policy and procedures to safeguard storage and maintenance
of Individual Healthcare Records (IHCRs) and individual case management records. The
program keeps two separate records, which are then further divided into health and mental
health/substance abuse records. The seven reviewed individual case management records
included the youth’s name, Department identification number, date of birth, county of residence,
and committing offense. Each reviewed record contained legal information, demographics,
correspondence, case management, treatment team activities, and miscellaneous sections.
Additionally, each reviewed record was labeled confidential and stored securely in the case
management office, not accessible to youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 17 of 64 (Revised September 2022)
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 created a community advisory board which meets at least every ninety to 120
days to support youth growth and connection to the community. A review of the program’s
documentation verified meeting dates of September 29 and December 29, 2023, February 23,
May 30, and August 30, 2024. The facility administrator (FA) provided communications for
active recruitment of different community partners for participation. Documentation included
communication with law enforcement, a judiciary representative, a faith-based representative, a
school board member, a community business owner, and LGBTQIA+ members. In addition, the
FA solicited participation from victim advocates and parents/guardians with children previously
involved in the juvenile justice system. The reviewed community advisory binder contained all
communications, pictures of activities, agendas, and sign-in sheets. Each meeting was held in
person. The FA interview confirmed a meeting is held every quarter and includes participation
from law enforcement, judiciary, the school board, local community business owners, faith-
based members, victims, and previous juvenile justice system youth and parents/guardians. A
board member was scheduled to be interviewed to assess their level of involvement in the
program’s board activities; however, attempts to contact the board member by telephone were
unsuccessful.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program maintains a written policy and procedures to ensure a system for evaluating staff,
performance standards, and frequency of evaluations. According to the program’s policy, staff
are to review their records annually along with the human resource manager. The program
completes informal evaluations every ninety days and a formal evaluation annually. Five staff
evaluations were reviewed and included position descriptions, and clearly identified standards,
which matched performance standards. The evaluation included a review of the program’s
standards for grievances with youth, program’s policies fitting their job descriptions, and areas
of improvement based on their performance for the year. Each formal evaluation was completed
within the specified twelve-month period. Each job description included the implementation of
the program’s behavior management system (BMS). A review of the contract and staff roster
verified all contractually required positions were maintained and performed, including a
recreation therapist. The recreation therapist met schedule requirements and performed job
functions as described in the contract. The facility administrator’s interview confirmed monthly
coaching using staff development sessions and annual formal evaluations are completed.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 18 of 64 (Revised September 2022)
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 ensured the implementation of all items and services detailed in the contract’s
memorandum of negotiation and special conditions. These items typically exceed the minimum
requirements outlined in Florida Statutes and Florida Administrative Code. An interview with the
facility administrator (FA), documentation review, and contract review indicated the contract
negotiated items are offered at the program. The contract requires the director of compliance to
be on-site at least quarterly. The reviewed visitors log since the last annual compliance review
reflected the director exceeded the requirement. Additionally, the regional director is required to
be on-site monthly to provide corporate oversight. A review of the tracker and sign-in sheet
supported the regional director exceeded the requirement since the last annual compliance
review. The contract stipulates the provision of regular faith-based opportunities and requires
diligent efforts to offer religious services and education which address all faiths. A review of the
visitor log confirmed compliance, showing the program provided these opportunities for the
youth. Furthermore, a church organization was on-site at least twice a month to facilitate these
activities.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a written policy and procedures which address data trend analysis
components. The quality assurance program is designed to monitor and evaluate program
outcomes, system fidelity, compliance, appropriateness, and quality of care, ensuring program
services are consistent with prevailing professional standards and to identify and resolve
problems objectively and systematically. The quality assurance program ensures the use of a
continuous quality improvement process. A review of internal documentation confirmed the
program’s practice uses review and analysis of data in decision making practices. Data trends
are shared among administrators and with staff to proactively make policy, practice, and
programming changes designed to foster system and program improvement. The program’s
practice is comprised of satisfaction surveys incorporated into the monitoring and verification
activities as a part of the program’s quality assurance program. The program’s satisfaction
surveys are provided on a quarterly basis. Surveys include youth, family, and staff. Surveys
target admission activities, specific assessments, and discharge satisfaction. Survey data is
reviewed and evaluated monthly at the program level and during corporate leadership meetings.
Survey outcomes are collected and communicated as a part of ongoing program communication
and quality improvement activities. Monthly incident trackers are distributed to the programs
which describe trends. Standardized Program Evaluation Protocol (SPEP) internal and external
evaluations are conducted using specific quality of service delivery evaluation guidelines and
findings are incorporated in monthly monitoring, verification reporting and the annual
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 19 of 64 (Revised September 2022)
Department SPEP report. The program gathers data, and the Department uses the data for long
term planning and provisions for staffing. A system of communication is used to keep staff and
stakeholders informed and provide opportunities for feedback, performance improvement, and
budgeting.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 20 of 64 (Revised September 2022)
Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a written policy and procedures regarding initial contact with the
parent/guardian and court notification. A review of seven youth case management records
showed the program notified the parent/guardian by telephone within twenty-four hours of
admission. Each reviewed record included documentation revealing the program notified the
parent/guardian in writing within forty-eight hours of the youth’s admission. Each record had
documentation indicating the juvenile probation officer (JPO) and applicable post residential
services counselor were notified in writing within five working days of the 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 written policy and procedures regarding youth orientation. A review of seven
youth case management records showed the program provided each youth an orientation on
the day of admission. Each reviewed case management record documented a signed receipt
acknowledging the youth received an orientation packet including a copy of the youth handbook.
The program’s orientation included services available, daily schedule, expectations and
responsibilities of the youth, written information on the program’s behavior management system,
including rules governing conduct and positive and negative consequences for behavior,
information on how to access medical and mental health services, access to the Florida Abuse
Hotline or the Department’s Central Communications Center (CCC) if the youth is over eighteen
years of age, the program’s zero-tolerance policy regarding sexual misconduct, how to report
incidents or suspicions of sexual misconduct, special accommodations which are available to
ensure all written information about sexual misconduct policies, including how to report sexual
misconduct, the right to be free from sexual misconduct, the right to be free from retaliation for
reporting such misconduct, the agency’s sexual misconduct response policies and procedures,
and items considered contraband, including illegal, prohibited items in which possession may
result in the youth being prosecuted. Additionally, the youth orientation included information on
the performance plan process, dress code and hygiene requirements, procedures regarding
visitation, mail, and use of the telephone, expectations for release from the program, including
the youth’s successful completion of Individual Performance Plan goals, recommendations to
the court for release based on the youth’s performance in the program and the court’s decision
to release, community access, grievance procedures, emergency procedures, including
procedures for fire drills and building evacuation, a program tour and a general layout of the
program, which focuses upon areas which are and are not accessible to youth, assignment to a
living unit, room, treatment team, and a staff advisor or youth group. Information is conveyed
verbally to youth with limited reading skills or who are visually impaired, deaf, or otherwise
disabled. Observations of a youth orientation were not conducted due to the program not having
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 21 of 64 (Revised September 2022)
an admission during the annual compliance review week. An interview was conducted with
seven youth. Each youth stated the orientation included the program rules, procedures, and
schedule. Each youth was able to explain the orientation process, to include receiving a booklet
about the program, and each stated the orientation was conducted on the day the youth arrived
at the program.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a written policy and procedures which address obtaining written consent of
youth who are eighteen years of age or older. A review of seven youth case management
records showed four youth records were applicable for youth who were eighteen years of age or
older. A review of each youth’s record found a consent form signed by each youth prior to any
release of information related to the youth’s physical or mental health screenings, assessments,
or treatments.
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 written policy and procedures regarding the classification process for youth
upon admission to the program and completion of reassessments as warranted. A review of
seven youth case management record’s documentation confirmed each contained an admission
classification form including all required elements. The program’s classification form included
physical characteristics of the youth, age, and maturity level, identified special needs, history of
violence, gang affiliation, criminal behavior, sexual aggression or vulnerability to victimization,
youth’s perception of vulnerability, youth’s history of potential or verified human trafficking,
suicide risk, medical risk, escape risk, and security risk. A review of seven youth case
management records confirmed the youth’s classification was completed on the date of
admission and took into consideration all elements on the classification form. A review of the
Department’s Juvenile Justice Information System (JJIS) alerts and the program’s internal alerts
confirmed there were no issues affecting each youth’s classification. Each of the seven
reviewed youth were applicable for risk factors. Risk factors included on the initial classification
included suicide risk, medical risk, escape risk, and security risk. Each of the seven youth were
classified for purposes of assignment to a living area, sleeping room, and youth group or staff
advisor. Youth with medical, mental health, substance abuse, security risk factors, and/or
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 22 of 64 (Revised September 2022)
special needs identified during or after the classification process are immediately entered into
the program’s internal alert system and JJIS. Reclassifications were conducted for each of the
seven youth reviewed and revealed there was an increase in each youth’s privileges or freedom
of movement. Reviewed documentation confirmed the program’s policy and procedures clearly
outline the classification process and include a classification system promoting safety and
security, as well as effective delivery of treatment services, based on the determination of each
youth’s individual needs and risk factors, which addresses, at a minimum, items outlined in
Florida Administrative Code. Reviewed documentation revealed reassessments were applicable
for six youth participating in work projects, or other activities involving tools or instruments which
may be used as potential weapons or means of escape, and for four youth attending off-campus
activities. The program’s policy regarding reassessment ensures all program youth are pre-
screened prior to admission by the treatment team conducting a thorough review of the
electronic commitment packet and a review of JJIS alerts. Upon admission, the program’s youth
participate in an initial intake screening process, including the completion of the Facility Entry
Physical Health Screening, Massachusetts Youth Screening Instrument, Second Version
(MAYSI-2), Vulnerability and Sexually Aggressive Behavior (VSAB) screening, and an
Assessment of Suicide Risk, if applicable. An interview with the facility administrator (FA)
confirmed within twenty-four hours, during intake, a classification meeting is held with a
minimum of the FA, clinical director, case manager, and parent/guardian. The program’s
classification form is designated to gather information to include gang membership and youth
aggressiveness. The information obtained is used to determine the youth's unit and room
assignment. An admission classification meeting is conducted to formally review the youth's
history, special needs, and risk factors to determine the appropriate levels of supervision.
Additionally, the alert status needs are identified for potential safety and security risks impacting
the living unit and room assignment. Classification factors shall include a minimum of physical
characteristics, gender, height, weight, general physical stature, age and maturity level,
identified special needs, including mental, developmental, intellectual, and physical disabilities,
history of violence, gang affiliations, criminal behavior, sexual aggression or vulnerability to
victimization, and identified or suspected risk factors such as medical, suicide, and/or escape or
security risks.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a written policy and procedures regarding gang identification including
notification to law enforcement. A review of seven youth case management records showed one
youth was applicable for notification to law enforcement of suspected gang association. Two
additional case management records were provided by the program. Each of the three
applicable records documented local law enforcement was notified of suspected gang activity
prior to the monitoring and quality improvement (MQI) seven-day notice. Reviewed
documentation confirmed each youth’s home county law enforcement program was notified of
the youth’s gang affiliation. Reviewed documentation reflected all gang alerts were maintained
in the program’s internal alert system and the Department’s Juvenile Justice Information System
(JJIS) and updated as required, upon notification. Each of the three applicable records
documented gang information was shared with the educational staff at the program and the
youth’s juvenile probation officer (JPO). None of the three applicable youth had a post-
residential services counselor.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 23 of 64 (Revised September 2022)
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a written policy and procedures regarding a youth’s participation in gang
prevention and/or intervention activities. The program’s policy addresses providing youth an
opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang. The
program utilizes the Project Renew curriculum and Impact of Crime (IOC) intervention groups as
part of the gang prevention and intervention curricula. A review of seven youth case
management records was conducted. One youth was applicable for being identified as a gang
member, or affiliated. The program was able to provide two additional applicable youth records.
Documentation supported two youth participated in gang prevention and intervention strategies
and the other youth was a new admission; therefore, had not participated in intervention
strategies at the time of the annual compliance review. The two applicable youth’s performance
plans included goals and objectives related to gang intervention strategies to be completed prior
to release from the program. A review of the program’s sign-in sheets reflected the youth’s
participation in the gang prevention groups. An interview with the facility administrator (FA)
confirmed the program’s gang intervention and prevention strategies, and process for providing
resources for identified, associated, or suspected gang members.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a written policy and procedures to ensure a Residential Assessment for Youth
(RAY) is completed for each youth within thirty days of admission. A review of seven youth case
management record’s documentation showed six records contained a RAY which was
completed within thirty days of admission. The other youth was a new admission; therefore, had
not completed an initial RAY at the time of the annual compliance review. The six applicable
youth’s initial RAYs were maintained in the Department’s Juvenile Justice Information System
(JJIS). Six youth case management records revealed each youth was applicable for
reassessments. Six youth records indicated RAY Reassessments were completed, at least
every ninety-days. All six youth’s initial RAYs and reassessments were maintained in the youth’s
official case record. The six applicable youth’s case records documented the dates of the
youth’s reassessment, and any other updates or reassessments were completed when deemed
necessary by the intervention and treatment team to effectively manage the youth’s case.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 24 of 64 (Revised September 2022)
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a written policy and procedures regarding the completion of the Youth Needs
Assessment Summary (YNAS). A review of seven youth case management record’s
documentation supported six youth’s YNASs were completed within thirty days of the youth’s
admission. Six applicable youth’s YNASs were documented in the Department’s Juvenile
Justice Information System (JJIS). The other youth was a new admission; therefore, had not
completed a YNAS at the time of the annual compliance review.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a written policy and procedures outlining performance plan development,
goals, and transmittal. A review of seven youth case management record’s documentation
confirmed six of the applicable youth’s Individualized Performance Plans (IPP) were developed
within thirty days of the youth’s admission and developed after the completion of the initial
Residential Assessment for Youth (RAY) and the Youth Needs Assessment Summary. The
other youth was a new admission; therefore, had not completed an IPP at the time of the annual
compliance review. Each of the six reviewed IPPs were developed and signed by the treatment
team leader, youth, administrative representatives, living unit representatives, treatment staff,
education staff, the Department of Children and Families (DCF) counselor, when applicable,
and all parties who had significant responsibility in goal completion. A review of documentation
showed each of the six completed IPPs were mailed to the youth’s parent/guardian requesting a
signature; however, none were returned to the program at the time of the annual compliance
review. Each of the six applicable IPPs had the signature sheet of parties who had significant
responsibility in goal completion filed in the youth’s official case record. The six reviewed IPPs
included the youth’s individualized goals based upon the prioritized needs identified during the
initial assessment addressing each youth’s three top criminogenic needs, specific delinquency
interventions based on RAY results, court-ordered sanctions, and transition activities targeted
for the last sixty-days of the youth’s anticipated stay. Each IPP outlined program staff
responsibilities and target dates for goal completion. Each of the six applicable youth’s IPPs
were sent to each youth’s committing court judge, juvenile probation officer (JPO), and
parent/guardian. One youth was involved with DCF; therefore, the IPP was sent to the youth’s
counselor within ten days of completion. Seven interviewed youth confirmed they participated in
the development of their performance plan, treatment goals, and received a copy of their
performance plans. Additionally, if the parent/guardian was unable to attend, the youth reported
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 25 of 64 (Revised September 2022)
their parent/guardian is called. The youth was informed the parent/guardian would receive a
copy of the plan in the mail.
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 written policies and procedures for revising youth performance plans. The
treatment team may update the Individualized Performance Plan (IPP) based on the results of
the Residential Assessment for Youth (RAY) Reassessment and youth demonstrated progress
in achieving their goals or any newly acquired or revealed information. One record was not
applicable for performance plan revisions due to the youth being a new admission. Each
applicable record indicated the performance plans integrated other existing plans. No youth’s
IPPs were revised in the last sixty days of the youth's stay, as transition activities were not being
facilitated during the time of the annual compliance review. Additionally, one youth had a
behavior support plan or case plan from the Department of Children and Families (DCF)
incorporated into their performance plan.
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 written policies and procedures for completing and transmitting Performance
Summaries for each youth at ninety-day intervals, starting ninety days after the signing of the
performance plan, or at shorter intervals if requested by the courts. Six out of seven reviewed
youth case management records were applicable for completing at least one Performance
Summary and performance plan. Each applicable youth record included Performance
Summaries, which were completed within ninety days of finalizing the initial performance plans.
All Performance Summaries included the required elements. Each applicable record had signed
documentation confirming the youth had read the summaries and could add comments. Each
youth was provided with a copy of the signed summary. Each Performance Summary was
signed and dated by the treatment team leader, the staff member who prepared the summary,
the facility administrator, and the youth. All six reviewed records had documentation to support
each Performance Summary was submitted to the youth's committing court, juvenile probation
officer (JPO), the youth, their parent/guardian, and the Department of Children and Families
(DCF), when applicable, within ten days of completion. Three closed youth case management
records were reviewed for release summaries. Each record included a copy of the original
summary sent to the JPO and the Pre-Release Notification (PRN) issued at least forty-five days
before the youth's anticipated release date. Each summary contained a justification for the
youth's release. The program notified the parents/guardians of all three youth regarding the
approval for release. Documentation supported each record contained a completed exit
Residential Assessment for Youth (RAY). None of the youth were applicable for the Sexually
Violent Predator Program (SVPP) or victim notification.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 26 of 64 (Revised September 2022)
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a written policy and procedures to ensure parental/guardian involvement in
case management services. The program makes efforts to include the parents/guardians in the
assessment process, in the development of the youth’s performance plan, in progress reviews,
during formal treatment team meetings, and in transition planning. An interview with the facility
administrator validated parent/guardian involvement solicitation occurs through monthly
treatment team invites, weekly visitations, monthly family sessions, quarterly family forums, and
family days. Seven youth case management records were reviewed. In each case management
record, documentation reflected the case manager sent the parent/guardian an admission letter,
including the dates and times for the youth’s treatment team meetings. If parents/guardians
cannot attend the meetings in person, they are allowed to participate by telephone or
conference call or provide verbal or written input prior to the meeting. Seven reviewed youth
records confirmed the parents/guardians participated in the assessment process, development
of the youth’s Individualized Performance Plans (IPPs), progress reviews, formal treatment
team meetings, and transition planning, when applicable. An observation of two treatment team
meetings during the week of the annual compliance review confirmed all treatment team
members participated in the meeting. One parent/guardian appeared by telephone, and the one
applicable Department of Children and Families (DCF) counselor for the other youth did not
answer the telephone. Seven interviewed youth stated parents/guardians are involved in case
management services.
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 maintains a written policy and procedures to identify treatment team members. A
review of seven youth case management records showed formal reviews were conducted at
least every thirty days for each youth. Each record documented the required treatment team
members participated as required. All documentation provided comprehensive details of the
formal treatment team meetings. Six of the seven reviewed records included informal reviews
conducted every thirty days documenting all essential information. One record was for a new
admission and was not applicable. A treatment team meeting was observed, covering various
topics and all required staff were present. Additionally, if the parent/guardian, juvenile probation
officer (JPO), or Department of Children and Families (DCF) counselor was unable to attend the
treatment team meeting, there was documentation confirming the attempts made to contact
them. Seven interviewed youth stated during treatment team meetings, youth discuss various
scenarios, maintain good eye contact, answer questions about their accomplishments, actively
seek input from staff, fill out a paper with sections to describe their progress, and check whether
their objectives are being met. Additionally, feedback is reviewed with both the case manager
and a therapist.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 27 of 64 (Revised September 2022)
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program maintains a written policy and procedures which address intervention and
treatment planning upon each youth’s release from the program. The policy outlines transition
planning, conferences, and Community Re-Entry Team (CRT) meetings. A review of three
closed youth case management records reflected each youth had a transition conference
conducted at least sixty days prior to the youth’s targeted release date. Reviewed
documentation found all required parties attended the transition conference. Each record
included documentation to confirm the program invited and encouraged the youth’s juvenile
probation officer (JPO), parent/guardian, and other pertinent parties to take part in the youth’s
transition conference. None of the reviewed youth were applicable for the attendance of a
human trafficking specific service provider. During the transition conference, the team discussed
all required topics including transition activities, completion dates, and necessary performance
plan revisions. Transition conference documentation contained acknowledgement of transition
goals and responsibilities of members through signatures of participants. All three reviewed
youth case management records documented a copy of the transition plan was sent with a
request for return with signature to anyone not in attendance who had a responsibility for
completion of transition goals. Each reviewed record confirmed a CRT invitation was sent, and a
meeting was held prior to the youth’s release.
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 maintains a written policy and procedures addressing the assembly of an exit
portfolio to assist each youth once they are released back into the community. Three closed
youth records were reviewed and documented each youth’s exit portfolio was discussed during
the transition conference. One of the three reviewed records included all required documents.
Two youth’s exit portfolios included all required documents except for the Social Security card
and birth certificate. One youth’s record included a signed waiver from the parent/guardian
declining to provide the required documents. Another youth’s record included supporting
documentation to validate the parent/guardian agreed to provide the documents to the program;
however, never submitted them to the program. Each youth’s exit portfolio was verified during
the exit conference, provided to the youth upon release, and forwarded to the assigned juvenile
probation officer (JPO). A review the program’s contract did not find any additional
requirements.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 28 of 64 (Revised September 2022)
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 maintains a written policy and procedures to ensure an exit conference is held for
each youth prior to release from the program. Three closed case management records were
reviewed for completion of the exit conference at least fourteen days prior to each youth’s
release. Each reviewed record included documentation to confirm the conference was
conducted after the program notified the assigned juvenile probation officer (JPO) of the youth’s
release. All youth records included documentation the exit conference was conducted at least
fourteen days prior to release. All three closed youth case management records included
documentation of the date of the conference, signatures, and a summary with pending transition
goals. Reviewed documentation supported all required parties participated in the exit
conference. All three case management records included documentation to support the status
of transition activities established at the transition conference and plans finalized for the youth’s
release were reviewed. Each record reflected the exit conference was held separately from the
transition and Community Re-Entry Team meetings. A review of the Department’s Juvenile
Justice Information System (JJIS) compared to case management records indicated the youth’s
admission and release dates from the program were accurate and coincided.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program maintains a written policy and procedures addressing written provisions for youth
input. The program features student council, youth surveys, and town hall meetings to create a
formal process for youth to provide constructive feedback about the program. Student council
meetings occur every other Thursday, while town hall meetings occur once a month to ensure
all youth-related concerns are addressed. During these town hall meetings, youth can
communicate their concerns with a board member, who then submits these issues to be
discussed at the student council meeting. A review of the program's sign-in sheets, agendas,
and meeting minutes confirmed these meetings were held as scheduled. In an interview, the
facility administrator (FA) stated the program formally seeks youth input through student council
meetings and town hall gatherings. Additionally, the program utilizes grievance forms and
monthly youth surveys. Seven interviewed youth indicated they could provide input by speaking
to staff members and the FA, filing grievances, and participating in town hall meetings.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 29 of 64 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program maintains a written policy and procedures requiring a designated mental health
clinician authority (DMHCA). The program has a clinical director who serves as the program’s
DMHCA. The program’s DMHCA is full-time and on-site at least forty hours each week as
required by the program’s contract to ensure appropriate coordination and implementation of
mental health and substance abuse services are taking place in the program. As a part of their
assigned responsibilities, the DMHCA ensures consistent and appropriate services in addition to
being on-call twenty-four hours a day, seven days a week for emergency consultation. The
program’s DMHCA is a licensed clinical social worker. The reviewed license reflected it was free
and clear in the State of Florida with an expiration date of March 31, 2025. The program’s back-
up DMHCA is the state-wide director of clinical services, who has a free and clear license in the
State of Florida with an expiration date of March 31, 2025. The interviewed DMHCA indicated
their role in coordination and implementation of mental health and substance abuse services
includes clinical supervision of non-licensed mental health therapists, in addition to facilitation of
individual, family, and group therapy services.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program’s
designated mental health clinician authority (DMHCA) serves as the program’s supervisor for all
on-site clinical staff. A review of the program’s staff listing and contractual requirements verified
there are no additional licensed staff requirements beyond the DMHCA; however, the program’s
statewide director of clinical services is a licensed mental health counselor. The director’s
license was free and clear in the State of Florida with an expiration date of March 31, 2025. The
director provides support and supervisory services to the DMHCA and clinical staff. The
program is licensed under Chapter 397 by the Department of Children and Families to provide
substance abuse services to adolescents. The Chapter 397 license expires April 1, 2025. The
program’s clinical staffing was in accordance with the contract which requires one DMHCA, one
recreation therapist, and three non-licensed mental health clinicians.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 30 of 64 (Revised September 2022)
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and procedures regarding non-licensed clinical staff.
The designated mental health clinician authority (DMHCA) confirmed their responsibility for
ensuring non-licensed clinical staff are working under their supervision and performing services
they are qualified to, based on education, training, and experience. The program’s practice is to
complete group and/or individual clinical supervision for the three non-licensed clinicians and
the recreation therapist. A review of clinical supervision logs since the last annual compliance
review was conducted. The clinical supervision was documented on the program’s form and
included all elements on the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. Documentation
verified each non-licensed clinical staff received clinical supervision for each week they provided
services. The program is licensed under Chapter 397 through the Department of Children and
Families to provide substance abuse services to adolescents. A review of the license reflected it
was displayed in the lobby with the program’s physical address listed. The reviewed license
expires on April 1, 2025. The program had no clinical staff vacancies during the annual
compliance review week. The program had four non-licensed mental health clinicians providing
therapeutic services since the last annual compliance review. One staff was no longer working
at the program. A review of the four non-licensed staff’s education documentation reflected each
held a master’s-level degree from an accredited university or college in the field of counseling,
social work, psychology, or a related human services field. Each non-licensed staff providing
clinical services was employed by a service provider which was licensed under Chapter 397.
Each of the four non-licensed clinical staff received training in the administration of the
Assessment of Suicide Risk.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program maintains a written policy and procedures which establish the system for gathering
important treatment and emergent need information prior to each youth’s entry into the general
population. The program’s policy requires the staff to administer a mental health and substance
abuse screening, including a suicide risk screening, upon a youth’s admission to the program. A
review of seven mental health and substance abuse records indicated the program completed a
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) on the day of
admission. The program documented the review of information to include the commitment
packet, reports, and records for existing documentation of mental health or substance abuse
problems, and/or history of human trafficking information. Each reviewed MAYSI-2 was
completed in full in the Departments Juvenile Justice Information System and included the date
of completion and the name of staff who completed the screening. Screenings were completed
by trained staff. Three of the seven reviewed MAYSI-2s indicated further assessment was
required; however, it is the program’s practice to refer all youth for further evaluation regardless
of screening results. None of the reviewed youth records were applicable for emergency
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 31 of 64 (Revised September 2022)
procedures or the youth being in crisis. No reviewed youth records were applicable for suicidal
ideation. The reviewed screening policy and procedures indicated the facility administrator (FA)
is responsible for the implementation of a standardized admission and intake mental health and
substance abuse screening process. The policy addresses the review of available information,
administration of the MAYSI-2, staff training in administration of the MAYSI-2, and a process for
youth in crisis requiring immediate attention. The interviewed FA reported a MAYSI-2 is
completed upon intake to identify suicidal risk factors, and additional screenings to include the
Assessment of Suicide Risk may be administered.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a written policy and procedures to establish an evaluation process to
guide the development of each youth’s individualized treatment plan. The program ensures the
mental health and substance abuse needs of the youth are identified through a comprehensive
mental health and substance abuse evaluation process. Each youth receives an in-depth
evaluation within the first thirty days of residential placement. All evaluations are to be
completed by a licensed mental health professional or mental health clinical staff working under
the direct supervision of the licensed mental health professional. Six of the seven reviewed
records indicated a new combined mental health and substance abuse evaluation for the youth
was completed. One youth evaluation was still pending due to the youth’s recent admission into
the program. Each of the six applicable evaluations were completed within thirty days of
admission and each youth consented to substance abuse services prior to the evaluation. Each
reviewed evaluation was completed by a non-licensed staff and signed by a licensed staff within
ten days. Each evaluation included the date of referral/admission, date of the evaluation,
identifying information, the reason for the evaluation, relevant background information,
behavioral observations, a Mental Status Examination, procedures administered, discussion of
findings, diagnostic impressions, patterns of alcohol and/or drug abuse, impact of use on major
life areas, risk factors for continued use, and recommendations. One out of the seven reviewed
records required an updated evaluation. The updated evaluation was clearly identified as such
and was attached to the previous comprehensive evaluation. The updated evaluation provided
new and additional information applicable to each area specified in the new evaluation areas,
was dated within the past twelve months, addressed the problems identified at the screening,
findings, and the original referral reason. An interview with the program’s designated mental
health clinician authority (DMHCA) stated the process for obtaining the comprehensive mental
health and/or substance abuse evaluation based on behavior is done during the intake process.
The program’s DMHCA gathers current information pertaining to the youth, and confirms
collateral information obtained in the youth’s records to complete the brief behavioral health
status exam. Each youth receives a comprehensive evaluation within twenty-one days of intake
based on their current and past behavior by licensed or non-licensed mental health
professionals, which is reviewed by the clinical director or designee.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 32 of 64 (Revised September 2022)
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a written policy and procedures outlining the program’s mental health
and substance abuse treatment services. A review of seven youth records indicated each
contained an initial mental health and substance abuse treatment plan within seven days of
admission. Each initial treatment plan was documented on the program’s form which included
all elements of the Department’s Initial Health and Substance Abuse Treatment Plan form. Two
of the youth were applicable for psychotropic medications and the plan included the medication
details. Each of the seven initial plans were completed and signed by the designated mental
health clinician authority (DMHCA). Each plan was signed by the youth, parent/guardian,
juvenile probation officer (JPO), treatment team leader, program administration, and a living unit
staff. Each plan documented the participation of the JPO and parent/guardian by telephone. Six
of the seven records were applicable for an individualized treatment plan to be completed within
thirty days and treatment plan reviews to be completed at thirty-day intervals. Two of the
reviewed individualized treatment plans were for youth prescribed psychotropic medications and
the plans included the medication monitoring schedule. The six applicable reviewed records
documented fifty-three treatment plan reviews, and each review was completed at least every
thirty days as required. Individualized treatment plans and reviews documented signatures of
the youth, parent/guardian, JPO, treatment team leader, program administration, living unit staff,
and education staff. Each plan was signed by the DMHCA on the day of completion. Each
applicable youth’s treatment plan prescribed services, goals, and objectives which were
individualized for each youth. Each plan included individual counseling, group counseling, family
counseling, and applicable psychotherapy. A review of video compared to sign-in sheets for
groups indicated they were occurring as scheduled and as documented.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program maintains a written policy and procedures addressing treatment and discharge
planning. A review of seven youth records indicated each youth was assigned to a treatment
team upon arrival to the program. Reviewed treatment team documentation and treatment team
assignment forms for each record confirmed the treatment team members were comprised of
the youth, program administration, living unit, education, medical staff, mental health and
substance abuse staff, and parents/guardians. Each youth with substance abuse treatment
goals received treatment by a qualified professional. The program is licensed under Chapter
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 33 of 64 (Revised September 2022)
397 to provide substance abuse services to adolescents. Each youth record contained a
substance abuse consent and the Department’s Authority for Evaluation and Treatment.
Reviewed progress notes were documented on the program’s form and contained all elements
of the Department’s Counseling/Therapy Progress Notes form. Reviewed progress notes
verified treatment included individual psychotherapy and psychosocial skills. Each record review
verified services were provided as stipulated in the youth’s treatment plan. A review of three
youth records was completed for discharge plans. Each of the three reviewed discharge
summaries were documented on the Department’s Mental Health and Substance Abuse
Treatment Discharge Summary form. None of the closed records were applicable for the youth
being released while on suicide alert/precautions. Each of the three reviewed summaries
documented the future services needed. Reviewed documentation supported the plans were
discussed during the exit conference with the youth, parent/guardian, and assigned juvenile
probation officer (JPO). Each record documented the youth and parent/guardian signed the plan
and the plan was sent to the assigned JPO.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program maintains a policy and procedures to establish a delivery protocol for Substance
Abuse Treatment Overlay Services (SAOS) programming. Substance abuse and mental health
treatment are provided on-site through the provision of SAOS. Required clinical treatment
groups include Living in Balance (LIB), Seeking Safety, Mindfulness for Addiction, Men’s
Trauma Recovery and Empowerment Model, and Trauma Focused Cognitive Behavioral
Therapy. Seven interviewed youth stated they participate in family and individual counseling at
the program. Seven interviewed staff indicated direct care staff do not facilitate any mental
health or substance abuse groups. An interview with the designated mental health clinician
authority (DMHCA) indicated the program provides individualized treatment through individual,
family, and group therapy services to address mental health and substance abuse concerns of
the youth. The interviewed facility administrator confirmed the required clinical groups at the
program. Documentation confirmed the DMHCA was on-site for forty-hours each week and
licensed staff was on site at least five days each week. The required counselor to youth ratio is
not to exceed one counselor to sixteen youth. A review of caseload assignments indicated they
were between ten and fifteen youth. The program provided individual therapy once every two
weeks, family therapy at least monthly, applicable psychiatric services every two weeks, and
mental health/substance abuse groups four times each week as required. This was verified by
the program’s group schedule.
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 maintains a written policy and procedures for the provision of psychiatric services
within the program. The program’s contracted psychiatrist is responsible for psychiatric
evaluations, consultation, medication management, and medical supportive counseling. A
review of the psychiatrist’s license indicated they held a medical doctor license which was free
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 34 of 64 (Revised September 2022)
and clear in the State of Florida with an expiration date of January 31, 2026. The psychiatrist is
available for emergency consultation twenty-four hours a day, seven days a week. The
psychiatrist provided psychiatric services and served briefly as a representative of treatment
team. Psychiatric recommendations for youth are incorporated into evaluations and planning at
the program. The program did not utilize a back-up psychiatrist during the annual compliance
review period. The program does not use a psychiatric advanced practice registered nurse. A
review of the psychiatric sign-in logs verified the psychiatrist was on-site bi-weekly since the last
annual compliance review. Reviewed documentation indicated the psychiatrist actively
participates in, manages, and supervises psychotropic medication services in the program. The
program has an independent contract with a licensed psychiatrist who provides services as
needed. The program does not utilize tele-psychiatry services. The psychiatrist reported they
are completing an Initial Diagnostic Psychiatric Interview and providing treatment for youth who
require psychiatric services. The interviewed psychiatrist reported they are on-site bi-weekly and
on call twenty-four hours daily as needed. The psychiatrist reported they have no concerns with
services provided at the program. The designated mental health clinician authority (DMHCA)
reported they meet with the psychiatrist to discuss youth receiving psychiatric services bi-weekly
when they are on-site. A review of seven records indicated two were applicable for psychiatric
services; therefore, an additional record was requested and reviewed. Each of the three youth
entered the program with prescribed psychotropic medications. Each youth was referred for a
psychiatric interview, and each diagnostic interview was completed within fourteen days of
admission. The applicable reviewed Initial Diagnostic Psychiatric Interviews for youth on
medications included history, a Mental Status Examination, a Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-5) diagnosis, treatment recommendations, prescribed
medications, explanation for the need of medications, target symptoms, initial treatment goals,
potential side effects, and frequency of medication management. Each youth was referred for a
psychiatric interview upon admission, as it is the program’s practice to refer all youth. Each
interview was documented on the Department’s Clinical Psychotropic Progress Note (CPPN)
form and included page three when medication was prescribed and/or continued. The three
youth were applicable for eighteen psychiatric medication reviews to be completed at least
every thirty days. All were completed as required. None of the reviewed records were applicable
for a psychiatric evaluation update. Each instance where page three of the CPPN was used, the
psychiatrist documented the identifying data, diagnosis, target symptoms of each medication,
effects of the medication, medication dosage, dosage range, frequency, route of administration,
side effects, adherence to the medication regime, and whether there was telephone contact with
the youth’s parent/guardian. Each was signed and dated by the psychiatrist. Three youth
records documented monitoring for Tardive Dyskinesia monthly as indicated on the CPPN.
None of the reviewed records were applicable for the use of tele-psychiatry.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program maintains a policy and procedures regarding the implementation of a Suicide
Prevention Plan. The plan shall provide guidelines for the identification, management, and
assessment of potentially suicidal youth. The program maintains a Suicide Prevention Plan
which was last signed and reviewed by the facility administrator (FA) on November 11, 2024. A
review of the plan reflected it included identification and assessment, staff training, suicide
precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, and a review process. The review process for suicide attempts and
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 35 of 64 (Revised September 2022)
mortality review included circumstances surrounding the event, facility procedures relevant to
the incident, all relevant training received by involved staff, pertinent medical and mental health
services involving the victim, possible precipitating factors, and recommendations.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
The program maintains a written Suicide Prevention Plan which serves as the program’s suicide
prevention procedures. The Suicide Prevention Plan addresses the program’s suicide
prevention services, suicide precautions and observation logs, as well as suicide prevention
training. A review of seven youth records indicated each was applicable for an Assessment of
Suicide Risk (ASR) to be completed upon admission as part of the program’s standardized
practice. The program reported they only had two youth who were identified as being actively
suicidal and requiring interventions since the last annual compliance review. A review of the
seven ASRs completed as part of the admission process indicated each was completed in full
and each youth was transitioned to standard supervision after a conference was documented
with the designated mental health clinician authority (DMHCA) and the facility administrator
(FA). Six were completed by licensed staff, and one was completed by a non-licensed staff and
signed by the DMHCA within twenty-four hours. Two youth requiring suicide interventions were
referred for an ASR after admission screenings. Both ASRs were completed within twenty-four
hours by a non-licensed staff and signed by the DMHCA the next day. Each ASR documented a
conference between the assessor, DMHCA, and the FA regarding the decision to continue the
youth on precautionary observation. A Follow-Up ASR was needed and completed for both
youth prior to the removal of youth from precautionary observation. Each Follow-Up ASR was
documented on the Department’s Follow-Up Assessment of Suicide Risk form. Both youth were
maintained on suicide precautions and constant supervision until the Follow-Up ASR indicated
suicide precautions could be discontinued. When the youth’s Follow-Up ASR indicated suicide
precautions could be discontinued, the youth was stepped down to close supervision prior to
transition to normal routines and standard supervision. Close supervision was maintained until it
was determined no longer necessary by the DMHCA for both youth. Reviewed documentation
indicated a conference was held with the FA and DMHCA to reduce the youth’s level of
supervision. Discontinuation of close supervision was documented in accordance with the
program’s Suicide Prevention Plan and documented the date and time the youth were stepped
down. The Department’s Juvenile Justice Information System suicide alerts were initiated for the
youth placed on suicide precautions, and accurately closed following the recommendations of
the Follow-Up ASRs. There was evidence in the program’s logbook indicating administration or
supervisory staff provided instructions related to the suicide risk assessment findings and
suicide precaution decisions. There were no video observations to verify precautionary
observations during the annual compliance review due to the program only storing thirty days of
video footage.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 36 of 64 (Revised September 2022)
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a written policy and procedures requiring staff to always maintain at
least constant supervision of the youth on precautionary observation and document their
observations of the youth on the Suicide Precautions Observation Log in intervals which do not
exceed thirty minutes. A review of seven youth records indicated none were applicable for being
placed on precautionary observation. The program had two youth applicable for placement on
suicide precautions since the last annual compliance review. The Suicide Precautions
Observation Logs were maintained for the duration the youth was under suicide precautions.
The appropriate level of supervision and observations of the youth’s behavior was documented
in real time and not exceeding thirty-minute intervals. For both reviewed records, warning signs
were observed, and notification to the facility administrator and mental health clinical staff was
documented on the Suicide Precautions Observation Log. Each Suicide Precautions
Observation Log was reviewed and signed by the shift supervisor and mental health clinical
staff. The Suicide Precautions Observation Logs documented safe housing requirements.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a written Suicide Prevention Plan which details suicide prevention
training requirements. A review of seven pre-service and seven in-service training records found
staff training records documented completion of suicide prevention training, with no noted
issues. The program is required to complete one mock suicide drill for each shift at least
quarterly. A review of suicide drills for the past twelve months reflected the program conducted
the necessary drills on each shift, as required. Reviewed drills included the use of lifesaving
measures to include the use of cardiopulmonary resuscitation (CPR), first-aid kits, suicide kits,
and an automated external defibrillator (AED). All drills were simulated, and the program youth
were not utilized in the simulated drills. Reviewed documentation confirmed all direct care staff
participated in at least one drill which involved the use of CPR annually. Staff who are not
present during quarterly suicide drills can review each drill scenario during monthly staff
meetings, to understand the process and receive the necessary training to respond to an
incident of a suicide attempt or incident of serious self-inflicted injury in the program. The
program has four suicide response kits which are co-located with first-aid kits in master control,
both youth living units, and medical. Seven staff were interviewed and reported when a youth is
suicidal, they are responsible for notifying mental health staff and documenting supervision.
Additionally, six staff reported maintaining constant sight and sound supervision, and three staff
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 37 of 64 (Revised September 2022)
reported searching the youth and room for sharp objects. Each interviewed staff reported drills
are conducted at least monthly. All seven staff were able to identify where the suicide kits were
located. During an interview, the facility administrator reported mental health and medical staff
conduct monthly drills with program staff.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a policy and procedures to outline operation procedures for crisis
intervention. The program’s Crisis Intervention Plan addresses mental health crisis intervention
services and Crisis Assessments. A review of the plan indicated it included notification and alert
system, referrals, communication, supervision, documentation, and review. The plan states it
shall be the responsibility of all staff to ensure crisis plans are implemented immediately to
afford youth with a maximum amount of safety and security.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program’s Crisis Intervention Plan addresses mental health crisis intervention services and
Crisis Assessments. A review of seven youth records indicated none were applicable for a
Crisis Assessment. The program had one youth applicable for a Crisis Assessment since the
last annual compliance review. The Crisis Assessment was completed the same day the youth
was determined to be in crisis. The Crisis Assessment included the reason for assessment,
Mental Status Examination and interview, determination of danger to self, initial clinical
impressions, supervision recommendations, treatment recommendations, recommendations for
follow-up or further evaluation, and notification to the parent/guardian of follow-up treatment.
The Crisis Assessment was conducted by a licensed mental health professional and a mental
health alert was entered into the Department’s Juvenile Justice Information System (JJIS) when
the youth was placed on precautions after completion of a Crisis Assessment. The reviewed
Crisis Assessment determined the youth posed a safety and security risk, so the youth
remained on alert until a follow-up Crisis Assessment had been completed. Constant
supervision of youth while on the mental health alert was documented on the Department’s
Mental Health Alert and Observation Log. The youth did not require an off-site Crisis
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 38 of 64 (Revised September 2022)
Assessment. The youth was not an alleged victim in a Prison Rape Elimination Act (PREA)
event.
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 maintains a written policy and procedures outlining the mental health and
substance abuse procedures for youth who are believed to be an imminent danger to
themselves or others because of mental illness or substance abuse impairment. The
Emergency Response Plan for Mental Health and Substance Abuse Emergencies requires
youth to receive the highest quality of care, safety, and management. A review of the plan
validated it included immediate staff response, notifications, communication, supervision,
authorization to transport for emergency mental health and substance abuse services, transport
for emergency Baker Act, transport for emergency Marchman Act, documentation, training, and
review.
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
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 maintains a written policy and procedures for an ongoing safety planning process
for each admitted youth. Safety planning is designed to identify stimuli which have both positive
and negative effects on the youth. Within fourteen days of admission, the intervention and
treatment team shall meet with each youth to develop the safety plan. The safety plan shall be
updated in an ongoing collaboration with the youth to identify specific behaviors or triggers
which may decrease the youth’s sense of safety and increase the likelihood the youth may
experience a traumatic stress related response. The safety plan shall include input from the
parent(s)/guardian(s) as well as information gathered from the youth’s history and evaluations, if
applicable. The plan shall be updated every thirty days or following any significant behavioral or
mental health event identified by the treatment team. A review of seven youth records indicated
each had a safety plan created within fourteen days of admission and reviewed every thirty
days. Each plan documented warning signs, youth baseline behavior, crisis recognition, jointly
developed coping strategies, preferred intervention strategies, and a debriefing process. Each
plan was jointly prepared with the youth, parent/guardian, and mental health staff. Each plan
incorporated information from previous assessments and interviews. None of the plans required
an update due to a significant behavioral or mental health events Six of the seven reviewed
records contained fifty-five safety plan reviews. One reviewed record did not require a review
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 39 of 64 (Revised September 2022)
due to the youth being in the program for less than thirty days. The plans are accessible to staff
and located in the administration hallway on a shelf. Seven interviewed youth reported they
contributed to the development of their safety plans. The interviewed facility administrator
reported safety plans are reviewed and updated monthly or as needed.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 40 of 64 (Revised September 2022)
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 maintains a policy and procedures ensuring a contracted health authority provides
on-site medical services to youth in the program. The program maintains a contract with a
designated health authority (DHA) who is a licensed physician (MD). The DHA holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
the State of Florida. The DHA has a clear and active license in the State of Florida, which
expires on January 31, 2026, with specialty training in pediatrics. The DHA is a current member
of the American Board of Pediatrics. A review of the Florida Department of Health records
confirmed the DHA had no disciplinary cases and/or public complaints on record. The program
does not utilize an advanced practice registered nurse (APRN) or physician’s assistant (PA) for
clinical duties. The DHA was on-site at least once a week, with a week defined as the seven-
day period beginning on Sunday and ending on Saturday. Reviewed documentation confirmed
at no time did more than nine days pass between on-site visits. A review of DHA sign-in sheets
since the last annual compliance review confirmed the DHA was on-site for a minimum of two
hours a week. The program has a back-up DHA who can be utilized. The back-up DHA is a
licensed physician with a clear and active license in the State of Florida expiring on January 31,
2025. The back-up DHA was utilized during the week of July 13, 2024. A review of the
program’s policy confirmed tele-medicine/tele-health is not provided by the program. An
interview with the DHA reported their role in the program is to conduct Comprehensive Physical
Assessments (CPAs), periodic evaluations, sick call, and policy and procedure development.
Additionally, they approve, edit, and correct all policies, procedures, and protocols for the
medical clinic at the program. The DHA reported they examine every new youth intake, and
perform routine checkups on all youth, as well as periodic evaluation follow-up exams to all
youth with chronic medical illnesses or conditions. The DHA assures all youth are treated for
any medical conditions to prevent any future medical problems. The DHA assures all youth
have a completed immunization record in accordance with health department standards.
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’s contract with the Department outlines the requirements for a health service
administrator (HSA) and one additional full-time registered nurse (RN). The program has one
HSA who is a full-time RN, one full-time RN, and one part-time RN on-site. A review of nurse
licensure credentials for nurses who provided services during the annual compliance review
period confirmed licenses were clear and active. Each RN held a current certification in
cardiopulmonary resuscitation (CPR). The required on-site hours for the nursing staff is forty
hours for RNs and forty hours for the HSA weekly. A review of the nursing schedule confirmed
the HSA and full-time RN are both on-site for forty hours a week. The schedule confirmed the
part-time RN is on-site twenty hours every other weekend or fills in as needed.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 41 of 64 (Revised September 2022)
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The designated health authority (DHA) is solely responsible for
an annual review of all health-related policies, procedures, and protocols. Reviewed policies
and procedures confirmed the DHA signed on November 5, 2024, the facility administrator
signed on November 6, 2024, and the psychiatrist signed on November 11, 2024. The nursing
staff reviewed, signed, and dated the cover page of all FOPs, healthcare protocols, and other
procedures listed on November 6, 2024. On November 5, 2024, the annual review of medical
FOPs and protocols was conducted. All newly employed healthcare personnel received a
comprehensive clinical orientation to the Department’s healthcare policies and procedures,
given by a registered nurse or designated, licensed healthcare professional. The approval of
treatment protocols or standing procedures were 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 maintains a written policy and procedures ensuring the completion of the Authority
for Evaluation and Treatment (AET) for all youth admitted into the program. Two of seven youth
were applicable for an AET, one youth was in the care of the Department of Children and
Families (DCF) where a court order was in place, and four youth were over the age of eighteen.
A review of the two applicable Individual Healthcare Records (IHCRs) confirmed the original
AET form was filed in the youth’s IHCR with a legible copy, or the word “COPY” clearly stamped
on each AET. Each applicable reviewed AET form was signed by the youth’s parent/guardian
and by a Department representative. Reviewed documentation confirmed there were no
parent/guardian refusals to sign the AET. One reviewed youth IHCR confirmed a court order
was filed. Four of seven reviewed IHCRs confirmed the youth were eighteen years of age or
older and contained a signed documented release of information. An interview with the nurse
reported the policy for obtaining a new or current AET is for the clinical manager or designated
staff member to immediately contact the juvenile probation officer (JPO) to request one. The
nurse reported the policy for documenting consent for youth who are eighteen years of age or
older is for the youth to sign an eighteen-year-old consent and they can consent for themselves.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program maintains a written policy and procedures ensuring the parent/guardian is
informed of significant changes in the youth’s condition and obtain consent when new
medications and treatments are prescribed. Seven youth Individual Healthcare Records
(IHCRs) were reviewed for parental/guardian notifications. Three of seven reviewed IHCRs
were applicable and confirmed documentation of parental/guardian notification for over-the-
counter (OTC) medications beyond those covered by the Authority of Evaluation and Treatment
(AET). Consent was provided by the parent/guardian and written notifications were sent utilizing
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 42 of 64 (Revised September 2022)
the Department’s Parental Notification of Health-Related Care form. Four youth were not
applicable for parental/guardian consent for OTC medications. Three of seven reviewed IHCRs
confirmed the youth were taking psychotropic medication at admission, one was for a youth
eighteen years of age. The two applicable IHCRs confirmed staff witnessed all telephone call
attempts and conversations for psychotropic medications. The two reviewed Clinical Psychiatric
Progress Notes (CPPN) confirmed whenever a new psychotropic medication was prescribed or
discontinued, or the drug dosage was significantly changed a parental/guardian provided verbal
consent for psychotropic medication. One youth was in the care of the Department of Children
and Families (DCF), where there was a termination of parental/guardian rights, and the court
authorized all treatment and procedures. Each of the seven reviewed IHCRs confirmed
vaccinations were verified within thirty days of the youth’s admission. An interview with the
nurse reported parental/guardian notifications are made in real-time and if the nurse is unable to
contact the parent/guardian, another attempt is made and documented. It was reported the
process for documenting parental/guardian exemption from immunization is through the
exemption form, which is signed by the parent/guardian and on file at their local health
department. The nurse reported timeframes for reviewing records are prior to intake and again
during the intake process. Records are reviewed by the designated health authority (DHA)
during the Comprehensive Physical Assessment and the initial visit.
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 maintains a written policy and procedures ensuring a healthcare screening is
completed for each youth upon admission into the program. The program’s practice is to
complete a rescreening and complete the Department’s Facility Entry Physical Health Screening
(FEPHS) form anytime a youth is admitted into the program or each time the physical custody of
the youth changes with subsequent return or readmission to the program. Seven reviewed
youth Individual Healthcare Records (IHCRs) contained a FEPHS form completed on the date
of admission. Each form was completed by a registered nurse (RN). None of the FEPHS were
completed by direct care staff. None of the youth were applicable for a change in custody
greater than twenty-four hours.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program maintains a written policy and procedures ensuring each youth admitted into the
program receives a healthcare orientation. Seven youth Individual Healthcare Records (IHCRs)
were reviewed, and each contained documentation the youth received a general healthcare
admission orientation. Each youth’s orientation topics included access to medical care, sick call,
what constitutes an emergency and when to notify staff, medication process to include side
effect monitoring, the right to refuse care and how it is documented, what to do in the case of a
sexual assault or attempted sexual assault, the non-disciplinary role of the healthcare providers,
and standard universal precautions. The Health Education form listed all
reviewed topics to include seatbelt usage, alcohol and drug- related problems, sexually
transmitted diseases/infections, tobacco products, including smoking cessation, dental hygiene
and dental care, basic personal hygiene, immunizations, infection control, prevention of sexual
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 43 of 64 (Revised September 2022)
and other physical violence, nutrition, physical fitness, and breast and testicular self-
examinations and was signed and dated by the youth. The Health Education form was not
applicable for parenting skills, prenatal, postpartum, and parenting education.
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 maintains a written policy and procedures ensuring the designated health authority
(DHA) is notified of all youth admitted into the program identified with chronic health conditions
or youth in need of emergency care. Four of seven reviewed youth Individual Healthcare
Records (IHCRs) confirmed the youth were known or suspected of having a chronic condition
upon admission and confirmed a referral to the physician was made. Reviewed documentation
confirmed notification to the DHA/designee was documented in the youth’s chronological
progress notes within the IHCR. Each confirmed the DHA was notified within twelve hours of
admission, and no later than noon the day following admission. Three of seven youth were
currently taking psychotropic medication upon admission and the psychiatrist was notified. An
interview with the nurse reported for youth admitted with serious or chronic conditions, the
process and time frame for notifying the DHA is upon intake and medical staff is responsible for
the notification. The nurse reported the notifications to the DHA are documented in the
admission progress note.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program maintains a written policy and procedures to address the completion of the Health-
Related History (HRH) form prior to the completion of the Comprehensive Physical Assessment
(CPA) upon each youth’s admission to the program. Seven reviewed youth Individual
Healthcare Records (IHCRs) confirmed each HRH was completed within seven calendar days
of admission. Each reviewed HRH form was completed prior to the CPA and focused
evaluations, as evidenced by a signature and date. Each HRH was reviewed by the designated
health authority (DHA). This was evidenced by a checkbox on the CPA indicating the HRH was
reviewed. An interview with the nurse reported the healthcare staff are responsible for
completing the HRH within seven days of admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the completion of the Department’s
standardized Comprehensive Physical Assessment (CPA) form for all youth admitted into the
program. Seven reviewed youth Individual Healthcare Records (IHCRs) confirmed the youth’s
physical assessment was completed on the Department’s CPA form within seven days. Each
form was completed by the medical doctor (MD) and documented the Medical Grade. All
sections of the CPA were marked with an “O” or an “X”. Six of seven youth refused part of exam
and clinician documented the word “refusal” with the youth’s signature and date. Each date
matched the date of the exam. Reviewed documentation confirmed the Department’s Problem
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 44 of 64 (Revised September 2022)
List was updated, as required for each. Each youth had at least one verified Tuberculosis Skin
Test (TST) documented on the Infectious and Communicable Disease (ICD) form. An interview
with the nurse reported the DHA completes a new CPA within seven days of admission and the
process and timeframe for Tuberculosis (TB) screenings are conducted at intake and a TST is
completed within seventy-two hours of admission.
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 ensuring all youth admitted shall be clinically
screened and medically evaluated for sexually transmitted infections (STIs) and human
immunodeficiency virus (HIV). The policy reflected HIV test results may only be disclosed to the
youth and entities approved by Florida Administrative Code. Seven reviewed youth Individual
Healthcare Records (IHCRs) confirmed each youth was clinically screened and evaluated for
STIs. Each youth required further evaluation and was referred to the medical doctor (MD). Each
referral was documented on the STI screening tool and testing was ordered. Each youth was
tested, and screening results, clinical evaluations, and applicable diagnoses were documented
on the Infectious and Communicable Disease (ICD) form and filed in the lab section of the
IHCR. Seven reviewed IHCRs confirmed the youth were offered counseling, testing, and if
indicated, treatment/referral for HIV. Six of seven youth received HIV testing. One youth
refused. Each applicable youth had documented consent, and the HIV results were filed
confidentially in a sealed envelope marked “Confidential,” and included a documented review by
a practitioner on the sealed envelope. Each applicable youth had documentation of pre/post-
test counseling on the IHCR and/or in the progress notes. Each youth’s confidentiality was
protected by not including the youth’s HIV status or any other STI diagnosis on the program’s
internal alert system. The program has a policy and procedures reflecting HIV test results are
only disclosed to the youth and the youth’s legally authorized representative, healthcare
providers during the course of consultation, diagnosis, or treatment of the individual, the
Department of Health for purposes of reporting and control of spread of disease, health facility
staff committees conducting program monitoring, evaluation, and service reviews, medical
personnel who have been subject to a significant exposure, and healthcare facility personnel or
agents for the healthcare provider who have a need to know in the course of patient care
activities or administrative operations. The health service administrator (HSA) reported the
program utilizes the medical doctor and the local health department to provide pre- and post-
test and counseling services. Seven youth were interviewed and reported they can ask for an
HIV test. An interview with the nurse reported youth are screened for STIs upon admission and
the DHA orders the testing during intake. The DHA is notified immediately of results for
treatment. It was reported the STI screenings, evaluations, referrals, and testing are
documented in the IHCR, which is behind the infectious communicable disease tab. The nurse
reported youth have a urine drug screen if they have been out of the program’s/Department’s
physical custody for more than thirty days and/or symptoms are present.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 45 of 64 (Revised September 2022)
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a written policy and procedures ensuring all youth shall be able to make sick
call requests and have their complaints treated appropriately through the sick call system. Sick
call care is provided by licensed healthcare professionals pursuant to their scope of practice and
according to protocols approved by the designated health authority (DHA). Seven reviewed
youth Individual Healthcare Records (IHCRs) confirmed none were applicable for sick call
requests. Three additional records were requested and reviewed to meet the sample size. None
of the applicable youth presented with a similar sick call complaint three or more times within a
two-week period. Each youth completed a Sick Call Request form, and forms were completed
by a registered nurse (RN). Each Sick Call Request form was filed in the youth’s IHCR in
reverse chronological order. Each Sick Call Request form and/or progress notes were
documented in accordance with Florida Administrative Code and on the Sick Call Index. Each of
the youth’s sick calls were documented on the program’s Sick Call Referral Log and the dates
listed on the Sick Call Index corresponded to the completed Sick Call Request forms located in
the IHCR. A review of the daily schedule, posted schedule, and nurse interview confirm sick call
was conducted daily, pursuant to contract requirements. Sick calls are provided seven days a
week, twice daily at 10:00 a.m. and 2:00 p.m. The sick call hours are posted in both living units
and only licensed nurses can conduct sick call. The program has a procedure whereby the shift
supervisor reviews all sick call requests as soon as possible and within four hours after the
request is submitted when there is not a licensed nurse on-site. All sick call request forms are
available to youth and an exam table and equipment is used to perform sick calls. Seven youth
were interviewed and two reported they see a nurse immediately once they make a sick call
request and five reported they see a nurse within one day after they make a sick call request.
An interview with the nurse reported the DHA conducts sick calls, if sick call is when they are
on-site, and sick calls are conducted in the medical clinic. The nurse reported the process for
youth to request to see a nurse and/or physician is to complete a Sick Call Request form and
sick calls are conducted twice a day. The nurse reported the process for referring youth to the
DHA when they have repeated complaints is to place them on the DHA log. During the time of
the annual compliance review, there were no sick call requests made; therefore, observations
were not completed.
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 ensuring the provision of episodic and emergency
care. Four of seven reviewed youth Individual Healthcare Records (IHCRs) required on-site
first-aid or episodic care. All first-aid/episodic care was provided by a licensed healthcare staff
and documented in subjective, objective, assessment, and plan (SOAP) format. None of the
episodic or first-aid care was provided by non-healthcare staff. The program has five first-aid
kits located in master control, medical, the kitchen, and one in each of the two vans. The
program has a process for ensuring contents are maintained and stored in accordance with
guidelines, to prevent expiration or deterioration, and replenished as needed. The nurse checks
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 46 of 64 (Revised September 2022)
kits weekly and opens kits quarterly. Two observed first-aid kits were fully stocked with DHA-
approved contents. The reviewed first-aid kit binder confirmed the first-aid kits were being
monitored as required. The program has one automated external defibrillator (AED) located in
master control. The AED procedures are in both living units. Nurses check to ensure the AED
batteries and pads are operable. During the annual compliance review week, the nurse
conducted a self-test of the AED in front of the Monitoring and Quality Improvement (MQI)
regional monitor. There were no issues observed. Reviewed documentation confirmed the AED
batteries expire on October 31, 2028, and the pads expire on October 3, 2025. The batteries
and pads were last changed on May 30, 2023. A list of emergency numbers including the
Poison Control Center were posted and accessible for non-licensed and licensed staff and
inaccessible to youth. Reviewed documentation confirmed authorized direct care staff were
appropriately trained on the administration of the epinephrine auto-injector. Seven staff training
records were reviewed and met episodic, first-aid, and emergency care training requirements. A
review of the program’s emergency medical drills reflected announced and unannounced drills
were conducted on each shift monthly for the past twelve months. Emergency medical drills
included the demonstration of cardiopulmonary resuscitation (CPR), first-aid, and the AED at a
minimum annually; however, reviewed documentation regarding medical drills found on six
separate occasions the drills did not document what action staff took to assist the youth in need.
The Department’s Office of Health Services was made aware of the issue during the week of the
annual compliance review. Additionally, the program provided documentation to confirm an
emergency training was held on July 30, 2024, to address issues relating to drills. Reviewed
documentation confirmed direct care staff have participated in at least one emergency “man
down” drill annually. Video observations of drills confirmed drills simulated episodic care events.
During an informal interview, the medical and mental health staff reported staff who are not
present during medical emergency drills can review each drill scenario during staff meetings. In
addition, reviewed documentation found staff signed drill review sign-in sheets to confirm they
were provided the opportunity to review the scenario. During the annual compliance review
week, there was no observation of an episodic care event. The program has a policy and
procedures on the use, access, and inventory of Narcan®. Narcan® is to be stored in the
medical cart and staff are trained on its use. Medical staff and supervisors are the only ones
who have access to Narcan®. The program documents the inventory of Narcan® in the over-
the-counter binder. Seven staff were interviewed, and five reported they are personally allowed
to call 9-1-1 if needed, one reported they would radio master control to call, and one reported
they would let the nurse know and they call. Seven youth were interviewed, and each reported
they see a doctor or dentist if needed. An interview with the nurse reported the program has five
first-aid kits located in the kitchen, medical, van one, van two, and master control. The nurse
reported youth who are sent off-site for emergency care are tracked through a transport log. It
was reported the medical staff checks to ensure the AED batteries and pads are operable. It
was reported emergency drills are held for each shift, at a minimum on a quarterly basis. It was
reported the process for documenting on-site episodic care is to document on a progress note in
SOAP form and then document the event on the episodic log. Non-healthcare staff providing
first-aid or episodic care document the encounter on the non-healthcare staff form, and it is
reviewed by the nurse the next day.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 47 of 64 (Revised September 2022)
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures ensuring timely referrals, coordination, and
documentation of medical services for off-site health providers for youth with emergent or non-
emergent needs. The designated health authority (DHA) reviews, signs, and dates the off-site
care instructions. Three of seven reviewed youth Individual Healthcare Records (IHCRs)
confirmed youth required off-site care. Each Summary of Off-Site Care Consultation Report
form was utilized and filed in the IHCR. Each applicable form confirmed the off-site emergency
care was documented on the Episodic Care Log. One of three parental/guardian notification
efforts were documented for youth under eighteen years of age. Two youth were eighteen years
of age. Each applicable form confirmed the DHA did review and sign/initial all off-site care
findings, instructions, and information. Two of the three reviewed youth required follow-up
testing, referrals, and appointments. The follow-ups were completed on September 11, and 19,
2024. Each applicable referral was tracked, and youth received appropriate, timely follow-up
care as needed. An interview with the nurse reported youth who are sent off-site for first-aid or
emergency care needs are tracked on the transport log and a planner. It was reported all
hospital orders are noted and reviewed by medical staff and the DHA to ensure tracking. The
nurse reported medical staff track follow-up testing, referrals, and appointments on the DHA
log/tracker. It was reported the DHA reviews information on the next scheduled visit.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a written policy and procedures ensuring youth who have chronic illnesses
receive regularly scheduled evaluations with the required follow-up. A review of seven youth
Individual Healthcare Records (IHCRs) confirmed one youth was identified with a chronic
condition after being admitted into the program; therefore, two additional youth IHCRs were
requested. None of the youth were identified as having a communicable disease. Three of the
applicable youth were taking prescribed medication on an on-going basis and undergoing
treatment for physical health conditions. Each youth was classified with an appropriate Medical
Grade. Each youth was placed on a chronic illness list and received periodic evaluations at least
every ninety-days. None of the applicable youth were taking anti-tuberculosis medications.
Reviewed documentation confirmed each received periodic evaluations prior to renewing a
prescription medication which expired. One evaluation was conducted off-site. The evaluation
was documented on the Summary of Off-Site Care form and filed in the IHCR’s chronological
progress notes. Reviewed documentation confirmed the designated health authority (DHA)
followed up with the youth after receiving off-site care and signed off on the documents. The
Department’s Problem List was updated in accordance with policy. An interview with the facility
administrator (FA) reported during daily management meetings with the leadership team,
procedures are put in place with the healthcare staff to review important youth medical issues.
The DHA reported periodic evaluations for youth with chronic conditions are completed every
ninety days unless a decision is made, which changes the timeframe to every thirty or sixty days
for specific conditions. The DHA reported to ensure all youth with chronic conditions receive a
periodic evaluation, they have a system to log every youth with their follow-ups on a calendar.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 48 of 64 (Revised September 2022)
The nurse reported the program monitors youth with chronic conditions on a tracker for chronic
conditions.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
-0
The program has a written policy and procedures which outline the process of how medications
are to be received, stored, inventoried, and administered in a safe and effective manner. Three
of seven reviewed youth Individual Healthcare Records (IHCRs) confirmed youth were admitted
with medication, which was verified prior to admission into the program. Each applicable youth
prescription verification was included in the chronological progress note. Documentation
confirmed the designated health authority (DHA)/designee and psychiatrist was contacted to
obtain the order to resume the specified medications prescribed prior to admission. The DHA
placed an order on the Practitioner Order form for all continued medications. Each Medication
Administration Record (MAR) clearly indicates medication start and stop dates. It was confirmed
staff initialed each administered medication entry. There were no undocumented explanations
for a lapse or errors in medication administration. Reviewed documentation confirmed nursing
staff documented weekly side-effect monitoring on the MAR. Two of three youth where
applicable and signed the Refusal of Treatment form indicating the refusal of medication. Each
applicable MAR clearly documented the refusals. Each reviewed MAR documented all required
elements to include youth name, Department of Juvenile Justice identification number (DJJID),
date of birth, youth allergies, precautions, Medical Grade, medical alerts, current picture of the
youth, and youth’s initials. Three youth were prescribed psychotropic medications upon
admission. The DHA was notified upon admission and the youth received an Initial Diagnostic
Psychiatric Interview within fourteen days of admission. Reviewed documentation confirmed
each youth received a medication monitoring/review every thirty days as required and confirmed
there were no standing orders for psychotropic medications, no emergency treatment orders for
psychotropic medication and no pro re nata (PRN) orders for psychotropic medications. During
the annual compliance review week, one medication pass was observed with no noted issues.
The youth was escorted to medical by direct care staff. The Six Rights of Medication
Administration were verified by the registered nurse (RN). The RN administered the medication
as required and did not pre-pour any of the medications. Seven youth were interviewed, and five
reported the nurse gives them medication and two responded they do not take any medication.
An interview with the nurse reported the program’s process to verify a youth’s medication
regimen when a youth is admitted with medication is to complete a prescription verification form
and a call is placed to the ordering physician. The nurse reported the preprinted pharmacy MAR
or standard Department MAR is used, and non-healthcare staff do not provide medications. The
nurse reported medication pass times are daily at 8:00 a.m. and 5:30 p.m. and medications are
procured through a vendor.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 49 of 64 (Revised September 2022)
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program maintains a written policy and procedures ensuring requirements for the storage
and inventory of medications and sharps and ensuring all medication is inaccessible to youth at
the program. It was observed all medical equipment classified as sharps to include syringes,
needles, scissors, and suture removal kits were secured and inventoried utilizing a routine
perpetual inventory descending count as each sharp was utilized and disposed of. All
medications were identified and secured in the locked area designated for storage of
medications. The observed medication cart was clean and organized with stock items separate
from youth-specific medications. All controlled substances had a perpetual inventory and were
stored separately from other medications. All medications were stored in a separate, secured
area which was inaccessible to youth. The program’s practice is to store narcotics on the
secured medication cart behind two locks. Medications which require refrigeration were stored
in a secured refrigerator, which is used for medication only. The program’s process for the
destruction and disposal of medications is for medications to be disposed of with a chemical
agent. Medications are destroyed with a pharmacy consultant and a nurse. The program returns
expired or discontinued medications. Perpetual and weekly inventories of all sharps and stock
over-the-counter (OTC) medications were completed as required. Supervisory-level, non-
healthcare staff were trained in the delivery and oversight of medication self-administration. All
trainings were delivered by a registered nurse (RN). During the week of the annual compliance
review, three OTC medications and three sharps were reviewed, and the inventories were
accurate. The program’s practice when there are count discrepancies is for the nurse to double
check inventory, inform the facility administrator, complete a discrepancy report, and call the
Department’s Central Communication Center (CCC). The program did not have any controlled
medications or narcotics on-site. An interview with the nurse reported medications are disposed
of with a chemical agent and controlled medications are destroyed with the pharmacy
consultant. The nurse reported the program’s practice in securing controlled substances, such
as narcotics, is to always keep controlled substances and narcotics behind two locks.
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 maintains a written Exposure Control Plan. The plan is written in accordance with
Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control
and Prevention (CDC) guidelines. The infection control policy was last reviewed and signed by
the designated health authority (DHA) on November 12, 2024, and the facility administrator (FA)
on November 11, 2024. The plan included procedures for illnesses to include Tuberculosis,
Hepatitis A, B, and C, human immunodeficiency virus (HIV), infectious diseases caused by
blood-borne pathogens, common infectious diseases of childhood, self-limiting, episodic
contagious illnesses, viral or bacterial infectious diseases, other outbreaks or epidemics caused
by any other infectious agent, outbreaks of lice or scabies, Methicillin-Resistant Staphylococcus
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 50 of 64 (Revised September 2022)
Aureus (MRSA) and other anti-biotic resistant microorganisms, food-borne illnesses, bio-
terrorist agents, and chemical exposures. The program maintains procedures for staff to adhere
to universal precautions and the program provides staff with the opportunity for Hepatitis B
immunizations and access to protective equipment. The interviewed nurse reported the program
has not had any instances which required notification to the local county health department,
CDC, and/or the Department’s Central Communications Center (CCC). The Exposure Control
Plan was written in accordance with OSHA standards and was last reviewed and signed by the
DHA on November 11, 2024, and the FA on November 11, 2024. The plan includes a process
for needle stick post-exposure evaluation. If staff experience a needle stick, sharps injury, or
were exposed to blood or other body fluid the procedures include immediate washing of nose,
mouth, or skin flushing with water, irrigation of eyes with clean water or saline, reporting the
incident to a supervisor, and immediately seeking of medical attention. Documentation
confirmed the facility administrator (FA) established a separate file which is maintained for youth
and staff who have experienced a facility/occupational exposure. The program has not had any
reportable infectious diseases since the last annual compliance review. An interview with the FA
reported the Exposure Control and Infection Control Plans are located on the administrative hall
and in the medical office. An interview with the nurse reported a copy of the Exposure Control
Plan is available to medical staff. It was reported the healthcare staff conduct the infection
control and exposure control trainings for staff. The nurse reported upon intake, infection control
training is provided to youth and additional training is provided as needed.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 51 of 64 (Revised September 2022)
Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a written policy and procedures promoting safety and security requiring
staff to maintain active supervision of youth, to interact positively with youth, closely observe
each youth’s behavior, and monitor changes in the behavior. Youth engage in a full schedule of
constructive activities following the programs daily activity schedule. The program staff are
required to account for the whereabouts of youth under their supervision and follow the one-to-
eight- staff-to-youth ratio during awake hours and the one-to-ten ratio during sleep hours. The
off-site transportation and visitation ratio is one-to-five youth. Observations of staff supervision
for four days during the annual compliance review week included line movement, restroom
breaks, and school. Each observation verified staff-to-youth ratios were maintained as required.
Observations of the program’s living units verified the interactions between youth and staff were
positive and appropriate.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program maintains a written policy and procedures addressing the development,
implementation, and training of the program’s behavior management system (BMS). The policy
includes a protocol where staff are trained and provided feedback regarding the implementation
of the BMS. The BMS has not changed since the last annual compliance review, and the system
includes an agreement between the program and the school by training all education staff on
the BMS. Seven staff records were reviewed, and each reflected the staff completed training in
the program’s BMS, and each job description explained the expected job functions related to
implementing the program’s BMS. The system utilizes the iChoose System, which is a
coordinated system of promoting, monitoring, recognizing, and rewarding a youth’s progress.
The system promotes individualized skill building, appropriate behavior, accountability, while
promoting safety, respect, and fairness, protecting youth rights, constructive disciplinary
actions/non-punitive, opportunities for positive reinforcement, recognition of accomplishments,
and positive behaviors at a ratio of four to one, promoting socially acceptable means for youth to
meet their needs, process for explaining to youth the reasons for any sanctions imposed, youth
having the opportunity to explain his/her behavior, staff, and youth to discuss the impact of
behavior on others, reasonable reparations for harm caused to others, discussions of alternate
behaviors, promoting positive dialogue and peaceful conflict resolution, and ensuring separation
of youth from the general population is minimized. The five levels of the BMS include
orientation, junior, varsity, college, and professional. A review of the BMS confirmed it is not
used to increase a youth’s length of stay, deny basic rights or services, promote group
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 52 of 64 (Revised September 2022)
punishment, allow youth to punish other youth, and did not include disciplinary confinement.
Youth earn points daily for abiding by the program’s rules and expectations in school. At the end
of each week, points are totaled, and the youth are rewarded on the total number of points
earned. Seven youth interviews were conducted, and each youth reported the consequences for
negative behavior include a level freeze. Two reported a write up/behavior report. Seven youth
were interviewed about the rewards used in the program, and all stated they could earn
incentives for snacks/canteen. Two youth reported video calls and one youth reported extra
telephone calls. All seven youth were able to explain the difference between each level and how
to move from level to level. Each youth reported staff are consistent in issuing rewards and/or
consequences. Each youth enters the program on an orientation level with hopes to progress to
the next level. During the annual compliance review week the BMS was posted in each living
unit and was accessible to youth. A review of the youth handbook indicated the BMS explains
the rules governing conduct and the positive and negative consequences. Seven youth case
management records were reviewed, and each indicated the youth participated in orientation,
which includes an orientation to the BMS. The assistant facility administrator was interviewed
and reported the program provides training to all education staff with the purpose of including
the use of the BMS during school hours.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a written policy and procedures in place to conduct and document ten-minute
checks during sleeping hours or any time a youth is in the room. The program has seventy
operational cameras. Video records are stored for a minimum of thirty days as required. Staff
are required to conduct room checks every ten-minutes when youth are sleeping. Checks shall
be documented in real time on the ten-minute check log. A review of ten-minute check logs
reflected staff conducted checks within ten minutes documenting the real time and initialing the
check sheet. A review of nine video samples of checks, which included each living unit and
each shift, confirmed staff investigated each youth’s room during the check. Some footage
showed staff utilizing a flashlight. The video footage of ten-minute checks and log sheets
reflected there were no discrepancies, and ten-minute checks were conducted at intervals
between eight to ten-minutes as required by the program. Seven staff were interviewed, and
each staff reported checks are conducted in eight to ten minute intervals. One staff reported
checks are completed randomly as well.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 53 of 64 (Revised September 2022)
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program maintains a written policy and procedures regarding youth census, counts, and
tracking. The policy and procedures require master control to maintain an ongoing count
throughout each day following a system of physically counting each youth. The program’s policy
indicates emergency counts are conducted in the event of a power outage, escape, riot, and
during drills. A review of logbooks for one random day throughout each month of the annual
compliance review period reflected master control documented counts at the beginning of each
shift, after each outdoor activity, during emergency situations, and randomly throughout the day.
Documentation was completed when youth were admitted, discharged, transferred, or
temporarily away from the program. Seven staff were interviewed, and four confirmed counts
are conducted every hour, two stated randomly, and one stated three times a week. The
interview results were provided to the program’s administration. Each interviewed staff
confirmed the emergency count procedure in the event a youth count cannot be reconciled.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a written policy and procedures regarding logbooks and shift reports.
The program maintains a chronological record of events, incidents, and activities in a logbook
documented by the master control staff. Logbooks from the annual compliance review period
were reviewed, and each book was bound with numbered pages. The review of logbooks for
one full day each month for the past twelve months confirmed documentation was completed as
required. All entries were made in ink, no logbook entries were destroyed or missing, there were
no mistakes, each entry included dates, and times of the events with the names of staff and
youth involved. Documentation reflected all internal incidents were reported to the Florida Abuse
Hotline and/or the Department’s Central Communication Center (CCC). Logbook entries
indicated adherence to the daily schedule with minimal interference. Perimeter and security
checks, youth transports, law enforcement requests, removal of any youth from the mainstream
population, admissions, releases, and information regarding escapes or attempted escapes
were included in the logbooks.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 54 of 64 (Revised September 2022)
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program maintains a written policy and procedures for key control. The policy included key
assignment, inventory, tracking, key storage, a procedure addressing missing keys, and the
procedure for reporting and replacement of damaged keys. The distribution and collection of
keys was observed during the annual compliance review week. Observations verified master
control staff collect personal keys from all staff and visitors, in return staff receive a chit and/or
work keys. Staff sign the key logbook, enter the date, key ring number, and time the key was
signed out. This process was confirmed by master control staff. An observation of five keys and
the key logbook confirmed the keys in use were properly assigned to the appropriate staff.
Three staff were informally interviewed, and two staff were able to identify the assigned key
number, the number of keys on the key ring, and the key’s function. One staff was unable to
identify the key number and function due to not normally working the day shift and working night
shift. The master control staff was informally interviewed on the process for restricting usage of
keys such as medical, youth and staff records, and youth property locker keys. The master
control staff confirmed keys are assigned by position, and restricted keys are only authorized for
use by the positions which require them. Staff sign an acknowledgment form indicating a key
identification number and the number of keys issued. The assistant facility administrator was
informally interviewed on the process for reporting and replacement of damaged keys or lost
keys. They reported the program is shut down, there is a two-hour window if keys are reported
lost, and a locksmith is called to change the locks. A review of the Department’s Central
Communications Center (CCC) reports verified there were no incidents relating to key control
reported to the CCC since the last annual compliance review. Interviews with seven staff
confirmed each was knowledgeable of the key control process. Each interviewed staff revealed
turning in their personal keys to master control and being assigned program keys until the end
of their assigned shift. The staff in master control maintains key inventory for each staff while
storing staff’s personal keys.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 55 of 64 (Revised September 2022)
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 written policy and procedures regarding contraband. The program`s policy
addressed contraband, prohibited items, and the consequences when illegal contraband is
found in the possession of youth, staff, or visitors. The policy includes the process of contacting
law enforcement if any item found would be considered illegal as defined in the Florida Statues.
Each youth is provided with a written copy of the youth handbook upon admission into the
program and each are oriented to the program rules including the list of items considered to be
contraband as outlined in Florida Administrative Code. Observations verified the visitors log
contained a contraband attestation statement. Upon hire, staff sign attestation forms regarding
contraband. Eighteen staff were hired since the last annual compliance review, and
documentation verified each staff signed attestation forms. The program delineated items
considered contraband to 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-program issued electronic equipment or devices to include smart watches, personal cellular
telephones, and/or equipment or electronic devices capable of taking pictures or video
recordings. The program’s policy specifies any unauthorized or contraband item is to be
disposed. A review of the Department’s Central Communications Center (CCC) reports verified
there were no incidents related to illegal contraband since the last annual compliance review.
There was an incident reported where staff reported to the CCC another staff was seen wearing
a smart watch and there was no action taken. A review of the program`s logbooks and incident
reports verified the frequency and quality of searches conducted throughout each day.
Unannounced room searches are conducted at least weekly at irregular and unpredictable times
and common area searches are conducted daily. A review of the program’s logbooks, daily
incident reports, and perimeter checks verified searches and program checks are conducted
daily on each shift. The facility administrator (FA) interview verified the contraband practices.
Seven interviewed staff were all knowledgeable of the contraband policy.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 56 of 64 (Revised September 2022)
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a written policy and procedures regarding search procedures. The program
shall perform searches to ensure no contraband is introduced into the program. Full body visual
searches are conducted according to Florida Administrative Code, to include at the time of
admission, after off-campus activities, and after visitation. An intake letter is sent at the time of
each youth’s admission notifying parents/guardians of searches during visitation. Youth
searches were observed throughout the annual compliance review week. Staff were observed
conducting youth searches before each movement, before transport, and following access to
obtain tools and equipment. Observations throughout the annual compliance review week
validated youth are provided instructions regarding the search, searches were conducted by
staff of the same gender as the youth, staff conducted each search in a manner as not to
degrade the youth,and were based on the Right Interactions (RI) training manual. Youth were
treated with dignity and respect minimizing each youth’s stress and embarrassment. Central
control staff were observed conducting staff searches during shift change. Seven staff were
interviewed, and each staff stated youth are searched after each movement. Seven youth were
interviewed and all indicated they are searched at every movement.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a written policy and procedures regarding vehicles and maintenance. The
program has one van to transport youth. Reviewed documentation verified the van received an
annual safety inspection. All maintenance records were documented inside of the program’s
transportation binder. The vehicle included a fire extinguisher, seatbelt cutter, window punch,
and the appropriate number of operating seatbelts. The door to the youth’s passenger area
could not be opened from the inside. The program is moderate-risk; therefore, did not require a
safety screen. First-aid kits with approved items by the designated health authority (DHA) are
kept inside of the master control area until the vehicle is ready for use. Six staff vehicles were
checked to ensure the vehicles were locked when not in use, five vehicles were locked, one was
not locked due to a broken key fob, whereby the staff was unable to lock the car’s door.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a written policy and procedures regarding the transportation of youth. The
policy and procedures included all elements required by Florida Administrative Code. An
informal interview and observations confirmed staff transporting youth are issued a radio and a
program cellular telephone. Staff and youth interviews verified the program’s transport practice
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 64 (Revised September 2022)
stating two staff members complete transports; one drives and the other sits in the back with the
youth. Prior to occupancy, the transport vehicle is searched for contraband. One transport was
observed during the annual compliance review week. Two transportation staff were supervising
the youth, one staff was of the same gender, and a staff was monitoring the youth in the back of
the vehicle following the one-to-five ratio as required. The program does not provide secure
transportation for high-risk and secure maximum-risk youth determined to be at greater risk.
Observations confirmed youth and staff wear seatbelts during transportation. The youth was not
attached to any part of the vehicle other than a seatbelt. The program has a system to ensure
all staff operating a program’s vehicle have a current driver’s license. An informal interview with
the assistant facility administrator (AFA) confirmed human resource (HR) staff track driver’s
licenses and driving record information to ensure the approved staff can continue completing
transports. A list of authorized drivers is posted in the master control area and updated monthly.
Youth are not permitted to drive program or staff vehicles. Seven staff interviews confirmed staff
are provided with a transport telephone during transports. Each staff was knowledgeable of the
emergency response procedures, the vehicle safety equipment, and the proper staff-to-youth
ratios during transport. Seven youth were interviewed, and six stated they have never been
handcuffed to any part of the vehicle. One stated they have never been transported. All youth
stated they never witnessed anyone place contraband in a transport vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a written policy and procedures to maintain a safe and secure physical
plant, grounds, and perimeter, and to conduct weekly safety and security audits. The assistant
facility administrator (AFA) conducts weekly safety and security audits, which are documented
on the Safety and Security Audit Inspection form. Reviewed documentation confirmed weekly
safety and security audits were conducted. Any identified deficiencies were noted on the
reports, including the status due date of any needed corrective action, and were added to the
program's tracker form. A review of the Safety and Security Audit Inspection forms for the past
twelve months indicated inspections were completed as required and documented deficiencies
and repair updates were completed. The program's Preventative Maintenance Checklist was
reviewed, and maintenance schedules and repairs were conducted as needed. A formal
interview was conducted with the facility administrator (FA), who indicated the AFA completes
the weekly safety and security checks.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a written policy and procedures to have a tool management system
which ensures youth do not use tools or equipment as weapons or for security breaches. The
policy addresses equipment and tool issuance, inventory, and control. A review of eleven tool’s
inventory logs and the tool storage room verified tools are securely stored when not in use,
easily marked for identification, and inventoried before work activities. All sharp-edged and
pointed tools, including kitchen tools, are inventoried daily. There is a monthly inventory of tools
which do not have sharp edges or points. Prohibited tools at the program include machetes,
bowie knives, and other long-bladed knives. If a tool is missing or lost, the program's practice is
to complete an incident report, stop all movement, review the camera, and conduct searches to
locate the missing tool. A review of the inventory used to document issuance and return of tools
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 58 of 64 (Revised September 2022)
found no discrepancies. All staff must complete a sign-out and sign-in log when items are taken
and returned to the designated storage room. No dysfunctional tools were disposed of during
the annual compliance review week. Observations of the tool storage area found it was well
organized and secure. Class B tools, including mops, dust pans, and buckets, are maintained in
a locked room inaccessible to the youth. The maintenance staff are responsible for conducting
the inventories and securely maintaining all Class A tools and equipment. The maintenance
staff completes a Daily Tool Log Inventory List, which documents each tool in inventory. All
maintenance tools were inaccessible to youth and were observed to be secured in the tool
storage area.
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 to ensure youth use tools safely and are
supervised appropriately to prevent injuries. The program's policy and procedures included
supervision requirements for issuing tools to youth and staff. Activities involving tools require a
five youth to one staff ratio, and vocational training requires an eight youth to one staff ratio.
Observations of youth in the living quarters using a broom and dustpan confirmed staff-to-youth
ratios were compliant during the annual compliance review week. Additionally, the youth was
searched after work detail and before returning to regular activities. A review of the program's
procedures and documentation verified staff are required to complete a sign-out and sign-in log
when Class B tools are taken and are returned to the designated storage room. Reviewed
documentation confirmed seven youth were trained on the intended and safe use of Class B
tools. Seven youth case management records were reviewed, and risk assessments were
completed prior to youth tool use; however, one youth was not allowed to use any Class B tools
due to only being at the program for less than a month. Youth are prohibited from using Class A
tools. Seven staff were interviewed, and each stated youth are allowed to use mops and
brooms. Seven youth were interviewed, and six reported only using mops and brooms, and one
youth reported not being allowed to use any tools.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a written policy and procedures establishing guidelines for outside
contractors who come on-site to complete repairs. An informal interview with the assistant
facility administrator (AFA) reported the program practice is for each time a contractor arrives to
the program, the individual signs-in, fills out the contractor form, and states what tools are being
brought into the program with a copy of the invoice. After work is completed, tools are checked
and the contractor signs-out. A review of the work project logs since the last annual compliance
review verified all contractors sign the Outside Contractor On-Site Work Project Log, which
includes the vendor's name, date, and time in, a list of tools needed for the job, the beginning
quantity of tools and ending amount of tools, staff name checking the tools, and date and time
out. The program's procedures specify tools are restricted to only the tools needed for the job,
tools are checked upon arrival and departure, and youth are restricted from the work area. The
form states the vendor must report any lost tools to administration immediately. Three reviewed
project invoices showed the project date matched the vendor sign-in sheets. Outside vendors
are accompanied by staff to the work area and youth access is restricted from the work area.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 64 (Revised September 2022)
Staff must supervise vendors in the work area where youth are located. The program's policy
stipulates the facility administrator (FA) is responsible for providing approval and permissions if
a personal cellular telephone and/or equipment/electronic devices capable of taking pictures
and audio or video recordings, including smartwatches, is needed by the contractor.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program's Continuity of Operations Plan (COOP) addresses fire, safety, evacuation
emergency processes, and the frequency of conducting drills randomly and under varied
conditions. Reviewed documentation validated fire drills were conducted for all shifts, each
month, as required. Drill documentation included the type of drill, date and time, participants, a
brief scenario description, deficiencies identified during the drill, and applicable corrective
actions. During the annual compliance review week, observations of the program indicated
there were fifteen annually inspected fire extinguishers, and egress plans are posted throughout
the program. Seven staff were interviewed, and all reported they have participated in fire and
suicide drills since the last annual compliance review. Seven youth were interviewed, and each
reported having been instructed on what to do in the case of a fire. Six youth reported
participating in drills monthly, and one youth reported very often. An interview with the facility
administrator (FA) indicated the program conducts drills monthly.
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 Department approved Continuity of Operations Plan (COOP) which is
available for all staff to review. The COOP is in master control and the supervisor's office and
was last updated annually on April 30, 2024. A review of the plan indicated alternative relocation
sites approved by the Department have been identified should the program require evacuation
due to an emergency or disaster. The COOP provides for primary care and custody of youth in
the event of an emergency or disaster. The COOP addresses emergencies including fire
prevention, bomb threats, evacuations, chemical spills, severe weather, and terrorist attacks.
The equipment and supplies required for continuous operation and services during emergencies
or disasters are in the administration hallway in a blue bin. The bin contains batteries,
flashlights, a garbage bag, tape, radio, tie wrap, and gloves. The program maintains identifying
information on each youth in the program, and if the program must evacuate, the youth record
accompanies the youth to the temporary location. A review of seven hard copy youth case
management records confirmed each contained the youth's name, a photograph, Department
identification number, admission date, date of birth, gender, and race, overall health status,
address, and parent/guardian contact information which included name, address, telephone
number of the person with whom the youth resides and their relationship to the youth, and
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 64 (Revised September 2022)
person(s) to notify in case of an emergency. In addition, the records contained the youth's
assigned juvenile probation officer (JPO), committing judge, state attorney, public defender, and
victim notification contact information. An interview with the facility administrator (FA) reported a
copy of the COOP is maintained in master control and the administration hallway.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains a written policy and procedures to ensure strict control of all
flammables, poisonous, and/or toxic items and materials, and to complete inventories. The
program's assistant facility administrator (AFA) and maintenance manager maintain a
monitoring system to ensure compliance with flammable, poisonous, and toxic items. All
flammable, poisonous, and toxic items such as bleach, cleaners, pesticides, and antifreeze
were secured behind double locked doors in the laundry room, to which youth do not have
access. A review of the flammable, poisonous, and toxic items and inventories verified the items
were securely stored and inventories were accurate. The program maintains a list of all staff
members who are authorized to handle the materials, including the facility administrator (FA),
maintenance manager, assistant facility administrator (AFA), and shift supervisor. A Safety Data
Sheet (SDS) binder is located inside the storage area, and a picture of each material
corresponding to the SDS is shown. A review of the inventory list verified this practice. The
program's maintenance manager, AFA, and the FA are responsible for disposing of unused
flammable, poisonous, and/or toxic materials through a local household hazardous waste drop
off-site when needed. The program maintains chemicals used daily in a locked storage area
inside the program. The program has a Chemical Daily Usage Log to track all toxic materials
when authorized staff use them. Observations of the storage area indicated it is clearly marked
hazardous chemicals, securely locked, and has a posted list of authorized staff. The program’s
procedure for disposing of hazardous waste is with the local bio-hazardous waste contractor. A
review of the Disposal Log indicated the program had not had any chemicals disposed of since
the last annual compliance review. If any chemicals need disposal, the maintenance staff fill out
the Disposal Log sheets and drop off the chemicals at the biohazardous waste station. All liquid
waste from work details is disposed of by pouring the liquid into plumbing drains. Kitchen liquid
waste, except for grease, is disposed of in the kitchen drain. Grease is placed in a separate
container for disposal by an outside vendor. The program has a procedure in place for a
chemical spill. If a chemical spill occurs, the FA, AFA, shift supervisor, and maintenance staff
are notified, the staff shut down the air handlers and ventilation systems, and close all windows
and doors at the direction of the FA. If necessary, assistance from outside the program can be
contacted. An interview with the FA reported disposal is made off-site at the county or city
disposal sites.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 64 (Revised September 2022)
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program shall strictly control 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 are not to clean, handle, or dispose of any toxic, bio-hazardous bodily
fluids, or human waste. Youth are strictly prohibited from the maintenance area where toxic
items and chemicals are stored. Seven youth were interviewed, and each reported being
prohibited from using any chemicals or cleaning products.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 64 (Revised September 2022)
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a written policy and procedures to ensure youth are allowed to receive
visitation and communication with approved family members. The program has a posted
visitation schedule and rules at the front of the program. The program's visitation policy
indicated consideration for requests for alternative visitation arrangements with
parents/guardians if needed. During admission, each youth is provided with the program's
visitation, telephone, and mail policies and guidelines. A review of the logbooks and visitation
sign-in sheets verified the program allows visitation for approved family members. Visitation is
held three days a week on Wednesdays from 6:00 p.m. to 8:00 p.m. and Saturdays and
Sundays from 1:00 p.m. to 3:00 p.m. Youth can write letters or call by telephone at least once a
week to approved family members. A review of the logbooks and visitation sign-in sheets
verified the program allows visitation for approved family members. A review of the telephone
chronological notes verified youth have consistent telephone communication with family
members. An informal interview with the director of case management reported all incoming and
outgoing mail is checked for contraband and given to the youth. A review of the mail logs since
the last annual compliance review showed the youth were receiving and sending mail to
approved family members. None of the reviewed youth had a history of human trafficking.
Seven youth were interviewed and reported being provided opportunities to communicate with
their family members by mail, telephone, and/or at visitation. An interview with the facility
administrator (FA) reported the program offers interpreter services provided by video remote
services.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program provides a variety of recreation and leisure activities. The program has a daily
activity schedule, which reflects each youth receives at least one hour of recreation each day for
leisure activities, including large indoor and outdoor muscle activities. A review of the activities
confirmed they promote social and cognitive skill development, creativity, teamwork, healthy
competition, mental stimulation, and physical fitness. Logbooks were reviewed for the annual
compliance review period, and recreation was documented each day for at least one hour, as
required. The program's contract required a recreation therapist. A review of the staff credentials
confirmed they met contractual qualifications. A review of seven youth Individualized
Performance Plans (IPP) confirmed each youth record contained a wellness plan goal. Seven
youth were interviewed, and each youth reported the program allows youth the opportunity to
play basketball, football, lift weights, and play cornhole. Seven staff were interviewed, and each
reported the youth received one hour of indoor and outdoor activities such as board games,
sports, and working out.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 64 (Revised September 2022)
The program's policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program's policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program's policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 64 (Revised September 2022)

report_type: QI Residential

program_name_raw: Broward Youth Treatment Center