summary: QI Residential - FY23-24 - 5 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Les Peters Academy
TrueCore Behavioral Solutions, LLC.
(Contract Provider)
3930 W Dr. Martin Luther King Jr. Blvd
Tampa, Florida 33614
Review Date(s): July 18-21, 2023
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Alexis Sapp, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Kara Brown, Office of Accountability and Program Support, Deputy Regional Supervisor
(Standard 1)
Monica Gray, Central Region Detention Services, Regional Director (Standard 5)
Cindy Jones, Office of Educational Services, Deputy Director (Standard 2)
Gustavo Mazorra, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Amanda Nelson, Office of Accountability and Program Support, Regional Monitor (Standard 1
and Standard 2)
Jennifer Tummino, Office of Accountability and Program Support, Regional Monitor (Interviews
and Standard 1)
Program Name: Les Peters Academy MQI Program Code: 1282
Provider Name: TrueCore Behavioral Solutions, LLC Contract Number: 10098
Location: Hillsborough County / Circuit 13 Number of Beds: 24
Review Date(s): July 18-21, 2023 Lead Reviewer Code: 207
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
2.20 Educational Access* 1.15 Youth Input
5.16 Fire, Safety, and Evacuation Drills 1.18 Recreation and Leisure Activities
5.06 Logbook Entries and Shift Report Review
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 69 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Youth Input Failed
1.16 Advisory Board Satisfactory
1.17 Staff Performance Satisfactory
1.18 Recreation and Leisure Activities Failed
1.19 Special Contract Conditions Satisfactory
1.20 Contract Specific Career and Technical Education Services Satisfactory
1.21 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 69 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Limited
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 69 (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 69 (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 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 7 of 69 (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 Behavior Management System Infractions and System Monitoring Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Failed
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 Limited
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 for Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Activities Satisfactory
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
5.25 Controlled Observation Non-Applicable
5.26 Controlled Observation Safety Checks and Release Procedures Non-Applicable
5.27 Update
* 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 69 (Revised September 2022)
Program Overview
The Les Peters Academy is a twenty-four bed program, for fourteen to eighteen year old
females, located in Tampa, Florida. The program is operated by TrueCore Behavioral Solutions,
LLC., through a contract with the Department. The program provides the following services:
intensive mental health treatment services with substance abuse overlay services. In addition,
the program fosters each youth by providing Impact of Crime, Teen Relationships, Voices: A
Program of Self Discovery and Empowerment for Girls, Mindfulness Movement, Social
Rhythms, Dialectical Behavioral Therapy (DBT) by Media Therapy, and Matrix Model. Additional
treatment services provided includes individual, family, recreational, and group therapy.
Program administration is comprised of a facility administrator, assistant facility administrator,
director of clinical services, health services administrator, and lead case manager. Case
management services are provided by one lead case manager, one case manager, and one
transitional services manager. Mental health staff at the program includes two licensed
therapists, two non-licensed therapists, one recreational therapist, one contracted psychiatrist,
and one contracted psychologist. Medical services are offered twelve hours a day, seven days a
week and are provided by the health services administrator, two full-time registered nurses, and
a designated health authority. Educational services are provided by the Hillsborough County
School Board. The layout of the program includes one main building, two education portables,
and maintenance sheds. The program has forty-eight security cameras, of which forty-five were
operational providing coverage. At the time of the annual compliance review, the program had
six vacant positions: one transporter, three supervisors, and two youth care worker IIs.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 69 (Revised September 2022)
Strengths and Innovative Approaches
• Youth completed a clothing drive where they assisted in collecting clothing to donate to a
charitable organization at one of the provider’s offices.
• Youth participated in a feeding the homeless community service project initiative, where
they assisted with the assembly of meals and with the distribution of meals to the
homeless in the community.
• Youth assisted in assembling baskets with essentials for distribution to teenage mothers.
• Youth are given the opportunity to participate in a strings program where they learn to
play a string instrument and participates in orchestra concerts for the public off-site.
• If eligible, youth can participate in an academic and career counseling program which
allow eligible youth with the opportunity to begin taking college courses during their time
at the program.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 69 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures in place regarding initial background screenings for
all staff members and volunteers. A review of the program’s staff and volunteer rosters found
twenty staff and twenty-two volunteers were applicable for an initial background screening
during the annual compliance review period. There was documentation to support each staff
and volunteer received a completed and eligible background screening in the Clearinghouse
system prior to their date of hire. None of the staff were applicable for an exemption and
reviewed documentation validated a criminal history report was reviewed for each staff and
volunteer. Each staff and volunteer were added to the program’s roster in the Clearinghouse
system and a pre-employment assessment tool was administered for each direct-care staff. One
staff did not receive a passing score on the pre-employment assessment; however, the program
had documentation to show the staff received a second interview prior to hire. One staff and
three volunteers had a break in service which was documented in the Staff Verification System
module (SVS) and a new background screening was completed for each. The program did not
have any volunteers who assisted or interacted with the youth on an intermittent basis who did
not require a background screen, as all program volunteers are background screened. The
program’s Annual Affidavit of Compliance with Level 2 Screening Standards was completed and
submitted to the Department’s Background Screening Unit (BSU) on December 12, 2022,
meeting the annual requirement. The Annual Affidavit of Compliance with Level 2 Screening
Standards for education staff was completed and submitted to the BSU on December 12, 2022,
meeting the annual requirement.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures in place for completing a background rescreening on
all existing staff members and volunteers every five years after their initial screening date. One
staff was applicable for a five-year rescreening during the annual compliance review period and
received a five-year rescreening within the required time frame. A rescreening was submitted to
the Clearinghouse at least ten business days prior to the five-year anniversary date, as
required.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 69 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures for the provision of an abuse-free environment
including the requirement for any staff who has knowledge of or has a reasonable suspicion a
youth has been in danger of being abused, should immediately report it to the Florida Abuse
Hotline. The policy requires the program youth to be given unimpeded and immediate access to
the Florida Abuse Hotline. If a youth requests to contact the Florida Abuse Hotline, staff should
notify the supervisor who will assist the youth in making the abuse call. Postings for the Florida
Abuse Hotline and the Department’s Central Communications Center (CCC) were observed
throughout the facility during the week of the annual compliance review. Five staff records were
reviewed and each contained a signed Code of Conduct. The program completed the Trauma
Responsive and Caring Environment (TRACE) self-assessment on February 22, 2023. The
program had six allegations of abuse against staff during the annual compliance review period.
None of the six allegations were substantiated; however, an abuse allegation against one staff
was still under investigation at the time of the annual compliance review. Five incidents were
reviewed and each incident was reported, as required. Five youth were interviewed and each
reported feeling safe at the program. Four youth reported knowing where the telephone number
for the Florida Abuse Hotline is posted. The remaining youth stated there is a telephone which
directly dials the Florida Abuse Hotline. One youth reported staff are respectful to the youth, one
youth reported the staff are respectful to the youth except for one, and the remaining youth
reported the staff are sometimes respectful to the youth. One youth indicated they have never
heard a staff member use profanity, two indicated they occasionally hear a staff member use
profanity, and two youth indicated they often hear staff using profanity. Three of the youth
indicated staff do not use profanity directed towards youth and the remaining youth stated staff
use profanity when they are angry or having a bad day. Each youth reported they have never
exchanged contact information or social media with a staff member. Five staff were interviewed
and each reported the youth are allowed unimpeded access to contact the Florida Abuse
Hotline or the CCC as needed and they have never witnessed a coworker tell a youth they could
not contact the Florida Abuse Hotline or CCC. All five staff reported they have never observed a
coworker use profanity when speaking to youth or using threats, intimidation, or humiliation
when interacting with youth. Each staff reported knowing the telephone number for the Florida
Abuse Hotline or knowing where to find it. The facility administrator (FA) was interviewed and
reported general standards of conduct and performance apply to all staff and contractors of the
company. The standards are categorized into three levels such as minor offense, major offense,
and critical offense. Failure to follow a standard of conduct may result in disciplinary action from
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 69 (Revised September 2022)
an oral warning to termination of employment. The severity of the penalty depends on the
frequency and nature of a particular offense. These standards are not all-inclusive; however,
they are intended to be illustrative of the minimum expectations for acceptable work
performance and workplace behavior. The system is progressive and the provider may at its
sole discretion deviate from any order of actions and utilize such form of discipline deemed
appropriate under the circumstances, up to and including immediate termination of employment.
Youth eighteen years of age or older are permitted to contact the CCC upon request to report
incidents of abuse or neglect. Youth who request to contact the Florida Abuse Hotline are
provided with the opportunity to do so immediately upon request. Youth are provided with a
private space to make their report. The FA also indicated the program incorporates trauma-
responsive practices by ensuring each youth has a safety plan created upon admission, which
is reviewed by all staff and is in a general location for staff reference, as needed. All staff are
trained in trauma informative care. The program has formed a TRACE initiative to ensure all
processes and interactions with youth are handled with trauma informed care in mind.
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.
Five reports of abuse against staff during the annual compliance review period were reviewed
and documentation validated the program management took immediate actions to address each
incident. Program management reported each applicable incident to the Florida Abuse Hotline
and/or the Department’s Central Communications Center (CCC), as required, and took
applicable corrective action. None of the reviewed allegations were substantiated; however, an
abuse allegation against one staff was still under investigation at the time of the annual
compliance review. None of the allegations included any potential human trafficking, child
sexual exploitation, or labor trafficking. The facility administrator (FA) was interviewed and
reported if management is made aware of any allegations of abuse, an internal investigation is
immediately initiated. Management will place the staff the allegation is made against on
suspension pending investigation with no youth contact to prevent further incidents/allegations.
Management will contact the Florida Abuse Hotline or CCC as appropriate to make the reports,
as required. Following the completion of investigation or when identified during the investigation,
disciplinary action will be issued following the program’s progressive disciplinary system which
can lead up to termination of employment. The FA indicated one staff had disciplinary actions as
a result of allegations of abuse during the annual compliance review period.
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 reported twenty-nine incidents to the Department’s Central Communications
Center (CCC) during the annual compliance review period. A review of five reportable CCC
incidents revealed each was reported to the CCC within the required time frame. Four of the
incidents were documented in the program’s logbook. The remaining incident was not
documented in the logbook. A review of internal incidents and grievances for the annual
compliance review period found no additional incidents which should have been reported to the
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Office of Accountability and Program Support Page 13 of 69 (Revised September 2022)
CCC. The program experienced an increase in CCCs since the last annual compliance review
period. The program reported the program has experienced an influx of admissions and
transfers resulting in an increase in reportable incidents. Additionally, the disposition of youth
being admitted is trending towards more aggressive and impulsive youth.
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program had ten Protective Action Response (PAR) incidents during the annual compliance
review period, five were reviewed. Reviewed documentation validated the PAR report was
completed by the end of the staff’s workday for each PAR incident. Four of the five PAR reports
included a statement from all involved staff. One PAR report did not include a statement from
one of the involved staff. None of the PAR incidents required the use of mechanical restraints
and none of the PARs resulted in injury to youth or staff. None of the PAR reports resulted in an
allegation of abuse. Each PAR incident report was reviewed by all required staff within the
required time frames and the reports were maintained in the program’s centralized file within
forty-eight hours of approval by the administrator or designee. A post-PAR interview was
conducted for each PAR incident and a PAR medical review was not required for any incident
based on the post-PAR interviews. The program’s PAR plan was updated on January 6, 2023
and approved by the Department on January 12, 2023. The program’s PAR rate during the
annual compliance review period was 0.58, which is below the statewide Residential PAR rate
of 1.22. The facility administrator (FA) was interviewed and reported PAR reports are reviewed
in morning management meetings and reported for tracking in the Morning Meeting Database.
The assistant facility administrator (AFA) of operations conducts a video review of the incidents
to ensure proper PAR procedures were followed, there was no use of excessive force, and a
PAR was a necessary level or response. A PAR Summary Report is completed monthly and
reviewed for trends and submitted to the Department for tracking. Five staff were interviewed.
Three staff reported they have never used PAR. The remaining two staff reported having used
PAR and were both able to explain the program's process and procedures for using PAR.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program has a policy and procedures to ensure all newly hired staff receive the appropriate
120 hours of training. Five pre-service training records were reviewed. One staff was rehired
after a three month period of separation. This staff completed all required annual update
trainings, except information security awareness. Three pre-service staff completed all required
trainings within 180 days of being hired. The remaining staff did not complete one of the
required pre-service trainings. A review of the program’s contract indicated there were no
additional training requirements. All training was entered into the Department’s Learning
Management System (SkillPro). Reviewed documentation validated all instructors who provided
training were trained to deliver the training provided.
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Office of Accountability and Program Support Page 14 of 69 (Revised September 2022)
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a policy and procedures to ensure all staff receive the required in-service
training each year. Five staff training records were reviewed for in-service training requirements.
Each staff completed the required twenty-four hours of training. Two staff completed all required
training except for information security awareness training and the remaining three staff
completed all required trainings. A review of the program’s contract indicated there were no
additional training requirements. Two supervisory staff training records were reviewed and both
staff completed the required eight hours of supervisory training. The program entered all in-
service trainings in the Department’s Learning Management System (SkillPro) for the two
supervisory staff. Trainings regarding mental health were not entered into SkillPro for the
remaining three staff. Reviewed documentation validated all instructors who provided training
were trained to deliver the training provided. The program submitted an in-service training plan
to the Department’s regional director on March 10, 2022. The program has an annual in-service
training calendar, which is updated as changes occur.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures regarding the grievance process including the
informal phase, formal phase, and appeal phase. The informal phase includes encouraging
resolution through informal conversation with staff without discouraging the youth from filing a
grievance. Complaints must be handled as expeditiously as possible but no later than twenty-
four hours from when the youth submitted the complaint (excluding weekends and holidays).
The program utilizes the “Let’s Talk” form for informal grievances. The formal phase of the
grievance process begins when grievance forms are submitted by youth in a box located in the
day room. A response must be given to youth in writing within seventy-two hours (excluding
weekends and holidays). If there is an allegation of sexual abuse or harassment, staff must
notify the youth within forty-eight hours of receipt and follow the appropriate policy. The program
maintained copies of the grievances for the annual compliance review period. Six grievances
were reviewed during the annual compliance review period and each grievance was responded
to within the required time frame. The program’s practice correlated with the program’s
grievance process for each reviewed grievance. Five youth were interviewed. Each youth was
able to describe the grievance process and indicated they can ask for help filing a grievance, if
needed. Five staff were interviewed and each was able to explain the youth grievance process.
Each staff reported there are grievance forms placed throughout the facility. Four staff reported
the facility administrator (FA) reviews grievances. Three staff reported youth can request
assistance in completing the form and the supervisor reviews grievances. One staff indicated
the grievance process has three phases. The FA was interviewed and indicated youth shall be
treated fairly, respectfully, and without discrimination and enjoy all constitutional rights afforded
to them under both state and federal law. Filing a grievance shall not result in retaliation or
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Office of Accountability and Program Support Page 15 of 69 (Revised September 2022)
barriers to services. There is no time limit for youth to file a grievance and there is no
requirement which prohibits youth from filing a grievance without first using the informal
complaint and resolution steps. Youth are encouraged to resolve questions, disputes, and
complaints through informal communication with program staff. A formal, written grievance may
be filed with the grievance officer (assistant facility administrator) at any time. Within seventy-
two hours (excluding weekends and holidays), findings of the grievance officer or designee must
be reviewed to determine whether the unsupported finding is appropriate. If unsupported finding
is appropriate, the grievance form shall be initialed and returned to the grievance officer or
designee for processing with the youth.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program provides interventions to each youth addressing the youth’s needs. The program
provides three non-clinical interventions such as Impact of Crime (IOC), Mindfulness Movement,
and Social Rhythms. Staff who facilitate IOC are required to be case managers who have
completed specific training in IOC facilitation. Five staff facilitated IOC during the annual
compliance review period and each received the required training. One staff who facilitated IOC
is not currently employed in a case management capacity; however, the staff has an extensive
background in case management due to recently being promoted from case management. Only
licensed or clinical staff may provide Mindfulness Movement and Social Rhythms. Eight staff
facilitated Mindfulness Movement and each facilitating staff is licensed/clinical. Ten staff
provided Social Rhythms and all ten staff are licensed/clinical. The program considers education
and experience when hiring for positions which involve intervention implementation. The group
schedule and group sign-in sheets were reviewed for Social Rhythms and Mindfulness
Movement and supported groups are being provided as required and outlined in the contract
table. IOC is a primary group, which is reviewed by Standardized Program Evaluation Protocol
(SPEP). The program’s activity schedule was reviewed and supports the program is providing
structured planned programming or activities for at least sixty percent of the youth’s awake
hours. The facility administrator (FA) was interviewed and indicated IOC is a restorative justice
group provided to all youth who enter the program prior to release. Within the group curriculum,
community service activities are designed to assist with applying the discussions. In addition,
community service activities are completed on-site and off-site to engage the youth in giving
back to their communities. Youth have participated in collecting clothing and hygiene products
to donate to the homeless and completing community service projects off campus with a local
organization. The designated mental health clinician authority (DMHCA) was interviewed and
reported services are provided by licensed eligible, masters-level therapists. There are currently
two licensed eligible therapists, a licensed assistant director of clinical services, and a licensed
director of clinical services. Based upon the findings of the comprehensive evaluation, youth
shall have an Individualized Treatment Plan developed which include service provision for all
identified treatment needs. Treatment interventions and frequency are specified on the plan. A
review of current services, as well as service needs, is based upon the findings of the
comprehensive evaluation. A review of current services, as well as service needs, is conducted
within monthly multidisciplinary treatment team meetings for each youth. At a minimum, youth
are provided weekly individual sessions, monthly family sessions, and daily group therapy
sessions to include specialized mental health group services. If a youth has an identified
substance abuse treatment need, services shall be specified on the treatment plan and provided
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on a weekly basis. Therapists are assigned to group therapy services which are identified on the
intervention service schedule maintained by the director of clinical services. The therapists
document these services in daily progress notes and complete a summary of services and
progress weekly. These notes are provided to and reviewed by the director of clinical services
or designee. The director of clinical services or licensed designee co-completes the substance
abuse portions of the comprehensive evaluation and co-signs comprehensive evaluations,
Individualized Treatment Plans and Treatment Plan reviews. These items are tracked by the
director of clinical services or designee to ensure completion. Daily management meetings are
conducted each weekday morning with the management team to review documentation and
program services to include clinical services. All clinical staff participate in clinical supervision
weekly facilitated by the director of clinical services or licensed designee in which clinical
services are reviewed. As part of the quality improvement process, both regional staff and the
director of clinical services monitor youth records and complete fidelity checks to ensure
services are being provided to the youth in accordance with the curriculum standard as well as
with their individualized treatment needs.
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 policy and procedures which ensure interventions or instruction
focusing on developing life and social skill competencies in youth are provided. The program
incorporates these services into the daily schedule and through clinical groups. These services
address communication, interpersonal relationships and interactions, non-violent conflict
resolution, anger management, critical thinking, and address the needs of the program’s
targeted gender group. The Daniel Memorial assessment, and Skill Plans are provided by case
management. Daniel Memorial Skill Plan completion certificates were reviewed and
documentation supported the life skills services were provided, as required. Each youth
receives the Daniel Memorial Assessment, where youth take a test and a skill plan is developed
according to the results. The program conducts a weekly group on life skills with all youth on
topics such as money management, job readiness, and communication. Several of the
program's clinical groups incorporate a life skills component. To level up in the program, youth
have to show progress in all areas. Five youth were interviewed and each was able to name
groups/activities they participated in at the program. Three youth reported participating in Impact
of Crime, three reported participating in Voices, one youth reported participating in the youth
advisory board, and one youth reported participating in my movement, substance abuse
services, Dialectical Behavior Therapy (DBT), and family day. Four youth indicated participating
in Voices for their gender-specific programming and the remaining youth reported they are not
sure what their gender-specific programming is. The facility administrator (FA) was interviewed
and reported mental health group is provided seven days a week and facilitated by trained
clinicians and licensed therapists. Delinquency groups are facilitated by case management two
days a week. The designated mental health clinician authority (DMHCA) was interviewed and
reported the youth have opportunities to travel to community organizations/events, as well as
participate in extracurricular activities within the facility through outside organizations in which
they can utilize therapeutic skills and interventions. Further, youth are able to practice coping
strategies on a daily basis throughout general milieu situations/interactions with peers and staff.
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1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program has a policy and procedures for the provision of restorative justice awareness to
youth. The program’s contract identifies Impact of Crime (IOC) as the required restorative
justice service provided to all program youth. IOC is a primary service at the program. In
addition to IOC, the program incorporated restorative justice activities. The youth were able to
participate in on and off-campus activities to include a clothing drive, feeding the homeless
community service project, string instrument concerts, fundraisers, a basket making fundraiser
for teenage mothers, and a guest speaker. An IOC group was observed which had the proper
youth, proper staff, and was the proper length. Five youth were interviewed and each reported
participating in IOC. The facility administrator (FA) was interviewed and indicated the youth are
required to participate in IOC unless they have already completed this curriculum during their
commitment due to a transfer into the program. The FA also reported youth volunteer at various
community events which allows them to make reparations while learning ways the community
can assist them. The FA indicated youth have participated in a clothing drive for a church,
fellowship and volunteering for a church, feeding the homeless, fundraisers, a car wash, a hair
supply donation, college courses for youth, making baskets for teenage mothers, making
donations to an animal shelter, staff field day, strings concerts for the public, volunteering at
family day, and volunteering at a race. The designated mental health clinician authority
(DMHCA) was interviewed and reported the program’s mental health groups include
Mindfulness Movement, Social Rhythms, and Dialectical Behavior Therapy (DBT). The
specialized groups include Matrix Model (substance abuse), Teen Relationships, and VOICES
(gender-specific).
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures which outlines how staff identify, document, and
update alerts, and how alerts are communicated to staff. The program has an alert board in the
staff duty station, which documents all youth alerts. The program utilizes a Medical Alert Log to
document medical related alerts. Alerts were reviewed for five youth. A review of alerts entered
in the Department’s Juvenile Justice Information System (JJIS) were consistent with the
program’s internal alert system for two youth. The remaining three youth each had one alert in
JJIS which was not on the alert board. This was remedied by the program during the annual
compliance review. All required alerts were documented in the logbooks. The facility
administrator (FA) was interviewed and reported the program utilizes an internal alert system to
include an alert roster and alert board which details all applicable youth alerts. Any change in a
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youth's alert status is updated on the board as well as documented in the shift logbook. The
outgoing shift supervisor will brief the incoming shift of any new/changed alerts. In addition, any
change/new alerts are discussed during morning management meetings. The internal alerts are
reviewed daily and updated, as needed. All internal alert trackers are reviewed on a weekly
basis during morning management meeting for fidelity monitoring. The nurse was interviewed
and reported medical alerts are updated by a registered nurse or a licensed practical nurse.
Five staff were interviewed. Four staff were able to explain how they are notified of youth alerts.
The remaining staff reported being unsure how staff are notified of alerts.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains separate case management, mental health, and Individual Healthcare
Records. Five youth case management, mental health, and Individual Healthcare Records were
reviewed and all records included all required information. All records were maintained in locked
file cabinets within the responsible program area’s office and inaccessible to youth. Each file
cabinet containing official youth records was clearly labeled as “Confidential.”
1.15 Advisory Board Failed Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a community advisory board (CAB). There has not been a CAB meeting
during the annual compliance review period. The last meeting was held on June 22, 2022. The
CAB does not have a representative from the judiciary community and there have been no
attempts to solicit one during the annual compliance review period. The facility administrator
(FA) was interviewed and reported the FA maintains the CAB requirements. CAB meetings are
held quarterly and include review of an agenda detailing program updates and CAB member
updates. Following each meeting, meeting minutes are shared with all board members to inform
those who may not have been present. Recruitment letters are mailed out periodically to solicit
new membership and ensure each position on the board is properly represented. An advisory
board member was interviewed and reported there has not been any meetings this year, but in
the past, they have attended two CAB meetings and discussed ideas for activities for youth.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures regarding staff performance. The policy requires
program staff to be evaluated on their performance at least annually and more if deemed
appropriate. Five staff personnel records were reviewed and each staff received an annual
performance evaluation, as required, which is based on established performance standards. In
addition, a review of position descriptions for five staff revealed each staff’s performance
standards were clearly identified and the performance standards matched the job descriptions.
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The facility administrator (FA) was interviewed and reported the program has experienced
turnover in each department this past year. There is a trend of staff moving on for promotion
purposes and some turnover in direct-care staff. The FA stated the program is dedicated to
ongoing recruitment and staff retention. Overall, the focus is always to fill vacancies; however,
there has been a great focus on maintaining the current staff with emphasizing staff moral and
engagement. The program hosts spirit weeks, staff outings, and on-campus socials to improve
the morale and boost staff engagement. Five staff were interviewed. One staff rated
communication amongst staff at the program as very good, one staff rated communication as
good, and the remaining three staff indicated communication amongst staff was fair. One staff
reported receiving yearly formal evaluations and one staff reported receiving evaluations
monthly. One staff reported receiving daily feedback on their performance, one staff reported
coaching is given as needed, and one staff reported being at the program for a short period of
time.
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.
A review of the program’s contract and Memorandum of Negotiation (MON) reflected the
program is required to provide home like furniture or clothing to youth, community involvement
opportunities, religious/spiritual opportunities, and self-sufficiency planning. Additionally, the
program shall have certain stock medications to include two boxes of epinephrine auto-injectors,
at least one vial of insulin, two boxes of albuterol inhalers, at least one vial of tuberculin purified
protein derivative, and at least one Glucagon, glucose tablets, or glucose tubes. The program
was short one box of epinephrine auto-injectors, one box of albuterol inhalers, and one vial of
insulin. The annual compliance review team contacted the Department’s Office of Health
Services (OHS) who stated insulin and albuterol is patient-specific and should not be kept as
stock medications. Additionally, OHS stated this program does not service youth who need
these types of stock medications. The program has home like furniture/clothing throughout the
program. The program provides multiple opportunities for religious/spiritual services to include
bible study, off-site church services, and faith-based mentors. Youth’s religious preferences are
determined during admission and any requests for religious services are provided to youth of all
religions/spiritual preferences. The program provides opportunities for youth to complete
community service hours and participate in community involvement activities at the program and
off-site. During the annual compliance review period, youth participated in fundraisers, gift
baskets for pregnant youth, and donations for local animal shelters. Youth also went off-site to
participate in local charity events and to feed the homeless. Documentation confirmed self-
sufficiency planning. A review of five open and three closed youth records reflected youth
received self-sufficiency goals in their performance and/or transition plans, received career and
technical services through the Daniel Memorial curricula, and two applicable youth received
assistance with independent living and housing. An interview with the facility administrator (FA)
stated youth receive traditional and non-traditional vocational services through the local school
district. An informal interview with the program’s regional compliance manager confirmed self-
sufficiency planning, religious/spiritual opportunities, and community involvement opportunities.
Five interviewed youth stated they were not applicable for special contract conditions.
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1.18 Contract Specific Career and Technical Education Services Failed Compliance
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
Pre-vocational and vocational instruction shall be provided so the interests, aptitudes, and skills
of youth are developed, while building upon their existing strengths in a manner supportive of
their employability and providing an occupational advantage in their own community. Program
provides career and technical education appropriate for the age of youth in the program, length
of stay, and classification of the youth in the program. A review of five active and five closed
case management youth records confirmed the program administers the Daniel Memorial
Assessment to every youth upon admission to determine youth vocational skill level and needs.
The program is required to provide the Life-Centered Education (LCE) curricula to youth. The
program did not provide LCE to youth during the annual compliance review period.
Youth receive pre-vocational and vocation instruction through a personal, career, development
class provided by the local school district. An informal interview with the lead teacher confirmed
these services were provided during the traditional school calendar year; however, this course is
not being provided during the summertime so youth can focus on credit recovery.
A review of five closed youth case management records confirmed youth are receiving a variety
of career and technical certifications to include cardiopulmonary resuscitation (CPR), first-aid,
and Certified Logistics Associate in manufacturing (CLA). Each reviewed youth record
contained documentation to support the youth completed a Daniel Memorial Skill Plan, CPR
certification, a personal career development class, and first-aid certification. Two youth received
assistance with independent living housing. One youth completed Understanding
Developmentally appropriate Practices, and one youth completed Child Care Facility Rules and
Regulations. The program provided a sample of youth who completed a CLA in manufacturing
Documentation confirmed instructors are qualified to provide instruction for these certifications.
Five youth were interviewed about career and technical education services in the program. One
youth stated they were “kitchen certified”, one youth stated they had graduated and were taking
a college course in “Intro to Entrepreneurship”, one stated they were in twelfth grade, and two
youth stated they were not receiving career and technical education services because they were
too young. One youth stated they are participating in career and technical education daily, one
youth stated they had to study and take a test for career and technical education, one youth
stated “nope” when interviewed on how often they receive these services, and two youth stated
non-applicable due to their age. The one youth who stated they were not receiving services
stated they did not know why they were not receiving services. An interview with the facility
administrator confirmed the program works in conjunction with the local school district regarding
specific pre-vocational and vocational services. The program has also incorporated Project
Anchor to provide specific job-related certificates.
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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 number of tools which are utilized for the purpose of data collection and
analysis. Aggregate data is accumulated by program dashboards, electronic records system,
survey completion, and use of the Department’s Juvenile Justice Information System (JJIS).
The program provided a summary of each tool such as the dashboard, electronic records
system, JJIS, surveys and analysis, and data usage and how the data is utilized. Process and
outcome measures collected and monitoring cover multiple aspects of the following program
components: operations (census, intakes, releases, transports, abuse calls, incidents, physical
interventions, use of controlled observation, grievances, behavior management milestones,
such as "average youth making day"), mental health (mental health alerts, precautionary
observation, secure observation, Baker Acts, one-to-one contact, number of missed services),
health services (youth injuries, medication refusals, emergency care, youth on psychotropic
medications, hospitalizations), support services (youth disciplinary hearing, special treatment
teams, number of special treatment teams, number of major/minor deficiencies), and human
resources/business (staff vacancies, staff injuries, worker's compensation, call offs).
Dashboards are updated every Monday with the previous week's data, which is available
electronically to staff at all times. Information is shared with staff and administration during the
morning management meetings, which are held daily, and during monthly all staff meetings
which encompass all aspects of the process and outcome measures mentioned above. A
review of the General Staff Meeting sign-in sheets and agendas confirmed the monthly staff
meetings were held. Three Morning Management Meeting sign-in sheets were reviewed and
confirmed the daily morning management meetings were held. Additionally, the program utilizes
anonymous youth, family, and staff surveys through a survey providing website. Surveys are
conducted and results are extracted and analyzed quarterly. Results are analyzed and guide the
programs to action plans which affect all aspects of programming. The program provided three
blank staff, youth, and parent/guardian surveys which were reviewed. Additionally, a sample of
one completed staff, youth, and parent/guardian surveys were reviewed, which were sent to the
program from corporate confirming information sharing on a quarterly basis. The movement of
data fluctuates freely through multiple management levels. Data is evaluated for both risk and
protective trends as well as for forecasting trends which can impact compliance or
programming. Additionally, trends are reviewed for possible policy changes or, if necessary,
ancillary trainings. Revised policies and survey results are discussed with facility administrators
during their one-to-one meetings with senior leadership and then with all staff during monthly all
staff meetings.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures to notify each youth’s parent/guardian by telephone
within twenty-four hours and in writing within forty-eight hours of each youth’s admission into the
program. The policy further requires the program’s assigned case manager to send written
notification and specific program information to the youth’s committing judge, juvenile probation
officer (JPO), and post–residential service case manager when applicable within five working
days of any youth’s admission into the program. Five youth case management records were
reviewed and each contained documentation indicating the youth’s parent/guardian was notified
by telephone within twenty-four hours of the youth’s admission to the program. All five youth
case management records included documentation reflecting the youth’s parent/guardian was
notified, in writing, within forty-eight hours of the youth’s admission into the program. Each
record included written notification to the committing judge and JPO within five working days of
the youth’s admission into the program. None of the reviewed youth were applicable for written
notification to the post–residential service case manager.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to address the youth orientation process. The
program provides an orientation to each youth on the day of admission. The program provides a
youth handbook which includes a more detailed description of program services and guidelines.
A review of five youth case management records found the program provided an orientation for
each youth on the day of admission. Each applicable record included documentation indicating
the youth completed the orientation process which included all required elements, upon
admission. The program did not have any admissions to observe during the week of the annual
compliance review. Five interviewed youth confirmed receiving an orientation to the program on
the day of admission into the program. Four of the five interviewed youth confirmed orientation
included program rules, procedures, schedules, and other pertinent information. The remaining
youth stated they had to learn this information on their own and had to request a youth
handbook. Documentation confirmed the youth signed an orientation checklist confirming they
had received an orientation on all required elements.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures to address consent for youth who are eighteen years
of age or older. Written consents are required for any youth eighteen years of age or older prior
to providing or discussing any information with the youth’s parent/guardian. One of the five
reviewed youth case management records was applicable for youth eighteen years of age or
older. A review of the youth’s record found a consent form signed by the youth prior to any
release of information. The program reported not having any additional applicable youth during
the annual compliance review period for consent of youth eighteen years of age or older.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a policy and procedures outlining the classification process for youth upon
admission to the program and completion of reassessments, as necessary. The program utilizes
a classification system to promote safety and security for which a youth’s classification is
determined by their individual needs and identified risk factors. A review of the program’s
classification form validated the form included all required elements. A review of five youth case
management records found documentation indicating each record contained an admission
classification form including all required elements outlined by the Department’s policy. A review
of the Department’s Juvenile Justice Information System (JJIS) confirmed a new Victimization
and Sexually Aggressive Behavior (VSAB) was completed and entered prior to each youth’s
room assignment for three of the five reviewed youth. The remaining two youth’s VSABs were
completed late. One VSAB was one day late and the other VSAB was fifteen days late. Each
applicable youth was classified for the purpose of assignment to a living area, sleeping room,
and group. The program maintains a constant updated internal alert system in JJIS
documenting any medical, mental health, substance abuse, security risk factors, and/or special
needs identified during or subsequent to the classification process. The program also maintains
an alert board in the staff duty station, which is updated as needed. The program’s policy and
procedures also address reassessment and reclassification of youth prior to an increase of a
youth’s privileges or freedom of movement, participation on work projects or other activities
which involve the use of tools, or a youth’s participation in any off-campus activities. One of the
five reviewed youth case management records was applicable for a reassessment. Two more
records were requested for reassessments. All three youth case management records included
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documentation for the reclassification of the youth prior to engaging in certain activities. An
interview with the facility administrator confirmed the program’s practice.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures to address gang identification including notification of
law enforcement. Five youth case management records were reviewed. One of the five
reviewed youth case management records was applicable for notification to law enforcement of
suspected gang association. The program confirmed there were no other youth applicable for
gang notification during the annual compliance review period. The one applicable youth case
management record confirmed the program notified local law enforcement and the youth’s
home county law enforcement in writing of the youth’s gang status. Documentation confirmed
gang information was shared with the educational staff at the program and the youth’s juvenile
probation officer. The youth was not applicable for notification of a post-residential services
counselor. The program identifies youth who are suspected gang members at intake and enters
any applicable alert in the Department’s Juvenile Justice Information System (JJIS). Reviewed
documentation reflected gang alert was maintained in JJIS and updated, as required.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures to address a youth’s participation in gang prevention
and/or intervention activities. The program utilizes the ARISE curriculum and Impact of Crime
intervention groups as part of the gang prevention and intervention curriculum. Five youth case
management records were reviewed and one was applicable for participation in gang
interventions. No other youth were applicable for gang intervention during the annual
compliance review period. The applicable youth’s Individualized Performance Plan included
relevant goals and objectives related to gang intervention strategies for the youth to complete
prior to release from the program. The program maintains sign-in sheets to document youth
participation in gang prevention and intervention activities. An interview with the facility
administrator confirmed the program’s gang intervention and prevention strategies.
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2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures to ensure a Residential Assessment for Youth (RAY)
is completed for each youth within thirty days of admission. A review of five youth case
management records indicated each record contained a RAY which was completed within thirty
days of admission. Each initial RAY assessment was maintained in the Department’s Juvenile
Justice Information System. All five youth were applicable for reassessments. Each record
documented RAY Reassessments were completed, as required. Each initial RAY and
reassessment were located in the youth’s case management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
The program has a policy and procedures to address the completion of a Youth Needs
Assessment Summary (YNAS) within thirty days of each youth’s admission. Five youth case
management records were reviewed for completion of a YNAS. Each record contained a
completed YNAS within thirty days of the youth’s admission into the program and documented
in the Department’s Juvenile Justice Information System.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a policy and procedures addressing the development of the intervention and
treatment plan. The treatment team members, including the youth, meet to develop an
Individualized Performance Plan (IPP) based on the findings of the initial assessment of each
youth within thirty days of the youth’s admission. Five youth case management records were
reviewed. Each reviewed youth record documented the IPP was developed within thirty days of
the youth’s admission and completed after the initial Residential Assessment for Youth (RAY).
Each reviewed IPP was developed and signed by the treatment leader, youth, treatment staff,
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and all parties who have significant responsibility in goal completion. Each of the five completed
IPPs were mailed to the parent/guardian. Two of the five youth records included signature
sheets, which were returned and attached to the original IPP. Three youth’s IPPs were mailed to
the parents/guardians; however, the signature sheets were not returned. Each reviewed IPP
included the youth’s individualized goals, specific delinquency interventions with measurable
goals, based upon the prioritized needs reflecting the risk, and protective factors identified
during the initial assessment process, to include delinquency interventions, recreation plan,
identified transition activities, youth’s responsibilities to accomplish goals, program staff
responsibilities to enable youth to complete goals, and target dates for goal completion. Four of
five youth’s IPP’s contained youth’s top three criminogenic needs. The remaining youth’s IPP
contained two of the top three criminogenic needs. Documentation confirmed reason why the
other criminogenic need was not used. When applicable, court-ordered sanctions which can be
initiated and/or completed while the youth is in the program were documented. None of the
reviewed youth were in the care of the Department of Children and Families (DCF) upon
creation of the initial IPP. All five IPPs were sent to each youth’s committing court judge,
juvenile probation officer (JPO), and parent/guardian within ten days of completion. Five youth
were interviewed and each reported they participated in the development of their performance
plan and were knowledgeable of their current performance plan goals. One of five interviewed
youth stated they received a copy of their performance plan. The remaining four youth stated
they did not have a copy of their performance plan. The program stated they would provide
each youth who stated they did not have a copy of their performance plan with a copy of their
plan.
2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
The program has a policy and procedures in place regarding revisions to a youth’s performance
plan. The treatment team may revise the youth’s Individualized Performance Plan (IPP) based
on the Residential Assessment for Youth (RAY) Reassessment results, the youth’s
demonstrated progress or lack of progress toward completing a goal, or newly acquired or
revealed information. Five youth case management records were reviewed and all were
applicable for IPP revisions. Each record reflected revisions were completed according to the
RAY Reassessment results and newly acquired/revealed information. Four of five records
reflected progress towards completing a goal. One youth was applicable for demonstrating lack
of progress toward completing a goal. Four of five youth IPPs were revised due to facilitating
transition activities during the last sixty days of the youth’s stay.
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2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a policy and procedures in place regarding the completion and transmittal of
Performance Summaries for each youth at ninety day intervals, beginning ninety days from the
signing of the performance plan, or at shorter intervals when requested by the courts. Five youth
case management records were reviewed. Each youth case management record was
applicable for the completion of at least one performance summary and transmittal. Each
youth’s record included Performance Summaries which were completed within ninety days of
the completion of the initial performance plans. Each Performance Summary included all
required elements. Each applicable record contained signed documentation confirming the
youth read and was allowed to add comments to their Performance Summaries. Each youth
was provided a copy of the signed summary. Each Performance Summary was signed and
dated by the treatment team leader, staff member preparing the summary, facility administrator,
and the youth. Each reviewed record contained documentation to support each Performance
Summary was sent to the youth’s committing court, juvenile probation officer (JPO), youth,
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 contained a copy of the signed original summary sent to the
JPO along with the Pre-Release Notification (PRN) at least forty-five days prior to the youth’s
anticipated release date or a discharge summary, if a direct discharge. Each summary
contained a justification for release. The program provided written notification each youth’s
parent/guardian of 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 notification to a victim.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to provide parent/guardian involvement in case
management services. The program makes efforts to include the parents/guardians in the
assessment process, participation in the development of the youth performance plan, progress
reviews, formal treatment team meetings, and transition planning. An interview with the facility
administrator validated the program’s practice. Five youth case management records were
reviewed. In each of the case management records, documentation reflected the case manager
sent an admission letter to the parent/guardian, which included the dates and times for the
youth’s treatment team meetings. If parent/guardians are unable to attend the meetings in
person, they are afforded the opportunity to participate by telephone or conference call or can
provide verbal or written input prior to the meeting. Five reviewed youth case management
records confirmed the parents/guardians participated in the assessment process and
development of the youth’s Individualized Performance Plans, progress reviews, formal
treatment team meetings, and transition planning, when applicable. An observation of a
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treatment team during the week of the annual compliance review confirmed the parent/guardian
participated in the treatment team meeting. Five interviewed youth reported their
parent/guardian are involved in their case management services.
2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
The program has a policy and procedures for the intervention and treatment team to reference
or incorporate each youth’s treatment plan into the youth’s Individualized Performance Plans
(IPPs). Five reviewed youth case management records validated each youth’s IPP incorporated
the youth’s education and wellness plans. Each applicable record had separate mental
health/substance abuse treatment plans, all of which were referenced in the IPPs. The goals
included the responsibilities of the program staff in assisting the youth to successfully complete
the goal(s). One of the five reviewed youth was applicable for involvement with the Department
for Children and Families (DCF). The program provided one additional youth case management
record for DCF involvement for a total of two records. There were no other DCF involved youth
for the annual compliance review period. Each youth’s DCF plan was incorporated into the IPP.
There were no youth applicable for Agency for Persons with Disabilities (APD) during the annual
compliance review period.
2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
The program has a policy and procedures outlining treatment team meeting requirements. The
program’s policy requires the treatment team to meet every thirty days to formally review each
youth’s performance to include Residential Assessment for Youth (RAY) Reassessment results,
progress on Individualized Performance Plan goals, and positive and negative behavior
including behavior which resulted in physical interventions. Five youth case management
records were reviewed and each included documentation reflecting formal treatment teams
were held once every thirty days. Each record contained documentation supporting informal
treatment team meetings were held biweekly to review the youth’s performance, progress on
Individual Performance Plan goals, behavior, and individual treatment plan, as well as to review
RAY Reassessment results, when applicable. Each youth’s record reflected formal treatment
team and informal treatment team documentation included all required elements. All required
parties were present either in person or by telephone during the formal and informal treatment
team meetings. During the annual compliance review, an observation of treatment team
meetings was conducted. All required program participants were in attendance or provided
written input. There was a review of the Individualized Performance Plan to determine
anticipated release dates. Youth was observed demonstrating skills acquired in the program.
Five youth were interviewed and each youth indicated staff review performance plans and
update, as needed. Four of five youth stated they were provided the opportunity to demonstrate
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skills acquired in the program. The remaining youth stated they are not provided an opportunity
to demonstrate skills acquired in the program; however, documentation in case record reflected
the youth being provided an opportunity to demonstrate skills acquired in the program.
2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a policy and procedures addressing transition planning conferences and
Community Re-Entry Team (CRT) meetings being conducted sixty days prior to the youth’s
target release date. A review of three closed youth case management records found the
program held a Transition Conference at least sixty days prior to each youth’s anticipated
release date. The program invited all required members to the transition meetings through mail
correspondence or email. The Transition Conferences were attended by the youth,
parent/guardian, juvenile probation officer, facility administrator, treatment team leader, and
other treatment team members. None of the reviewed youth records required a human
trafficking specific service provider. During the Transition Conferences, the team discussed all
required topics including transition activities, completion dates, and parties responsible for
completion of goals. All attendees signed each Transition Conference form and the forms were
mailed to all parties for their signature. There was documentation in each record to reflect a
CRT meeting invite and confirmed the CRT meeting was conducted prior to the youth’s release.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures outlining the requirements of the Exit Portfolio. Three
closed youth case management records were reviewed and documented each youth’s Exit
Portfolio was discussed during the Transition Conference. Each Exit Portfolio contained a
transition plan, calendar with all dates, time, and locations of the youth’s upcoming community
appointments, educational and/or vocational certificates, educational records, transcripts, and
résumé. One of three youth records contained a sample employment application. The remaining
two youth completed a sample application through an online job search database and the
program was unable to print a copy of the application. Two of three youth Exit Portfolios
included a state issued identification card, birth certificate, and social security card. One youth’s
Exit Portfolio did not include a state identification card, birth certificate, and social security card
due to the parent/guardian not providing the requested documents to the program. The program
reported they requested the required documentation from the parent/guardian. Documentation
confirmed multiple requests from the program to the parent/guardian for the requested
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documents. Each youth’s Exit Portfolio included signed documentation indicating each youth
was given a copy of the Exit Portfolio upon release from the program. All three youth closed
case management records included documentation the program staff forwarded the Exit
Portfolio information to the juvenile probation officer. The program’s contract does not require
any additional requirements for the Exit Portfolio.
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures to ensure an Exit Conference is conducted to
coordinate release procedures and prepare each youth for re-entry back to the community.
Three closed youth case management records were reviewed. Each record documented an Exit
Conference was conducted at least fourteen days prior to the youth’s release date. Each Exit
Conference was conducted after the juvenile probation officer (JPO) was notified of the release.
Each record had documentation indicating the Exit Conference date, signatures, and a
summary of pending transition goals. Each record had documentation to confirm the treatment
team leader, parent/guardian, education representative, therapist, JPO, youth, and other
pertinent parties participated during the Exit Conference. Each record had documentation
reflecting the status of transition activities and finalized plans for the youth’s release. The date of
admission and date of release correlated with the Department’s Juvenile Justice Information
System for each youth. Each Exit Conference was held separate from the Transition
Conference and Community Re-Entry Team meeting.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program maintains a policy and procedures to encourage formal constructive input by
youth. The program has a youth advisory board to promote a formal process for youth to have
constructive input regarding the program. Youth advisory board meetings are held biweekly and
address issues initiated by youth in the program. Agendas, sign-in sheets, and minutes are
maintained in a binder for the youth advisory board. Documentation confirmed youth advisory
board meetings were held as required during the annual compliance review period, except for
August 2022 when no meetings were held. The program also utilizes quarterly youth surveys,
daily meetings, Trauma Responsive and Caring Environment (TRACE) assessment, and My
Voice Matters forms to solicit youth input. Five youth were interviewed on how they provide
input about what is happening at the program. Two youth stated they provided input through the
youth advisory board, one stated they complete surveys, one stated they can provide input
during the daily meeting, and one utilizes My Voice Matters. An interview with the facility
administrator stated the program’s formal process to solicit input from youth is provided through
My Voice Matters, grievance forms, daily meetings, and youth advisory board.
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2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program maintains a written policy and procedures to provide career education. The
program offers type two career education to all youth which includes personal accountability
skills and behavior appropriate work habits for employment. Programming incorporates
communication, interpersonal skills, and decision-making skills. Five closed youth case
management and education records were reviewed. All five records contained a résumé which
were uploaded into a job search website. Only one record included a completed job application.
however, the transition manager indicated all youth complete job applications specific to their
home locations through a website which assists with employment opportunities. All records
contained a local Career Source Center’s address and hours of operation, as well as a copy of
the youth’s state of Florida identification card. The facility administrator was interviewed and
indicated youth are provided cardiopulmonary resuscitation (CPR) and serve safe certificates. If
there is a need, the program will work with Project Anchor for post-secondary and/or needed
technical certificates. The lead educator was interviewed and indicated youth are administered a
career assessment upon entering the program.
2.20 Educational Access (Critical) Limited Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide educational access for the youth.
Educational services are provided through the Hillsborough County School District which
approves the 250 day school calendar. A review of the daily education schedule revealed youth
are provided with a minimum of twenty-five hours of instruction each week, incorporating six
fifty-minute class periods, as indicated on the daily school schedule. The 250 day calendar
includes 240 days of instruction and ten days for training or teacher planning throughout the
school year. The lead educator indicated the daily schedule is followed with minimal
interruptions. Eight randomly selected logbook entries were reviewed, covering five different
months during the annual compliance review period. All reviewed days showed the youth were
following the daily school schedule with little deviation. On two reviewed days, the youth were
between five and ten minutes late getting to the first period class, but the last period was
extended to compensate for missed time. There were three days of video footage reviewed for
transition to education. On all three days, it was discovered the youth did not transition to and
from classes according to the daily schedule. On two reviewed days, the youth missed fifty-four
minutes of instruction and thirty-seven minutes another day, falling short of the weekly
requirement for educational access. It was also noted the program’s activity schedule and the
daily school bell schedule do not match. Five youth were interviewed and all responded there
are interruptions to the educational time, mainly due to fights during the school time.
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2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program has a policy and procedures requiring an educational transition plan to be
developed upon the youth’s admission into the program. Five closed youth case management
records were reviewed and confirmed the program’s instructional staff and the youth completed
an Education Transition Plan upon admission. One youth entered the program as a graduate
and did not have an Education Transition Plan. The plans included services and interventions
based on each youth’s assessed educational needs, post-release education plans,
recommended post-release placement, and specific monitoring responsibilities for individuals
responsible for the reintegration and coordination of the provision of support services. The
development of each plan and subsequent plans, such as the youth’s exit transition plan and
Electronic Educational Exit Plan (EEEP), included key members including the youth,
parent/guardian, education representative, and school district personnel responsible for
providing guidance services. The lead teacher was interviewed and stated any plans or services
needed by youth are addressed in their transitional plans and youth transition plans are a part of
the EEEP process. Five youth were interviewed, and four of the five youth indicated the plans
were collaboratively developed upon the youth’s entry into the program. The five youth also
reported they felt the program was preparing them very well or well when it came to preparing
them for the high school equivalency diploma (GED) platform, high school, vocational school,
employment, and/or college.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program’s designated mental health clinical authority (DMHCA) is a licensed clinical social
worker (LCSW), who has a clear and active license which expires on March 31, 2025. The
DMHCA is a full-time staff at the program and works a minimum of forty-hours a week, Monday
through Friday. The DMHCA is also on call as needed on Saturdays, Sundays, and holidays.
The DMHCA provides specialized treatment services and is responsible for the coordination and
implementation of mental health and substance abuse services at the program. The DMHCA
has a medical doctor who serves as the back-up DMHCA to cover for absences. The back-up
DMHCA has a clear and active license with an expiration date of January 31, 2025. The
DMHCA was interviewed and indicated part of the DMHCA’s responsibilities is to ensure
documentation is completed timely and accurately meeting the requirements outlined within
their guidelines. The DHMCA is responsible for reviewing the Comprehensive Mental Health
and Substance Abuse Assessments within ten calendar days of completion and Individualized
Treatment Plans and treatment plan reviews within five days of completing. Additionally, the
DHMCA is responsible for the review and approval of various assessments. The DHMCA also
completes group fidelity checks for clinical and delinquency groups monthly to ensure
application of services is within guidelines. The DHMCA maintains a caseload, as needed,
conducting individual and family sessions. Additionally, the DHMCA provides coverage for
individual and group therapy, and other assessments, as needed. The DMHCA is responsible
for ensuring clinical treatment programming complies with all requirements outlined within the
specialty services guidelines for intensive mental health services. The DHMCA provides and
ensures emergency coverage twenty-four hours a day, seven days each week in the event of a
mental health emergency.
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 has a policy and procedures which requires the designated mental health clinical
authority (DMHCA) to be responsible for the licensed staff under their supervision and to ensure
the staff hold proper licensure and experience to provide services. During the annual
compliance review period, the program had one licensed clinical social worker (LCSW) and one
licensed mental health counselor (LMHC). Each of the licensed clinical staff’s licenses were
maintained on-site for review, and both were clear and active with an expiration date of March
31, 2025.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures which requires the facility administrator to ensure
mental health and substance abuse services are provided by individuals with appropriate
qualifications. The clinical supervisor is required to ensure clinical staff working under their
supervision are performing services the staff are qualified to provide based on education,
training, and experience. Each non-licensed mental health clinical staff working under the direct
supervision of a licensed mental health professional must receive a minimum of one hour a
week of on-site, face-to-face direct supervision by a licensed mental health professional in order
to oversee and direct the mental health services provided in the program. A review of the
weekly face-to face Direct Supervision Logs revealed one of the two non-licensed clinical staff
missed two weekly face-to-face direct supervision sessions and the second non-licensed clinical
staff missed six sessions during the annual compliance review period. This issue was identified
by the program’s internal regional compliance manager in January 2023 and a performance
improvement plan (PIP) was put in place, with a target completion date of March 10, 2023.
Since March 2023, there have been no discrepancies in this area. Each direct supervision
session was recorded on a form which contained all the elements of the Department’s Licensed
Mental Health Professionals and Licensed/Certified Substance Abuse Professionals Direct
Supervision Log form. The program is currently not licensed under Chapter 397; however, is in
the process of applying for a 397 license. All substance abuse services are provided by the
designated mental health clinician authority (DMHCA), who is a LCSW and the assistant
director of case management, who is a licensed mental health counselor (LMHC). The
program’s contract requires a recreational therapist. A review of the program’s staffing roster, as
well as the therapist’s credentials, verified the recreational therapist is qualified to provide
services to youth. At the time of the annual compliance review, there were no vacancies for non-
licensed clinical staff. The program has two non-licensed clinical staff, who provide services to
youth. Both have master’s-level degrees in science; one in mental health counseling and the
other in counseling. The non-licensed staff do not provide substance abuse services. Both non-
licensed mental health clinical staff conduct Assessments of Suicide Risk (ASR). Both have
completed twenty hours of training and supervised experience in assessing suicide risk, mental
health crisis intervention, and emergency mental health services. The training included
administration of, at a minimum, five ASRs or Crisis Assessments conducted on-site in the
physical presence of the DMHCA.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a policy and procedures which requires the mental health and substance
abuse needs of youth be identified through a comprehensive screening process to ensure
referrals are made when youth have identified mental health and/or substance abuse needs or
are identified as a possible suicide risk. A review of five mental health and substance abuse
youth records was conducted, and all were screened with the Massachusetts Youth
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Screening Instrument – Second Version (MAYSI-2). Further review of the youth mental health
and substance abuse records indicated staff reviewed available information to include each
youth’s commitment packet, reports, records for existing documentation of mental health or
substance abuse problems, and history of human trafficking on the day of admission. All five
youth had the MAYSI-2 administered, on the day of admission, by trained clinical staff. The
screenings were completed in the Department’s Juvenile Justice Information System (JJIS) and
conducted in a confidential manner. Each of the five MAYSI-2s were completed in full and all
indicated further assessment was required and each youth had a referral for further evaluation.
The facility administrator (FA) ensured an Assessment of Suicide Risk (ASR) was conducted
within twenty-four hours when the MAYSI-2 category “suicide ideation” indicated further
assessment was needed. The youth reviewed all had an ASR and a Comprehensive Evaluation,
with the reason for the referral documented on the MAYSI-2. The FA was interviewed and
confirmed the MAYSI-2 tool is utilized to identify youth at-risk for mental health and substance
abuse problems or suicide.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a policy and procedure which requires 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. Five mental health and substance abuse youth records were reviewed, which
showed all youth received a combined Mental Health and Substance Abuse Evaluation. All
evaluations were completed after thirty days of each youth admission. One evaluation was
completed one day late, one was twenty-nine days late, one was forty-one days late, one was
forty-four days late, and one was forty-nine days late. This issue was identified by the program’s
internal regional compliance manager in January 2023 and a performance improvement plan
(PIP) was put in place, with a target completion date of March 10, 2023. An additional three
youth mental health and substance abuse records were reviewed of youth admitted after March
10, 2023, and all had the comprehensive evaluation completed within thirty days of admission.
Three of the initial five youth records reviewed had the evaluation reviewed and signed by a
licensed mental health professional after the ten day time frame. One was one day late, one
was two days late, and one was four days late. The additional three records reviewed of youth
admitted after March 10, 2023, all had the evaluation reviewed and signed by a licensed mental
health professional within the ten day time frame. Each of the evaluations contained the
required information, to include demographics, reason for evaluation, relevant background
information, behavioral observations, mental status examinations, procedures administered,
discussion of findings, diagnostic impressions, and recommendations. Since March 2023, there
have been no discrepancies in this area.
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3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedure which requires an Initial Mental Health or Substance
Abuse Treatment Plan for youth determined to have a serious mental disorder or substance
abuse impairment and are receiving mental health or substance abuse treatment in a program.
The policy also requires an Individualized Treatment Plan be developed within thirty days of
admission and be reviewed and/or updated every thirty days. Five mental health and substance
abuse youth records were reviewed and found three did not have an Initial Treatment Plan
developed. This issue was identified by the program’s internal regional compliance manager in
January 2023 and a performance improvement plan (PIP) was put in place, with a target
completion date of March 10, 2023. Three additional mental health and substance abuse youth
records were reviewed for youth admitted after March 10, 2023and found each had their Initial
Treatment Plan developed on the day of admission. The two applicable youth records and the
three additional youth records reviewed all had the Initial Mental Health Treatment Plan or Initial
Substance Abuse Treatment Plan developed within seven days of the onset of treatment, or for
youth prescribed psychotropic medication, within seven days of the Initial Psychiatric Diagnostic
Interview. Each of the applicable Initial Treatment Plans were signed by the clinical staff
completing the form. Four of the applicable Initial Treatment Plans were completed by a
licensed clinical supervisor, and one was completed by non-licensed clinical staff. The one
completed by non-licensed clinical staff was signed by the licensed clinical supervisor within ten
days of completion. Each of the Initial Treatment Plans were signed by all treatment team
members who participated in the development of the plan and included the youth’s psychiatric
needs, when applicable, including medication and frequency of monitoring by the psychiatrist.
Four of the initial five youth mental health and substance abuse records reviewed, had
Individualized Treatment Plans which were not developed within thirty days of admission, as
required. One was three days late, one was twenty-seven days late, one was thirty-three days
late, and one was fifty-five days late. This issue was identified by the program’s internal regional
compliance manager in January 2023 and a performance improvement plan (PIP) was put in
place, with a target completion date of March 10, 2023. Three additional mental health and
substance abuse youth records were reviewed for youth admitted after March 10, 2023 and
each had the Individualized Treatment Plan developed within thirty days of admission. All
applicable Individualized Treatment Plans were developed on a form which contained all the
elements of the Department’s Individualized Mental Health/Substance Abuse Treatment Plan
form, and were signed by the clinical staff completing the plan. Three of the five applicable
Individualized Treatment Plans were completed by a non-licensed staff and reviewed and
signed by the licensed supervisor within ten days of completion. The remaining two applicable
Individualized Treatment Plans were completed by licensed clinical staff. and were signed by all
treatment team members who participated in the development of the plan. Each of the
applicable Individualized Treatment Plans included psychiatric services, including psychotropic
medication, when applicable, and frequency of monitoring by the psychiatrist for all youth who
received psychotropic medication. Each were completed on a form which contained all of the
information in the Department’s Individualized Mental Health/Substance Abuse Treatment Plan
form. Each of the applicable Individualized Treatment Plans were reviewed every thirty days, as
required, and contained the prescribed services for each youth. The goals and objectives were
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individualized for each youth. A review of groups was conducted which included a video review,
logbook review, and group sign-in sheet review. This revealed the clinical groups were being
conducted in accordance with the program’s schedule, youth were attending their prescribed
groups, and for the required length of time. Since March 2023, there have been no
discrepancies in this area.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program has a policy and procedures requiring all youth who receive mental health and/or
substance abuse treatment while in a program to have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program. Five youth
mental health and substance abuse records were reviewed. Each youth were assigned to a
treatment team upon admission to the program. A review of treatment team documentation for
each youth indicated the youth, facility administrator (FA), residential living unit staff, education
staff, medical staff, mental health and substance abuse staff, and the parent/guardian
participated in each treatment team.
Each of the five reviewed youth received substance abuse treatment provided by a licensed
mental health professional in accordance with their Initial and Individualized Mental Health and
Substance Abuse Treatment Plan. Each of the reviewed records contained a signed Authority
for Evaluation and Treatment (AET) form and a signed Youth Consent for Substance Abuse
Treatment form. Mental health and substance abuse group therapy for the five reviewed records
included individual counseling and psychosocial skills training. A review of progress notes
confirmed each youth received services as stipulated on their treatment plan.
Three closed records were reviewed. Each of the three closed mental health and substance
abuse youth records contained a copy of the Discharge Plan which was documented on the
Department’s Mental Health and Substance Abuse Treatment Discharge Summary form. None
of the youth were released on suicide alert/precautions. Each of the three Mental Health and
Substance Abuse Treatment Discharge Summary forms documented the services needed for
daily maintenance of positive improvement in behavioral, emotional, and social skills made by
the youth during treatment. The closed mental health and substance abuse youth records
contained documentation which indicated the program discussed the Discharge Plan with each
youth, parent/guardian, and juvenile probation officer (JPO) during the Exit Conference. A copy
of the discharge summary was provided to each youth, JPO, and parent/guardian, as required.
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3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program has the following contractually required clinical groups: Teen Relationships which
is a mental health treatment group. This group runs for twenty-four weeks, twice a week, and
has no more than ten youth attending at any given time. The group is facilitated by a trained
therapist. Female Healthy Relationship Bundle/VOICES is a gender-specific group which meets
twice weekly for nine weeks. This group is limited to ten youth and facilitated by a trained
therapist. Dialectical Behavioral Therapy (DBT) is another mental health treatment group which
meets one day a week for sixteen weeks. This group is limited to twelve youth and is facilitated
by a trained therapist. Matrix Model is a substance abuse treatment group which meets once a
week for twenty weeks. This group is limited to fifteen youth and is facilitated by a licensed
therapist. Five youth were interviewed and asked if they participate in individual and family
counseling and at what frequency. Each of the five youth stated they participate in individual
and family counseling once a week for individual, and once a month for family. Five staff were
interviewed if they or other direct-care staff facilitate any mental health or substance abuse
groups. Each of the five staff stated no. The designated mental health clinical authority
(DMHCA) was interviewed and advised at a minimum, youth are provided weekly individual,
monthly family, and daily group therapy to include specialized mental health group services. The
DMHCA indicated mental health groups include Mindfulness Movement, Social Rhythms, and
DBT. The specialized groups include Matrix Model (substance abuse), Teen Relationships, and
VOICES (gender-specific).
A review of five youth mental health and substance abuse records, along with group sign-in
sheets, confirmed youth are attending group as required. Daily therapeutic activities, such as
psychosocial skills training, psychoeducation, and supportive counseling are provided by mental
health clinical staff. Youth with co-occurring substance abuse disorders are also receiving
substance abuse services. The therapist’s caseloads average eight youth and never exceed
twelve. Therapy groups are limited to less than ten youth at a time for mental health groups. The
substance abuse groups are facilitated by the DMHCA and assistant clinical director, both of
whom are qualified to provide substance abuse education.
The program provides urinalysis drug testing and ensures positive tests are followed by
appropriate clinical intervention and sanctions. Each youth receives daily therapeutic activities,
such as substance abuse education, relapse prevention, substance refusal skills, and coping
skills. Youth with co-occurring mental health disorders receive mental health treatment as well.
The program is currently not licensed under Chapter 397; therefore, is in the process of applying
for a 397 license. The program has a licensed psychiatrist who provides psychiatric evaluations
as needed, medication management, and participates in treatment planning weekly. Substance
abuse clinical staff are on-site five days a week, and on call weekends and holidays.
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3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
The program has a contract with a psychiatrist who is a licensed medical doctor with a clear and
active license in the state of Florida with an expiration date of January 31, 2024. The
psychiatrist briefs a representative of the treatment team regarding the psychiatric status of
each youth receiving psychiatric services who is scheduled for treatment team review. The
psychiatrist’s evaluation and recommendations for each youth are incorporated into the mental
health clinical staff’s evaluations of the youth and the youth’s Individualized Mental Health or
Substance Abuse Treatment Plan. The program does not use a psychiatric advanced practice
registered nurse (APRN). A review of the weekly psychiatrist sign-in/sign-out logs and treatment
team logs confirmed the psychiatrist conducted weekly visits during the annual compliance
review period, as required by the contract. The psychiatrist actively participates in and manages
psychotropic medication services at the program. The psychiatrist has a back-up psychiatrist,
who is a medical doctor with a clear and active license in the state of Florida with an expiration
date of January 31, 2025. The psychiatrist was interviewed and advised they work with mental
health and nursing teams to implement the full range of psychiatric treatment recommendations.
The psychiatrist reviews and has input on the facility operating procedures related to psychiatric
care and works with the pharmacy committee. The psychiatrist is on-site once a week, typically
on Wednesday, and evaluates every new youth. The psychiatrist diagnoses and treats
psychiatric disorders with medications and other modalities. Youth not in psychiatric care are
referred and seen promptly. The psychiatrist has a medication management meeting every
Wednesday which the clinical director attends. The psychiatrist speaks with the facility
administrator (FA) frequently. When there is a medication refusal, nursing staff documents the
refusal and if there are three refusals in a row, the psychiatrist is notified. The psychiatrist meets
with nursing staff every week to discuss each youth. During medication management sessions,
nursing staff attend and bring up pertinent medical issues involving youth. The designated
mental health authority (DMHCA) was interviewed on how often they meet with the psychiatrist
to discuss youth receiving psychiatric services. The DMHCA advised medication management
meetings are held weekly with the psychiatrist to discuss youth receiving services.
Five youth mental health and substance abuse records were reviewed, and found four of the
five youth entered the program on psychotropic medications; however, all were referred for a
psychiatric interview. The four youth who were admitted taking psychotropic medication all
received a diagnostic interview within fourteen days of admission. Each diagnostic psychiatric
interview included the youth’s medical, mental health, substance abuse history, Mental Status
Examination, Diagnostic and Statistical Manual of Mental Disorders (DSM5) diagnosis,
treatment recommendations, prescribed medications, if applicable, explanation of the need for
psychotropic medication, target symptoms, initial treatment goals, potential side effects, risks
and benefits of taking the medication, and frequency of medication monitoring and
management. The Initial Diagnostic Psychiatric Interview was documented on the Department’s
Clinical Psychotropic Progress Note (CPPN) form in all five records reviewed and was clearly
identified as the Initial Diagnostic Psychiatric Interview. The Initial Psychiatric Diagnostic
Interview resulted in a new prescription of psychotropic medications or changes to the youth’s
existing psychotropic medication regimen for the four youth who were admitted taking
psychotropic medication which was completed and reflected on page three of the CPPN. The
four youth taking psychotropic medications received medication reviews by the psychiatrist at a
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minimum of every thirty days, as required. The medication reviews were documented on the
Department’s CPPN form. When psychotropic medication is prescribed, dispensed or
administered, the identifying data, diagnosis, target symptoms of each medication, evaluation
and description of effect of prescribed medication on target symptoms, the name, dose,
frequency, and reasons for changes of prescribed psychotropic medication, side effects, youth
adherence to medication, height, weight, blood pressure, telephone contact with
parent/guardian, signature of psychiatrist, and date of signature was documented. The program
does not provide 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 has a policy and procedures which requires the development and implementation
of a Suicide Prevention Plan which includes identification and assessment of youth at risk of
suicide, staff training, suicide precautions, levels of supervision, referral, communication,
notification, documentation, immediate staff response, and review process. The review process
for suicide attempts and mortality review includes circumstances surrounding the event, facility
procedures relevant to the event, all relevant training received by involved staff, pertinent
medical and mental health services involving the victim, possible precipitating factors, and
recommendations for changes in policy, training, physical plant, and medical or mental health
services if needed. The Suicide Prevention Plan was reviewed and signed by the designated
mental health clinical authority on January 30, 2023.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
Five youth mental health and substance abuse youth records were reviewed, and found two
youth were placed on precautionary observation during admission. An additional mental health
and substance abuse record was provided. Each of the three applicable records, had an
Assessment of Suicide Risk (ASR) within twenty-four hours of the start of the precautionary
observation. All three youth were placed on constant supervision. The parent/guardian of all
three youth was notified of the youth’s potential suicide risk. A follow-up ASR was not required
for any of the youth prior to their removal from precautionary observation. All three ASRs
indicated a conference was held by the facility administrator (FA) and the licensed mental health
professional to reduce the level of supervision. All three youth were stepped down from constant
supervision to standard supervision. The discontinuation of close supervision was documented
in accordance with the program’s Suicide Prevention Plan and all three ASRs were completed
by the licensed mental health professional. All three youth had a suicide alert entered and
accurately closed in the Department’s Juvenile Justice Information System (JJIS) according to
the recommendations on their ASR. A review of logbooks indicated supervisory staff provided
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instructions related to the ASR findings and suicide precaution decisions. All three ASRs had
documentation of the actual date and time the licensed mental health professional conferred
with the FA of or designee. The program does not utilize secure observation. Video footage was
reviewed for one youth placed on precautionary observation within the past thirty days. There
were no other youth placed on precautionary observation within the past thirty days. The youth
was placed on precautionary observation and a staff stayed with the youth until the youth went
to medical. The assistant facility administrator (AFA) was with the youth until the youth was
placed on constant supervision. The youth remained on constant supervision until the youth met
with the licensed mental health professional and was removed from precautionary observation.
Five staff were interviewed and each advised if a youth expresses suicidal thoughts; they are
responsible for notifying mental health staff, searching the youth and room for sharp objects,
maintaining sight and sound supervision of the youth, documenting actions taken, and advising
the AFA. All five staff stated one knife-for-life is stored in the duty station, three staff indicated
an additional kit is stored in medical, one staff stated an additional kit is stored in master control,
and one staff stated an additional kit is stored in the supervisor's office.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Five youth mental health and substance abuse records were reviewed, and found two of the
youth were placed on precautionary observation during admission. An additional mental health
and substance abuse record was provided. Each of the three applicable records reviewed, had
Suicide Precaution Observation Logs maintained for the duration the youth was on suicide
precautions and the appropriate level of supervision and observations of each youth’s behavior
was documented in real time not exceeding thirty-minute intervals. The Suicide Precaution
Observation Logs were all signed by each shift supervisor and the mental health clinical staff
and documented safe housing requirements.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Five pre-service training and five in-service staff training records were reviewed. All records
indicated staff received the appropriate amount of suicide prevention training, which included
suicide drills. The program has two suicide response kits; one is in master control and the other
is in the staff duty station. Both are co-located with first-aid kits. Suicide prevention drills were
reviewed for the annual compliance review period. All required drills were completed, except for
one missed drill for the first shift during one quarter. All staff participated in the required drills for
the year. All suicide prevention drills in response to a suicide attempt and/or incident of serious
self-injury were simulated, did not include program youth, and included the use of
cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator (AED).
Staff who were not present during a quarterly drill, have the opportunity to review each drill
scenario and procedures in an effort to understand the process and receive the necessary
training to respond to an incident of a suicide attempt or self-inflicted injury. The facility
administrator (FA) was interviewed and advised the licensed clinician completes mock mental
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health and suicide prevention drills across all shifts, ensuring all staff members participate in a
minimum of one drill on a quarterly basis. Each drill is reviewed monthly during a general staff
meeting with all staff. Five staff were interviewed and two reported drills are conducted monthly,
one indicated weekly, one reported all the time, and one indicated rarely.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a written Crisis Intervention Plan. This plan includes notifications and alert
system, means of referral to include youth self-referral, communication, supervision,
documentation, and review. The plan was approved and signed by the designated mental health
clinical authority on January 30, 2023.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
Five youth mental health and substance abuse records were reviewed, and found none of the
youth were applicable for a Crisis Assessment. The program provided two additional youth for
examples of Crisis Assessments, there were no other applicable records available for the
annual compliance review period. In both applicable incidents, each youth received a Crisis
Assessment the day the youth was determined to be in crisis. Each Crisis Assessment included
the reason for assessment, Mental Status Examination and interview, a determination of danger
to self and others, initial clinical impressions, supervision recommendations, treatment
recommendations, recommendations for follow up or further evaluation, and notification to the
parent/guardian regarding follow-up treatment. Each assessment was conducted by a licensed
mental health professional. Neither of the two youth were determined to be at-risk after
completion of the Crisis Assessment.
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3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has an Emergency Mental Health and Substance Abuse Services Plan. This plan
includes immediate staff response, notifications, communication, supervision, authorization to
transport for emergency mental health or substance abuse services, transport for emergency
mental health evaluation and treatment under Baker Act or emergency substance abuse
assessment and treatment under Marchman Act, documentation, training, and review. The plan
was approved and signed by the facility administrator (FA) on June 5, 2023.
3.17 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program had two incidents of a Baker Act during the annual compliance review period. Both
incidents involved the same youth. In both cases, the youth was determined to be in need of
emergency care due to self-harm gestures and threats. Staff referred the youth for an
Assessment of Suicide Risk (ASR) in both instances. These referrals were made as soon as the
youth was discovered making the self-harm gestures and threats. The youth was placed on
one-on-one supervision at the time of discovery both times. Mental health staff were involved in
both instances and the designated mental health clinician authority (DMHCA) authorized
transportation of the youth on both occasions. Each time when the youth returned from the
Baker Act, the youth was placed on constant supervision and a mental health referral was
completed indicating a Mental Status Examination (MSE) was to be conducted. Both ASRs
were completed by the DMHCA and the youth was maintained on constant supervision until
properly transitioned to a lower level of supervision, which only occurred after an appropriate
assessment was conducted and the DMHCA conferred with the facility administrator (FA) in
both instances.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedures which requires an on-going safety planning process
for each youth. The safety plans are designed to identify stimuli which have both positive and
negative effects on each youth. Five youth mental health and substance abuse records were
reviewed. All youth safety plans included warning signs which indicate a youth is escalating in
their behavior, youth baseline behavior, crisis recognition, jointly developed coping strategies,
intervention strategies, and a debriefing process. Four of the five safety plans were completed
within fourteen days of admission. One was twelve days late. Four of the five safety plans were
jointly prepared by the youth, parent/guardian, clinical staff, and behavioral specialist. The
remaining initial plan was not signed by the therapist. All five safety plans incorporated
recommendations from previous or current clinical assessments or screening instruments and
incorporated trauma responsive practices. None of the plans were reviewed and updated every
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thirty days. The first youth had one of eight plans reviewed five days late, the second youth had
one of seven plans reviewed forty-one days late, the third youth had one of eight plans reviewed
six days late, the fourth youth had two of seven plans reviewed late; one which was twenty-
seven days late and one which was six days late, and the remaining youth had two of six plans
reviewed late; one which was twelve days late and one which was six days late. This issue was
identified by the program’s internal regional compliance manager in January 2023 and a
performance improvement plan (PIP) was put in place, with a target completion date of March
10, 2023. An additional three mental health and substance abuse records for youth admitted
after March 10, 2023 were reviewed. There were no discrepancies noted in this area. The safety
plans are maintained in each youth’s record, as well as the staff duty station for staff who have
contact with youth to review, as needed. Five youth were interviewed and each reported they
contribute to their safety plan. Five staff were interviewed. Three staff reported safety plans are
kept in the staff duty station, one stated on the computer, and one stated with the case worker.
The facility administrator (FA) was interviewed and advised safety plans are updated every
formal treatment team meeting and after any incident of a mental health crisis.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The designated health authority (DHA) is a licensed physician, who hold holds an unrestricted
license and meets all requirements for independent and unsupervised practice in Florida. The
DHA license expires on January 31, 2025. The DHA’s specialty training is for internal medicine.
The DHA does not have any disciplinary cases or public complaints on record. The program
does not employ a physician assistant (PA) or advanced practice registered nurse (APRN).
Sign-in and sign-out logs spanning the annual compliance review period were reviewed. The
DHA was on-site at least once a week for the required contract minimum hours; two hours each
week. There were no noted days of which the DHA had any scheduled absences during the
annual compliance review period. The program has a back-up licensed physician, who carries
an equal license, which expires on January 31, 2024. There were no noted days where the
back-up licensed physician was utilized during the annual compliance review period. The
program does not have any provisional language contained within the contract to include either
telemedicine/telehealth type services. The DHA was interviewed and indicated they will see
youth on initial intake for physical exams, periodic evaluations, sick call, and referrals to
specialists as needed. The DHA indicated they are on-site once weekly and they communicate
with program staff regarding youth medical needs by telephone, through written orders, and
when on-site. The DHA indicated they are available by telephone and through an answering
service when not on-site. The DHA stated nursing staff place all off-site care findings,
instruction, and information in a chart or folder for their review. The DHA indicated they are
informed of any new medical changes with youth and they meet with healthcare staff quarterly.
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 currently has two full-time registered nurses (RNs). An additional RN has been
hired and will begin training on July 23, 2023, putting the program in compliance with the
contractual requirements of employing three nurses. The program does not currently employ a
licensed practical nurse (LPN). During the scope of the annual compliance review period, the
program had a vacant nurse position. The program utilized the provider’s regional nurse, two
provider nursing staff, and a pro re nata (PRN) RN to assist with medical coverage, meeting the
contracted 120 hours. A review of all nursing licensure credentials were found to be clear and
active. In addition, the nursing staff who provided services at the program had a current
certification in cardiopulmonary resuscitation (CPR). One of the established RN positions is the
program’s health service administrator (HSA). The on-site contract requirement for nursing
coverage is twelve hours a day, seven days a week. The HSA provides clinical supervision,
along with medical support services, Monday through Friday from 8:00 a.m. to 4:30 p.m.
Medical services are provided by nursing staff, who are on-site seven days a week from 7:00
a.m. to 7:00 p.m.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has procedures for all health-related practices and protocols utilized. The
designated health authority (DHA) reviewed and signed the program’s treatment procedures on
July 6, 2023. The psychiatrist reviewed and signed treatment procedures on July 6, 2023. The
facility administrator (FA) reviewed and signed treatment procedures on July 5, 2023. Nursing
staff reviewed the treatment procedures and then dated and signed the cover page, as required.
Newly employed health care staff receive a comprehensive clinical orientation to the program’s
medical services. Training covering medical services at the program is provided by on-site
registered nurses (RNs). Documentation was provided to support the DHA approved treatment
protocols and standing procedures and did not delegate to any other person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
A review of five youth Individual Healthcare Records (IHCRs) found each had a valid and legible
copy of an Authority for Evaluation and Treatment (AET) form filed. Each of the AETs were
signed by the youth’s parent/guardian. Each of the AETs were signed by a Department
representative. One of the five youth reviewed had recently been placed under care of the
Department of Children and Families (DCF). The youth did have an AET prior to arrival;
however, a court order was filed in the youth’s IHCR. One of the five youth turned eighteen
years of age while at the program, subsequently there was a release of information
authorization form for youth eighteen years of age and older contained within the youth IHCR.
An interview with the nurse revealed the nurse reviews all projected intakes in the Department’s
Juvenile Justice Information System (JJIS) and validates the youth AET. All new admissions are
discussed with case managers prior to youth arrival. The juvenile probation officer (JPO) is
contacted to obtain a new AET, if necessary.
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.
A review of five youth Individual Healthcare Records (IHCRs) found the program informs each
youth’s parent/guardian of changes in the youth’s condition and obtains consent when new
medications and treatments are prescribed. Each youth had appropriate notifications for the
parent/guardian, with no exceptions. Four of the five youth were applicable for prescribed
psychotropic medication. Each of the four IHCRs contained documentation on page three of the
Department’s Clinical Psychotropic Progress Note (CPPN) form for prescribed, discontinued,
and/or changes to psychotropic medication. One of the five youth were applicable for notification
communicated between the program and the Department of Children and Families (DCF). In
this case, the court order authorized all treatment and procedures. In each of the youth
reviewed, vaccinations were verified within thirty days of the youth’s admission to the program,
with no exceptions. None of the youth were applicable for consent being obtained prior to
administering vaccinations. All five youth had up-to-date immunizations. None of the youth were
applicable for religious exemption from immunization. The program accesses immunization
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records online. The medical department is notified of a youth admission prior to arrival. Attempts
are made prior to the youth arriving to verify immunization records, or within thirty days of
arrival. An interview with the nurse revealed a written notice of health-related care is provided to
the parent/guardian of a youth regarding the need for delivery of a specified health care service
or medications. Parents/guardians are notified within twenty-four hours with written parental
notification. Verbal consent is obtained as soon as possible after an order is written by the
physician.
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.
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff. A review of five youth Individual Healthcare Records
(IHCRs) revealed each youth had a completed Facility Entry Physical Health Screening
(FEPHS) form. Each of the FEPHS forms were completed by a registered nurse (RN) on the
date of the youth admission to the program. There was no indication of the FEPHS being
completed by direct-care staff. None of the youth reviewed were out of the physical custody of
the Department for greater than twenty-four hours. An interview with the nurse stated the
program is notified by the commitment manager by email or telephone prior to each youth's
admission to the program. The admission screening tool is generally completed by the RN upon
admission. If the FEPHS is completed by direct-care staff, the RN signs the FEPHS form
acknowledging it has been reviewed.
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.
All five youth Individual Healthcare Records (IHCRs) contained documentation to support the
youth were oriented to the general process of healthcare delivery services at the program. Each
youth’s admission orientation to healthcare services contained all necessary required topics.
The youth and medical staff’s signatures were documented on each of the Orientation to
Healthcare Services forms.
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.
A review of five youth Individual Healthcare Records (IHCRs) was completed to determine if the
designated health authority (DHA) or designee was notified when a youth being admitted to the
program required emergency care or routine notification in accordance with Department
requirements. None of the youth required emergency care upon admission. Three of the five
youth had a known or suspected chronic condition upon admission. Four of the five youth were
taking psychotropic medications prior to arrival to the program. All five youth had notification to
either the DHA and/or psychiatrist documented within the youth’s IHCR. The appropriate
notifications were made within twelve hours for each youth’s admission to the program.
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Nursing interview stated the DHA is notified by telephone or verbally if on-site regarding a
youth's medical history and chronic conditions. Notification occurs once the initial nursing
assessment is conducted and medical records are reviewed. The registered nurse (RN)
completing the admission is responsible for notifying the DHA. The notification to the DHA is
documented on the DHA Admission Notification form.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
A review of five youth Individual Healthcare Records (IHCRs) was completed to determine if the
Department’s Health-Related History (HRH) form was utilized for all youth admitted into the
physical custody of a Department facility. Each IHCR reviewed had a completed and/or updated
HRH form, completed within seven days of admission. Each HRH was completed prior to the
Comprehensive Physical Assessment (CPA). Each HRH was reviewed by the designated health
authority (DHA). An interview with nursing revealed the HRH form is completed by the
registered nurse (RN) during the initial nursing assessment. They are also updated by the RN
when any significant medical events or changes occur and annually.
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.
A review of five youth Individual Healthcare Records (IHCRs) was conducted to determine if the
Comprehensive Physical Assessment (CPA) form was utilized for all youth admitted into the
physical custody of a Department program. Each IHCR reviewed had a completed CPA. The
reviewed CPAs were completed within seven days of each youth’s admission to the program.
Each youth’s Medical Grade was documented on their CPA. All sections of each CPA were
marked, as required. Each of the youth’s Problem Lists were updated, as required. There was at
least one verified tuberculosis skin test (TST) documented in each youth’s IHCR. Results of the
TST was also found to match on the CPA and Infectious and Communicable Disease Form for
each reviewed youth. An interview with the nurse was conducted. The designated health
authority (DHA) completes the initial CPA within seven days of admission. An annual CPA is
also completed for youth who have remained in custody for more than a year.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
A review of five youth Individual Healthcare Records (IHCRs) was conducted to ensure all youth
are evaluated and treated, if necessary, for sexually transmitted infections (STIs). Four of the
five youth reviewed were clinically screened and evaluated for STIs. The remaining youth was
not applicable for STI screening. In each of the four cases, the youth were appropriately referred
to the designated health authority (DHA). The referrals were documented on the STI form.
Testing was ordered and subsequently performed. The testing, screening results, clinical
evaluations, and diagnoses were documented accordingly on the Department’s Infectious and
Communicable Diseases (ICD) form. None of the five youth were out of the program’s physical
custody and/or had symptoms present. All five youth reviewed were offered counseling and
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testing for human immunodeficiency virus (HIV). Four of the five youth were applicable to
receive HIV testing. The remaining youth refused HIV testing. The four youth who consented for
HIV testing, had an applicable consent maintained in their respective IHCR. Each youth had the
HIV results filed in their IHCR, which were maintained in a sealed envelope, and marked
“Confidential”. The four applicable envelopes contained the practitioner signature, on each of
the sealed envelopes. In addition, each youth had documentation of pre-test/post-test
counseling contained within the IHCR. There were no alerts found posting of any youth’s HIV
status observed. The program has a policy and procedures, reflecting HIV test results; whereas,
results are only disclosed to the youth, and entities outlined in Chapter 381, Florida Statute. The
program has a local wellness center providing both pre-test/post-test counseling and testing for
HIV. The wellness center holds a 500/501 certificate. Four of five interviewed youth reported
they are able to request HIV testing. The remaining youth stated no. All five reviewed IHCR
records identified each youth was offered HIV testing. One youth signed a refusal form. An
interview with the nurse established youth are interviewed during the initial nursing assessment
to obtain their health history. The nurse indicated the DHA has standing admission orders where
all youth are screened for STI's regardless of their risks. The STI testing is completed upon
admission and youth referred to the DHA as needed for evaluation and treatment. The STI
screenings are located in the infectious and communicable disease information section. The STI
lab results are filed in the laboratory section of the IHCR.
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.
A review of five youth Individual Healthcare Records (IHCRs) found youth in the program are
able to submit sick call requests and have complaints treated appropriately through a sick call
system. A total of fifteen sick calls for four applicable youth were reviewed. The remaining youth
never requested a sick call while at the program. None of the youth were presented with a
similar sick call compliant three or more times in a two-week period. In each sick call complaint
reviewed, each youth completed a Sick Call Request form. Subsequently, for each sick call, the
nurse completed the Sick Call Request form. There were no occasions where a licensed
practical nurse (LPN) conducted a sick call. Each sick call was found filed within the proper
youth’s IHCR. There were no occasions of youth being placed within restricted housing of any
kind. Each sick call form was documented in accordance with Florida Administrative Code. In
addition, the sick calls were documented on each youth’s Sick Call Index and on the program’s
Sick Call Referral Log. The date listed on the Sick Call Index corresponded to the completed
sick call forms located within each youth’s IHCR. The program is contractually required to
provide sick call at a minimum three times daily; 7:00 a.m. to 9:00 a.m., 1:00 p.m. to 3:00 p.m.,
and 5:00 p.m. to 7:00 p.m., seven days a week. There were no noted exceptions. The
program’s sick call hours are posted outside the medical office. In addition, sick call times are
reviewed during orientation with youth at admission to the program. The reviewed sick calls,
demonstrate the program has only registered nurses (RNs) conducting sick calls. The program
has procedures, whereby shift supervisor reviews sick call requests within four hours after the
youth has submitted them. Sick Call Request forms are available to youth and located in the
supervisor office, living unit, and with staff members who carry forms with them. There were no
sicks calls conducted during the annual compliance review week; therefore, an observation of a
sick call could not be completed. Five staff were interviewed, which revealed the nurse reviews
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and conducts sick calls. Five youth were interviewed. One youth reported they can see a nurse
immediately, another youth reported they can see a nurse within a day. Three youth reported
they see a nurse within three days of a sick call request. A review of fifteen sick calls made by
five different youth, revealed the sick calls were addressed by nursing staff within one day of
request. An interview with nursing staff revealed youth can submit a sick call at any time by
completing a Sick Call Request form and placing it in the sick call box. The box is monitored by
the nurses throughout the day, at least every two hours and then prioritized and completed
during the scheduled time. Youth are assessed within twenty-four hours of placing a sick call.
Sick call is conducted by the RN. If conducted by an LPN, the documentation is reviewed and
signed by the RN to acknowledge approval of the implemented treatment plan. Sick call is
conducted in the medical office. Sick call is conducted three times daily from 7:00 a.m. to 9:00
a.m., 1:00 p.m. to 3:00 p.m., and 5:00 p.m. to 7:00 p.m., seven days a week.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
A review of five youth Individual Healthcare Records (IHCRs) documented the program has a
comprehensive process for the provision of episodic and first-aid care. Two of five youth had
either a first-aid and/or episodic event. One additional IHCR was provided for review a minimum
of three youth IHCRs for episodic/first-aid and emergency care. Each of the three IHCRs
reviewed had a combined nine on-site first-aid and/or episodic events. Eight of the nine events
were completed by on-site licensed healthcare staff. Documentation was found in each youth’s
IHCR in problem-oriented manner; subjective, objective, assessment, and plan (SOAP). The
remaining episodic event was completed by a non-healthcare staff. The event was documented
on the Department’s Report of On-site Health Care by Non-Health Care Staff form. The noted
event had a documented follow-up evaluation from a licensed healthcare staff the following day.
The program has procedures, addressing episodic and emergency care practices. The program
has seven first-aid kits. Two of the seven first-aid kits are for transportation vehicles. Each of the
first-aid kits have content specific lists contained within each kit, notating the expiration dates.
Medical staff check to ensure the kits are in locations as designated weekly and conduct
monthly content checks. A review of three first-aid kits was conducted with on-site nursing staff.
Two of the three kits were missing a roll of tape, no other exceptions were observed. There is
one automated external defibrillator (AED) at the program, located in the administration hallway.
The procedures for the AED are located with the AED. The medical staff check to ensure the
AED batteries and pads are operable. The nursing staff conducted a self-test of the AED in
presence of the regional monitor during the annual compliance review week, there were no
issues discovered during the AED test. The AED batteries expire in December 2024 and were
last changed in December 2020. The AED pads expire in May 2025 and were last changed in
February 2023. The program had thirty-six emergency medical drills documented, which
covered three separate shifts, with no exceptions. Emergency medical drills included the
demonstration of cardiopulmonary resuscitation (CPR) and AED at a minimum annually. In
addition, drills simulated episodic care events which called for immediate first-aid and/or
administration of CPR techniques, along with the initiation of emergency procedures to follow
when life-threatening emergencies occur. The program’s emergency medical drills were
announced and unannounced and were conducted at a minimum quarterly on each shift. The
program maintains a list of emergency telephone numbers in master control, medical, and in the
supervisor’s office which are accessible to all staff and inaccessible to youth. Direct-care staff
are appropriately trained on the administration of the epinephrine auto-injector, which is
administered by the on-site registered nurse (RN). A review of ten staff training records
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documented staff met requirements for episodic, first-aid, and emergency care training, with no
exceptions. There were no episodic care events conducted during the annual compliance
review week; therefore, an observation of an episodic care event could not be completed. The
program has Narcan on-site, which is kept in the medical office. The program is in the process
of updated the policy and procedures to include the use, storage, access, and inventory of
Narcan. Staff receive training on the use of Narcan when they receive CPR and first-aid training.
Five staff were interviewed and all five staff agreed they are able to make a call to 9-1-1. Four of
five interviewed youth agreed they can see a dentist. The remaining youth indicated they cannot
see a dentist. Three of five youth agreed they can see a doctor, if needed. The remaining two
youth indicated they cannot see a doctor, if needed. An interview with nursing staff confirmed
nursing progress notes reflect episodic care and episodic care is noted on the Episodic Care
Log. Non-licensed staff can complete a form to notify nursing staff upon their return to assess
youth who received treatment after hours. Documentation of off-site emergency care is reflected
on the Episodic Care Log.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
A review of five youth Individual Healthcare Records (IHCRs) found the program provides timely
referrals and coordination of medical services to an off-site health care provider, for both
emergent and non-emergent services. Two of the five youth IHCRs reviewed were applicable
for off-site care/referrals. An additional youth IHCR was requested to meet the minimum sample
size of three applicable IHCRs to review. There were five separate off-site care events from the
three applicable IHCRs. Each youth’s off-site events were included on the Summary of Off-site
Care Consultation Report form and found filed in the youth’s IHCR. There were no occasions of
any of the events reviewed requiring off-site emergency care. Parental notification efforts were
found for each of the off-site care events. In addition, there were discharge and other applicable
documents found filed in each of the youth’s IHCRs. In each of the reviewed events, the
designated health authority (DHA) reviewed and signed off on the findings, instructions, and/or
information. Two of the five off-site events required follow-up appointments. One of the two
youth had follow-up, as required. The remaining youth recently had their first off-site event and
the follow-up appointment was scheduled for a later date. An interview with nursing staff
revealed off-sites for first-aid/emergency care needs are documented on the Episodic Care Log.
The nursing staff coordinates to ensure all applicable individuals are notified. The hospital
discharge documentation is reviewed by medical staff upon a youth’s return to the facility. The
DHA is contacted and hospital discharge documentation is reviewed with the DHA. All off-site
documentation is reviewed and signed by the DHA. Documents for signature are flagged in
each youth's IHCR. Medical staff also complete regular chart audits to ensure all documentation
has been reviewed and signed. Follow-up testing, referrals, and appointments are tracked using
the nursing calendar and medical trackers and logs.
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4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
A review of five youth Individual Healthcare Records (IHCRs) was conducted to ensure youth
who have chronic conditions receive regularly scheduled evaluations and necessary follow-up.
Four of the five youth records reviewed were applicable. Three youth were identified on the
Facility Entry Physical Health Screening form with a current chronic condition at admission. The
remaining youth was later added to the chronic illness list upon completion of the designated
health authority (DHA) evaluation. Each of the reviewed youth were classified with a Medical
Grade of two through four. There were no youth identified as being pregnant. Each of the four
youth were placed on the Chronic Illness List at the program. The youth were in receipt of
periodic evaluations at least every ninety days. Progress notes documented each of the youth’s
periodic evaluations. There were no occasions of any youth requiring off-site periodic
evaluations. There were no indications of lapses in care or missed periodic evaluations. The
Department’s Problem List for each youth was updated in accordance with the Florida
Administrative Code. An interview with the facility administrator (FA) revealed sick call is daily.
Youth fill out a sick call form for non-emergency medical issues and place it in the box. The
nurse meets with the youth and schedules them to see the doctor, if needed. The FA formally
meets with the healthcare staff monthly, and as needed throughout the month. An interview with
the DHA revealed periodic evaluations for youth with chronic conditions are completed and
tracked every sixty days and there is a tracking system in place. An interview with the nursing
staff revealed once a youth is identified upon intake or by the DHA as having a chronic medical
condition, the information is placed on the medical tracker for monitoring and tracking of due
dates.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
A review of five youth Individual Healthcare Records (IHCRs) found medication is received,
stored, inventoried, and provided in a safe and effective manner to youth. Four youth were
admitted on medication. The remaining youth was later prescribed medication. The four youth
who were on medication upon admission to the program had documentation on the Facility
Entry Physical Health Screening form. Each youth’s medication was verified prior to being
admitted into the program. Documentation of the prescription verification was found in each
youth’s chronological progress notes contained within their IHCR. The designated health
authority (DHA) and when applicable, the psychiatrist, was contacted to obtain an order to
resume the specified medication prescribed prior to admission. All five youth taking medications
contained a current, valid order, and medications were administered pursuant to current
prescription on file. There were no occasions of youth being in restricted housing. Over-the-
counter (OTC) medications were administered in accordance to approved protocols or signed
practitioner’s orders. The program utilizes a pre-printed pharmacy Medication Administration
Record (MAR), to document delivery of medications. There were no occasions of non-
healthcare staff assisting in the delivery of medications. Side effect monitoring was found
documented on each youth’s MAR at a minimum of once a week. Two of five youth reviewed
had documented refusals of treatment indicating the refusal of taking a prescribed medication.
Each of the refusals were clearly documented on the youth’s MAR. Each of the youth’s MARs
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contained all necessary elements required within Florida Administrative Code. None of the
reviewed youth required any parenteral medication. Four of five youth reviewed were on
psychotropic medication. The four youth were in receipt of an Initial Psychiatric Interview within
fourteen days of admission. In addition, each youth was in receipt of medication monitoring
every thirty days, as required. The program does not have any standing orders for psychotropic
medications. In addition, there are no emergency treatment protocol or pro re nata (PRN) orders
for psychotropic medications. A medication pass was observed, with no noted exceptions. Each
youth was escorted by direct-care staff to the medication pass. One youth at a time approached
the nurse individually. The registered nurse (RN) administering the medications identified
themselves prior to passing any medication, stating the purpose of the youth in receipt of
medication. The RN was able to verify any youth allergies and alert status prior to administering
medications. There were no occasions of non-healthcare staff administering medications to
youth. The RN was able to observe each youth take the prescribe medication and swallow.
None of the medications were pre-poured from the original packaging subsequent to
administration. The six rights of medication delivery were followed during the medication pass
for each youth. Four of five interviewed youth stated a nurse gives them their medication. The
remaining youth indicated they do not take medication. All four youth who take medication were
able to describe the process of getting medication. One youth stated their medication is crushed
and added to water. They drink it and sweep their mouth. One youth stated the nurse gives
them their medication and a supervisor watch them take it. One youth stated they are to state
their name and allergies, roll up their sleeves, show their mouth, and then get the medication.
The remaining youth indicated they receive medication in the morning and at night from a nurse.
Five interviewed staff stated the nurse provides the youth with medication and one stated the
supervisor. Nursing staff was interviewed and indicated only nursing staff complete admissions
at the program. Medications are verified with the Department’s Medication Transfer and
Disposition form. Medications are also reviewed by the parent/guardian or youth, if applicable.
The program utilizes pre-printed pharmacy MARs. There is a monthly access to medication
training conducted biannually and updated as needed for authorized staff. The list of staff is
located in the medical department. Medication pass times are 7:30 a.m., 12:30 p.m., and 7:00
p.m. An order is completed by the DHA or psychiatrist using the physician order sheet. The
order sheet is reviewed and signed by the designated nurse. The order is then faxed to the
pharmacy to be filled. The order is usually delivered to the facility within forty-eight hours.
Medications are inventoried daily with a perpetual count. Weekly counts are also conducted.
The youth medication storage is locked within the medical clinic and medication administration
room.
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.
An observation of the program’s medical area revealed medical equipment classified as sharps,
as well as stock medications, are secured and inventoried utilizing a routine perpetual inventory
descending count as each sharp is utilized and disposed of, or when the medication is
administered. Medications were secured in a locked cabinet designated for storage of
medications. The program’s medication cart was observed to be clean and organized with stock
items separate from youth-specific medications. The program did not have any controlled
substances. All sharps and medications were observed to be stored in a separate, secured
area, which was locked and inaccessible to youth. The program did not have any medications
which required refrigeration. The program has an agreement with a pharmacy to return any
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unused medications, expired medications, or discontinued medications. A review of the
program’s internal medical logbook documents this process. A review of inventories of sharps
and over-the-counter (OTC) medications demonstrate the program conducts perpetual and
weekly inventories, with no noted exceptions. A list was provided of the supervisory-level, non-
healthcare staff trained in the delivery of medication self-administration. Training is provided by
the on-site registered nurse (RN) as needed at a minimum annually. An observation of the RN
counting three OTC medications and three sharps was completed with no exceptions. All
reviewed inventories matched the on-site inventory numbers. Should the program have a
discrepancy with inventory, the error would be reported pursuant to internal procedures and
documented on the program’s Medication Error Report form. An interview with the nursing staff
at the program described the controlled substances are kept in a lock box within the medical
cart and signed off by the nursing staff as well as a witness each time the medication is given; a
daily narcotic count is completed as part of this process.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has an Infection Control and Exposure Control Plan, which includes prevention,
containment, treatment, and reporting requirements related to infectious diseases, according to
Occupational Safety and Health Administration (OSHA) regulations and Centers for Disease
Control and Prevention (CDC) guidelines. The designated health authority (DHA) reviewed the
program’s plan on July 6, 2023. The facility administrator (FA) reviewed the plan on July 5,
2023. The plans include all required components, are available to all staff, and located in the FA
office and medical office. The program makes available Hepatitis B immunizations to all staff.
Staff at the program have access to personal protective equipment. There were no indications
the program had any instances which required notification to the local county health department,
CDC, and/or the Department’s Central Communications Center (CCC) during the annual
compliance review period. The program’s process for needle stick post-exposure begins with a
medical evaluation and follow-up for any staff who may have had an exposure incident. Specific
on-going steps are addressed in the program’s Exposure Control Plan. The FA maintains a
separate file for youth and staff having experienced a facility and/or occupational exposure
incident. The program has not encountered any reportable instances of infectious diseases
since the last annual compliance review. In addition, there has not been any instances involving
the quarantining or hospitalization of at least ten percent of the total population since last annual
compliance review.
4.19 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
The program has not had any youth since the last annual compliance review requiring prenatal
care. A review of five youth Individual Healthcare Records (IHCRs) was conducted for the
inclusion of education relating to youth covering alcohol/drug use, smoking, nutrition, sexually
transmitted infections, contraception, prenatal care, and parenting skills. Each youth had
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education documented within their IHCR. A review of five non-healthcare staff (in-service)
training records documented receipt of training on education on girl healthcare was completed
annually. Training completed was conducted by the on-site registered nurse (RN). A review of
training materials provided to staff included observation and monitoring of emergency care
needs and symptoms of possible miscarriage. A review of on-site protocols noted the program
has nursing protocols for pregnant youth. Nursing staff were interviewed and stated pregnant
youth are monitored by the designated health authority (DHA) and are seen at regular intervals
by an obstetrics provider. Pregnant youth also receive weekly pregnancy education from the
nursing staff. Female youth are routinely tested for pregnancy upon admission, as required by
policy. Youth are monitored at least twice daily for pregnancy complications. Pregnancy
monitoring is documented on the Medication Administration Record. Pregnant youth receive
double portions or double protein as part of a regular diet. Pregnancy education is provided to
non-healthcare staff by the RN yearly and as needed. Pregnant youth are provided with
education on pregnancy complications, neonatal and infant development, parenting, and related
topics.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures requiring staff to maintain active supervision at all
times, including interacting positively, and engaging in a full schedule of constructive activities.
The program’s staff to youth ratio is one to six during awake hours and one to eight during
sleeping hours. Staff were observed during daily activities such as school, recreation, meals,
groups, and line movement during the annual compliance review. There was positive interaction
observed between youth and staff. Staff were able to provide an accurate youth count upon
request. Proper ratio was maintained at all times. No youth were observed roaming freely
without supervision. The daily activity schedule was posted in the day area and living unit and
was being followed by staff. Youth were engaged in a full schedule of activities. Five staff were
interviewed, and four staff were able to articulate the program's process for when a youth count
is unable to be reconciled. The remaining staff reported they do not do this in their position.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program has a policy and procedures for their behavior management system (BMS). The
BMS was posted in the day area, living unit, and in the youth handbook. The program’s BMS
included rules governing conduct, and positive and negative consequences. All facility staff are
involved in the development, implementation, and on-going maintenance of the BMS. The
cooperative agreement reflects classroom management with the program and the Hillsborough
County Public School. A training roster was provided which reflected BMS training was
completed with the teachers by the regional compliance manager. Five staff training records
contained documentation to support each staff was trained in the BMS. Five youth case
management records were reviewed and confirmed youth orientation included a review of the
program’s BMS. Positive behaviors are given at a four to one ratio, as indicated in the
contractual agreement. The BMS does not increase length of stay for the youth, deny youth of
basic rights, allow group punishment, allow discipline of youth by other youth, or allow isolation.
The program’s BMS contains all required elements, including a process wherein staff explain to
each youth the reason for any sanction imposed prior to the end of the staff’s workday and the
youth is given an opportunity to explain their behavior. Staff and the youth discuss the
behavior’s impact on others, reasonable reparations for harm caused to others, and alternative
acceptable behavior. The program provides a variety of rewards/incentives. Staff and youth
interactions were observed and supported adherence to the BMS requirements. Five staff were
interviewed and each reported receiving training in BMS, were able to explain how youth are
informed of their consequences and able to explain their behavior, and were able to list
incentives the program uses. Each staff reported the BMS includes reward and consequences
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in a one-to-four ratio. Three staff reported the BMS includes a point system, three staff indicated
the BMS includes a level system, and two staff indicated the BMS is included in the youth
handbook. Three staff reported the youth cannot have anything taken away as a consequence,
the remaining two indicated they can and clarified the youth may have their radio taken away if
they are not using it appropriately. Five youth were interviewed and each was able to explain
the consequences used in the program and the process for receiving consequences. Four youth
were able to explain incentives and rewards. The remaining youth indicated they do not feel the
youth get rewarded. All youth interviewed were able to explain the level system and indicated
youth do not punish other youth. Four youth agreed the staff apply the BMS fairly, one youth
reported they do not feel the staff are fair. One youth rated the BMS as very poor, two rated
BMS as poor, one rated it as fair, and the remaining youth rated the BMS as good. The facility
administrator (FA) was interviewed and reported the program utilizes a BMS compiled of a
series of levels. Youth complete each level by earning daily points to earn a positive day in the
program. Earning positive days allows youth to participate in nightly incentive. If a youth has a
behavioral infraction, they will not earn points for the task. After so many deducted points, youth
will not earn enough points to make their positive day which hinders their progression in the
level. Additionally, youth can earn a special treatment team referral for more serious behavioral
violations. Youth will meet with their treatment team to provide feedback and share their input
on the situation and together they will determine an appropriate consequence. The program
utilizes a daily tracker to manage youth progress and as a means of communication between
staff regarding youth progress in the program. Point cards are reviewed daily by the shift
supervisor and youth who initial acknowledging the points earned. Any time a point is not
earned, the reasoning is explained on the point card, so youth and other staff are aware in the
event a youth has a question. Staff are evaluated from commendable to unacceptable in
participation in the maintenance of the therapeutic milieu of the living unit, enforcement of the
level system, or other methods of the BMS. Performance evaluations are completed at ninety
days of employment or promotion and annually.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program’s policy, procedures, and practice confirm the program does not use room
restriction; therefore, this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program currently has a total of forty-eight cameras, of which forty-five were operational at
the time of the annual compliance review. Video recordings are stored for thirty days. The
program has one living unit for youth and the staff are currently on twelve-hour shifts. Ten-
minute observation checks were reviewed through video review, which confirmed checks were
completed with staff pausing and looking in the youth rooms. Checks were reviewed from both
shifts on weekdays and weekends. One day, one ten-minute check was three minutes late.
Another day, one check was one minute late. Ten-minute check sheets were reviewed for the
same days video review was completed. Reviewed documentation supported ten-minute checks
were done correctly. Five staff were interviewed and two were able to explain the process for
room checks. Two staff do not complete room checks due to their position, and the remaining
staff did not describe the room check process. One staff reported room checks are completed
every ten minutes, two staff reported room checks are completed every eight minutes, one staff
reported room checks are completed every fifteen minutes, and one staff reported they do not
conduct room checks due to their position.
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 has a policy and procedures pertaining to census, counts, and tracking of youth.
The facility administrator (FA) ensures the program develops, updates, and maintains a
Continuity of Operations Plan (COOP) which follows state law and the Department’s policy.
Facility logbooks were provided by the program from August 2022 to July 2023 for review, which
reflected facility population counts were completed as required. Youth counts were observed
during the annual compliance review during movement to class, from class, from lunch, and to
group. Five staff were interviewed and each reported counts are completed at every movement.
Three staff reported emergency counts are conducted when there is an unaccounted youth. The
remaining staff reported counts are conducted when there is any type of emergency. Three staff
were able to identify how many youth are currently at the program. The remaining two were
unsure.
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5.06 Logbook Entries and Shift Report Review Failed Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures pertaining to shift logbooks being used to document
all counts, movement, incidents in chronological order, drills, reports to the Department’s
Central Communications Center (CCC), transfers and admissions, off-site events, youth
supervision status, logbook reviews, and alerts. The shift supervisor or designee maintains the
logbook throughout the shift. The logbook serves as the shift report and the previous shift is
reviewed by the shift supervisor with the on-coming shift. Staff are required to review, sign, and
date the review of the logbook. Staff signatures, dates, and times were observed in the logbook
during the logbook review. The logbook for September 4, 2022 to September 26, 2022 was no
longer bound and was missing pages 183 through 372. The missing pages included the entries
from September 27, 2022 to October 1, 2022. Logbooks for October 2, 2022 to November 17,
2022 and November 18, 2022 to January 02, 2023 were falling apart with some lose pages.
Additionally, the logbooks had errors written over, instead of being crossed through with a single
line and initialed. Documentation of CCC report information was observed in logbooks for four of
the five CCC reports reviewed. All logbook entries were made in ink; however, the program’s
policy states entries are to be made in blue or black ink only which some entries were made
with red ink. The required activities were documented in the logbooks.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures for key control, key assignments, key usage,
restrictions, inventory, tracking, secure storage, and procedures for missing, lost or damaged
keys. The program’s master key inventory is color-coded indicating which keys are determined
restricted, active, and permanently issued. Restricted keys include areas such as medical,
therapists, administrative, and supervisory keys. Permanently issued keys are documented on a
receipt form of permanently issued keys from an administrator, which are signed and dated by
staff receiving and issuing the permanent keys. These staff include the facility administrator
(FA), assistant facility administrator (AFA), physical plant manager, and the clinical director.
Keys are stored in secured boxes marked “Active Key Box”, “Restricted Key Box”, and
“Emergency Key Box” in master control. Inventories of two samplings of keys were conducted
for each box and each included keys matching the total number of keys on each ring and the
assigned key number according to the key inventory provided. The supervisor or administration
staff assigns staff their keys when a staff member arrives to the program and documents the
information on the Key Control Log which indicates the staff’s name, date/time issued, set of
keys issued, personal keys being turned in, and the time out and time in for the keys. The key
control process was observed during the annual compliance review and was conducted
appropriately. Personal staff and visitor keys are stored securely in a key box. Visitor keys are
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exchanged with a numbered badge. Three random staff were requested to present their keys,
which were compared with the Key Control Log and the inventory to ensure the keys were
correct. All three were correct and the staff had signed their keys out. All three staff were aware
of the key functions. The physical plant manager is solely responsible for replacing damaged
keys. A broken key report is completed, and the key is made on-site, or a local key vendor is
utilized, if needed. There were no reports to the Department’s Central Communications Center
(CCC) since the last annual compliance review in reference to lost or missing keys. Five staff
were interviewed and each were able to explain the key control procedures at the program.
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’s policy and procedures address illegal contraband and prohibited items. All staff
were required to sign the Contraband Attestation Memo prior to March 1, 2023, and all new
hires were required to sign upon hire. The program’s policy addresses any staff who is found in
possession of contraband in the program will be subject to disciplinary action up to and
including dismissal as outlined in Florida Administrative Code, and law enforcement will be
contacted if any found items are considered illegal as defined in Florida Statutes or if there is
evidence of any kind of unlawful activity. All visitors are made aware of the policy and it is noted
at the bottom of the sign-in log for acknowledgement, which was reviewed. All youth are
provided a list of contraband items in the youth handbook and are made aware of the
consequences. All staff and visitors are subject to search when entering the program. Incoming
and outgoing mail for youth is searched by the assigned case manager in the presence of the
youth. All searches were documented in the shift logbook. Security Audit Forms and Room
Search Forms were reviewed and all searches were documented. The searches included
searching youth following visitation, room searches, and perimeter searches. A review of the
Department’s Central Communications Center (CCC) report information since the last annual
compliance review was completed and found there were no incidents of contraband being
introduced. The facility administrator (FA) was interviewed and stated upon entry into the facility,
staff and visitors are searched in efforts to prevent contraband from entering the facility. All
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visitors and staff are noticed of Florida Statue 985.711 as it is posted at the entrance doors of
the facility. In addition, a list of items identified as contraband are noted within the program’s
parent/guardian and youth handbook and the staff handbook. All staff are required to remove
shoes and jackets upon entry to the facility. Bags are also searched upon entry to the facility.
Weekly room and common area searches are completed and findings are documented on the
search log. Any unauthorized item or illegal contraband is documented on the log and disposed
of properly. Any findings of illegal contraband require notification/reporting to law enforcement
and the CCC.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy pertaining to searches of youth, staff, and visitors to prevent
contraband from being introduced into the facility. Searches are completed by staff of the same
gender following all movement of the youth throughout the day within the facility. Youth were
observed being searched by female staff during the annual compliance review following
movement from class, meals, and groups. The staff explained to each youth the searches were
going to take place and the youth were observed being treated with dignity and respect. The
searches were observed being conducted, as required. Searches were unable to be observed
during visitation, off-site activities, or admissions due to none occurring during the annual
compliance review. Five staff were interviewed, and they all reported youth searches are done
after all movement and only conducted by female staff. Five youth were interviewed and stated
searches are done after all movement or when there is suspicion of contraband.
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 two vehicles utilized for transporting youth. Both have a safety screen and the
doors to the youth passenger area cannot be opened from the inside. All preventive
maintenance and annual safety inspections were reviewed for the annual compliance review
period, and inspections and maintenance were completed as required. If an inspection
documented any deficiencies, they were corrected in a timely manner. The two facility vehicles
and three staff or visitor vehicles were secured when checked. Both transporting vehicles had
all seatbelts intact and accounted for, fire extinguishers were present, and the seat belt cutter
and window punch were attached to the vehicle keys. Transport cellular phones and first-aid kits
are assigned to both vehicles but are maintained inside the facility due to the heat. Five youth
were interviewed and three stated they are shackled and handcuffed when being transported in
the vehicles. The remaining youth reported they have not been on a transport. Five staff were
interviewed and three stated they were not transporters and the remaining two stated the youth
are handcuffed, placed in shackles, and staff place the seatbelts on them.
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5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures which comply with all requirements outlined by the
Department relating to transportation of youth and driver eligibility. The facility has an approved
driver’s list, which is posted in the administrative hallway on a bulletin board, and in the staff
record. There were no transports scheduled during the week of the annual compliance review to
be observed; however, staff were interviewed and stated they are provided a transport cellular
phone while on transports. Shift logbooks were reviewed to ensure the staff-to-youth ratio of one
staff to five youth is followed. According to policy, female staff are present during transport as
required based on the authorized driver list and logbook reviews. Five staff were interviewed
and three stated they were not transporters and the remaining two stated a transport phone is
assigned to them. Three stated they were not transporters and two stated the vehicles are
equipped with a first-aid kit, wheel lock, window punch, fire extinguisher, and jumper cables. All
five staff stated staff are not allowed to use their personal vehicle to transport youth and the
transport vehicles are searched prior to and after each use. Three staff stated they were not
transporters and the remaining two stated in case of an emergency during a transport they
would remain in the vehicle, call 9-1-1 and the facility administrator (FA). Five youth were
interviewed. Five youth interviews denied ever seeing anyone place contraband in a transport
vehicle. Four youth stated staff drive safely and one stated they have not been on a transport.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program developed a policy and procedures outlining the audit or inspection process to
include the responsibility of the physical plant manager to conduct the weekly safety and
security audits and develop and implement corrective action warranted as a result of safety and
security deficiencies found during internal or external reviews, audits, or inspections. Weekly
safety and security audits were provided by the program from August 2022 to July 2023, which
confirmed the practice and the requirements were completed. The physical plant manager
completes the Weekly Safety and Security Inspection form and provides the documentation to
the Department’s residential operations staff. The physical plant manager completed the
Preventive Maintenance Checklist as scheduled and provided the documentation to the
Department’s contract manager each quarter. The facility administrator (FA) interview stated the
program’s physical plant manager and FA complete weekly safety and security audits. Findings
are documented on the Weekly Safety Inspection Report and provided to the FA for review. The
report details identification of any issues and tracks the correction of the deficiencies. All efforts
are made to correct deficiencies in a timely manner, dependent of the severity of the issue.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures ensuring youth do not use tools or equipment as
weapons or a breach of security. All tools were observed and were secured and inaccessible to
youth in the laundry room, closet, or shed. Maintenance tools were secured and stored in the
maintenance shed located outside. The tools were labeled with an identification number, on a
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shadow-board and pegboard. The physical plant manager inventories the items daily, and
documents this on the Master Inventory form. Any tool in use is signed-in and out as reflected
on the reviewed tool sign-in and sign-out logs. Eleven tools were reviewed, the only exception
was a chisel was not in the place noted on the perpetual inventory, but documentation was
provided to support the tool was damaged and disposed of. The board was updated during the
annual compliance review. Kitchen knives were observed and were secured behind a locked
cabinet using a shadow-board system in the kitchen. All knives were accounted for according to
the inventory forms provided and observation of the cabinet. The dietary staff provided sign-out
and sign-in logs of the sharps. Class B items were secured in the south hall closet and laundry
room. These tools consisted of brooms, mops, mop buckets, scrub brushes, toilet brushes, dust
mops, and dust pans. There are pictures above the items in these areas, a youth risk
assessment list, and a sign-out and sign-in log. The physical plant manager was interviewed
and confirmed youth are only allowed to use the items in the closet and laundry room with staff
supervision. Youth are never permitted to use tools out of the maintenance shed. The program’s
policy does not allow machetes, bowie knives, or other long blade knives.
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 has a policy and procedures to ensure youth use tools safely and youth are
supervised appropriately in order to prevent injuries to themselves, other youth, and staff.
During clean-up and use of Class B tools, staff to youth ratio is one to five. A Youth Risk
Assessment List is posted in the class B closet. Clean-up is scheduled in the evening and was
not able to be observed during the annual compliance review period. Five youth case
management records were reviewed and had documentation of risk assessments being
completed for each youth. Five youth were interviewed and stated they are allowed to use scrub
brushes, mops, and brooms. Five staff were interviewed and four staff stated the youth are
allowed to use scrub brushes, mops, and brooms. The remaining staff stated youth do not use
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 has a policy and procedures with guidelines for outside contractors which includes
tool control and restrictions. Vendors or outside contractors are provided a Written Notification
and Guidelines for Outside Contractors Form, which is reviewed and signed by the contractor
and the facility administrator (FA) or the physical plant manager prior to being on-site. Providers
are made aware all tools must be checked and inventoried upon arrival, during the visit, and at
departure. If tools are missing, they are also notified of the procedures to be followed. The
outside contractors form also references recording devices not being allowed in the program.
The outside contractor binder was provided and included the Written Notification and Guidelines
for Outside Contractors Forms with invoices attached.
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5.16 Fire, Safety, and Evacuation Drills Limited 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 has a Continuity of Operations Plan (COOP) which addresses drills to be
completed. The program is required to complete COOP/emergency drills and fire drills monthly
for each shift. The program is currently on twelve-hour shifts with two shifts. Drill documentation
provided by the program from August 2022 to June 2023 was reviewed. There was no
documentation to confirm the program completed drills on either shift in September, October, or
November of 2022 or on second shift in August 2022, however, all other drills were completed
as required. Fire evacuation routes and egress plans were posted in master control, the
conference room, day area, living unit, medical, and the classrooms. The program provided
documentation reflecting there are thirteen fire extinguishers in the facility and the annual
inspection has been completed. Three fire extinguishers were randomly reviewed and had the
monthly inspection conducted by the physical plant manager documented on the tag. The
facility administrator (FA) was interviewed and stated COOP drills are completed on a monthly
basis, across each shift. These drills include disturbances, riots, threats, severe weather,
evacuation, and escape. In addition, fire drills are conducted on a monthly basis across each
shift. Each drill is reviewed monthly in general staff meeting. Five youth were interviewed. One
youth reported they have not been instructed on what to do in case of a fire, the remaining four
reported they have been instructed on fire drill procedures. Three youth indicated fire drills are
conducted monthly, one reported one was completed the week before the annual compliance
review, and one indicated it has been a while since the last fire drill. Five staff were interviewed
and each indicated they have participated in a fire drill and COOP drill during the annual
compliance review period.
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 has a Continuity of Operations Pan (COOP) located in the facility administrator’s
office and the staff duty station, which is accessible to all staff. The COOP was last reviewed,
updated, and submitted to the regional director on February 8, 2023 and was approved on
February 11, 2023. The COOP includes a cooperative agreement for relocation sites approved
by the Department’s residential operations staff. The program’s Emergency Disaster
Preparedness Plan and COOP are one combined plan. The program COOP’s Annex 7 includes
the on-site resources inventory which contains flashlights, batteries, water, and dry goods in
closets within the program clearly marked as COOP supplies and equipment. The program’s
COOP included all required topics. A review of five youth records found each included all
required documentation except for one missing the admission card. The facility administrator
(FA) was interviewed and stated the COOP is available in the FA’s office and the staff duty
station.
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5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program has a policy and procedures on the storage and inventory of flammable,
poisonous, and toxic items and materials. The physical plant manager stated the only chemicals
kept at the facility are items used in standard cleaning practices. There were only two locations
used to store these items, which were the south hallway closet in a locked cabinet and the
kitchen. These areas are inaccessible to youth. The inventory tracking and Safety Data Sheets
(SDS) for the items were in the closet and the kitchen. Other sheds on-site were inspected
during the annual compliance review and did not have any chemicals present. All items
observed had a corresponding SDS in a binder with the product photo behind the SDS forms.
The facility inventory for five chemicals were reviewed and matched the items stored. These
items included cleaning products. The facility provided a copy of staff by title which are
authorized to handle chemicals.
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 has a policy and procedures regarding youth handling and supervision for
flammable, poisonous, and toxic items and materials. The policy states program staff shall
ensure youth do not handle or have access to flammable, poisonous, toxic, and caustic
materials. Staff are required to spray chemicals for youth for cleaning purposes and always
provide supervision. Youth confirmed this practice during random interviews. They also stated
they do not clean up other youth’s bodily fluids or waste. The chemicals were observed being
secured during the annual compliance review period and youth did not have access to them.
Youth cleaning activities were unable to be observed during the annual compliance review
period. Five youth were interviewed and three stated they do not use chemicals or cleaning
supplies, one stated they use laundry soap, and one stated they use window or toilet cleaner.
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5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a policy and procedures on disposal of flammable, toxic, caustic, and
poisonous items. The procedures are in accordance with the Occupational Safety and Health
Administration (OSHA) Standards. The policy indicates at no time shall a toxic or caustic
substance be disposed of by flushing into sewers, pouring on the ground, or any unsafe
method. The physical plant manager stated he is the only one authorized to dispose of toxic
chemicals; however, he has not had to dispose of any flammable, poisonous, or toxic items or
materials since the last annual compliance review. Kitchen grease is disposed of by contacting
the approved disposal vendor who comes to the program to empty the grease trap located
outside the facility behind the kitchen. Documentation was provided to confirm this practice. A
random interview with direct-care staff, dietary staff, and youth revealed standard mop water is
poured down the floor drains. The program has an agreement with a biohazard waste company
which comes monthly to the facility to remove the biohazard waste, as needed. The biohazard
containers are secured in the medical office. The facility administrator was interviewed and
indicated the program participates in the local county waste program. Disposal can be made the
first Saturday of each month, as needed.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 69 (Revised September 2022)
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures which allows visitation, telephone calls, and mail
communication for youth while in the program. The visitation schedule is posted within the day
area and living unit of the program. It is also in the youth and parent/guardian handbook.
Regular visitation for authorized visitors is on Saturday and Sunday afternoon. The program
also has family day during the week. The visitation binder was provided by the program from
August 2022 to June 2023, which reflected the visitor sign-in sheets and searches. The
assigned case managers maintain an approved mail list, telephone log, and visitation list for
each youth. The case manager communicates with the youth’s assigned juvenile probation
officer to confirm the parent/guardian and other family members. This information was verified
when reviewing youth case management records. All outgoing and incoming mail is searched
with the youth present. The program offers youth the opportunity to write letters and make
telephone calls home weekly. The facility utilizes a language translator service as needed for
the youth or parents/guardians. Five youth were interviewed and each stated they can call their
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 69 (Revised September 2022)
parent/guardian or send a letter. Each reported English is their primary language and they are
unsure what services are in place for youth whose primary language is not English. Five staff
were interviewed and each reported the program has translators available. The facility
administrator was interviewed and stated the program utilizes an interpreter service to ensure all
youth and families can accurately represent themselves.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a policy and procedures including a variety of recreation and leisure activities
for youth. The daily activity schedule was posted in the common areas of the program.
Logbooks were provided and reviewed from August 2022 to July 2023, which reflected various
activities offered and participated in. Recreation outdoor activities were offered after school
based on the heat index or inclement weather and included large muscle activity. If the weather
does not permit outside activities, youth would participate in yoga, board games, or arts and
crafts. The activities promote cognitive skill development, creativity, teamwork, healthy
competition, mental stimulation, and physical fitness. The program contract requires the
program to have a recreational therapist. The recreational therapist’s credentials and schedule
were provided by the program and confirmed the contractual requirements were met. Five youth
case management records were reviewed and each had documentation to support recreational
therapy was included in each youth’s Individual Performance Pan. Five youth were interviewed
and reported the program allows them the opportunity to exercise, play outside, read books, or
play board games. Each youth reported being provided an hour of recreation daily with a variety
of activities. Five staff were interviewed and all five staff reported the youth receive thirty-five
minutes to an hour of recreation daily with a variety of activities.
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.26 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 69 (Revised September 2022)

report_type: QI Residential

program_name_raw: Les Peters Academy

rule: Indicator 1.15

excerpt: Advisory Board

rating: Failed Compliance

rule: Indicator 1.18

rule: Indicator 2.20

excerpt: Educational Access (Critical)

rating: Limited Compliance

rule: Indicator 5.06

excerpt: Logbook Entries and Shift Report Review

rule: Indicator 5.16

excerpt: Fire, Safety, and Evacuation Drills