summary: QI Residential - FY24-25 - 3 findings

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Daytona Juvenile Residential Facility
Rite of Passage, Inc.
(Contract Provider )
1386 Indian Lake Road
Daytona Beach, Florida 32124
Review Date(s): November 5 - 8, 2024
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Jennifer Tummino, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Kara Brown, Office of Accountability and Program Support, Deputy Regional Supervisor
(Standard 4)
Cheryl Francis, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Kristin Hanson, TrueCore Behavioral Solutions, Regional Compliance Manager (Standard 2)
Gustavo Mazorra, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Amanda Nelson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Luis Rodriguez, Office of Accountability and Program Support, Regional Monitor (Interviews and
Standard 1)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Sandra Thompson, Office of Accountability and Program Support, Regional Monitor (Standard
5)
Program Name: Daytona Juvenile Residential Facility MQI Program Code: 1226
Provider Name: Rite of Passage, Inc. Contract Number: 10693
Location: Volusia County / Circuit 7 Number of Beds: 33
Review Date(s): November 5 - 8, 2024 Lead Reviewer Code: 201
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
3.08 Specialized Treatment Services*
5.01 Youth Supervision *
5.07 Key Control*
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 70 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Non-Applicable
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 70 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 70 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Limited
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Satisfactory
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 70 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 70 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Limited
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Limited
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 70 (Revised September 2022)
Program Overview
The Daytona Juvenile Residential Facility is a thirty-three bed program, for thirteen to eighteen
year old males, located in Daytona Beach, Florida. The program is operated by Rite of Passage,
Inc, through a contract with the Department. The program provides juvenile sexual offender
treatment services through Pathways: A Guided Workbook for Youth Beginning Treatment,
Roadmap to Recovery, or Footprints: Steps to a Healthy Life. In addition, the program fosters
each youth by providing Anger Management for Substance Abuse and Mental Health Clients,
Conflict Resolution from the Inside Out, Transforming Anger to Personal Power, Social Skills
Lessons, and Activities for grades seven through twelve, Stress Management for Adolescents,
100 Interactive Activities for Mental Health/Substance Abuse Recovery, Creative Therapy, and
The Council for Boys and Young Men. Additional treatment services provided include family and
individual therapy, group therapy, and recreation therapy. Program administration is comprised
of a program director (PD) and a human resources coordinator. Case management services are
provided by a transitional service manager and a transitional manager. Mental health staff at the
program includes a contracted psychiatrist, a clinical director who serves as the designated
mental health clinician authority (DMHCA), three master-level therapists, and a recreation
manager. Medical services are offered seven days a week, from 7:00 a.m. to 5:00 p.m., and are
provided by a health services administrator (HSA) who is a registered nurse (RN), one part-time
RN, and one contracted medical doctor who serves as the designated health authority. There is
one full-time RN vacancy, and the part-time RN resigned the week of the annual compliance
review. Educational services are provided by Florida Virtual School. The layout of the program
includes two primary buildings including an administrative and education portable, and a brick
building which houses the youth dormitory, medical office, cafeteria, multi-purpose room, and
staff offices. The program has forty-one security cameras providing coverage, and ten additional
security cameras which were not functioning. A work order was submitted, and repairs were
completed the week of the annual compliance review. At the time of the annual compliance
review, the program had three vacant positions including one full-time RN and two coach
counselors.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 70 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures addressing pre-employment background screenings.
The program also has a policy and procedures for volunteers, mentors, and interns who work
with youth less than ten hours a month requiring sight and sound supervision. The program’s
policy requires a staff, who is background screened, to always be in the presence of and within
the line of sight of the volunteer who is not background screened. An Annual Affidavit of
Compliance with Level 2 Screening Standards was completed and submitted to the
Department’s Background Screening Unit (BSU) on January 19, 2024, meeting the annual
requirement. Teachers who are paid by the school board, or had funding provided by the school
board or Department of Education, received an annual screening, which was completed on
January 19, 2024. A review of the program’s staff, volunteers, and contractor rosters found nine
staff and two volunteers were applicable for an initial background screening during the annual
compliance review period. Each of the nine applicable staff and two volunteers had a completed
and eligible background screening, as required, prior to contact with youth and confidential
youth records. Reviewed documentation validated a criminal history report was reviewed for
each staff and volunteer. A pre-employment assessment tool was administered for each direct
care staff and a pre-employment assessment passing score was documented in each reviewed
direct care staff record. Two of the nine staff were added to the program’s roster in the Agency
for Healthcare Administration’s Clearinghouse system, as required. The remaining seven staff
and both volunteers were added to the program’s roster during the annual compliance review
week. None of the nine staff had a break in service indicated in the Department’s Staff
Verification System (SVS). A signed contraband attestation form was completed for all nine staff
and both volunteers. It is noted the contraband attestation form for one staff was completed
during the annual compliance review week.
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 addressing five-year background rescreening for
staff. There were no staff, volunteers, or contracted providers applicable for a five-year
background rescreening during the annual compliance review period.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 70 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to ensure program-related incidents, which place at-
risk or have the potential to place at-risk, the health, safety, or welfare of the public or of youth,
staff, visitors, the security of the facility, or the reputation of the provider are reported and
handled appropriately and in a timely fashion. The program has a zero-tolerance policy in
regard to any abuse. All staff shall immediately report any knowledge or suspicion regarding an
incident of abuse which occurred in the program by calling the Florida Child Abuse Hotline, and
additionally the notification is made to the Department’s Central Communications Center (CCC)
and their program director or supervisor on duty as soon as possible. The program had no
incident reports of a claim against staff for physical, psychological, or emotional abuse during
the annual compliance review period. The program conducted the Trauma Response and
Caring Environment (TRACE) self-assessment on April 15, 2024. Staff adhere to a code of
conduct, as acknowledged by the review and signing of a code of conduct form during their
orientation and contained in the staff records. Seven staff code of conduct forms were reviewed
which confirmed each staff signed the form. During the facility tour, the Florida Abuse Hotline
and CCC telephone numbers were observed to be posted throughout the facility. All seven
interviewed youth reported they feel safe in the program. All seven youth reported they have
never been prevented from making a call to the Florida Abuse Hotline or the CCC since they
have been at this program. All seven youth reported knowing the telephone number for the
Florida Abuse Hotline. All seven youth reported staff are respectful when talking with youth. Six
of seven youth indicated they have never heard staff use profanity when speaking to youth. The
remaining youth stated they have heard a staff use a profanity only once. The youth described a
single situation where they made the staff mad. None of the seven youth have ever exchanged
emails, telephone numbers, or social medica contact information with staff. Each of the seven
interviewed staff were familiar with and able to articulate the program’s abuse reporting
procedures. All seven interviewed staff reported they have never observed a coworker denying
a youth the right to an abuse call, and reported they have not witnessed their coworker’s using
profanity while speaking with youth. The program director (PD) reported the program’s code of
conduct includes how staff will represent the Department and the program, along with how staff
will protect individuals from the misconduct of others. Conduct which interferes with operations,
discredits the company, or is offensive to staff, youth, and their families is not tolerated. The
program uses a progressive corrective action system; however, does not tolerate offenses in
which physical abuse, threats, or profanity are directed towards youth. The PD indicated the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 70 (Revised September 2022)
program incorporates trauma-responsive practices by utilizing the champion team, which
includes representatives from each department. Additionally, the program completes the self-
assessment tool which assess and aids in implementing the trauma responsive approach and
caring environment for youth and staff. The PD indicated it is the policy of the program to
provide accurate reporting and dissemination of information regarding occurrences which
require the immediate and/or urgent response, action, or other intervention to protect and
ensure the safety and security of the youth, the public, and significant incidents relating to the
care, safety, and humane treatment of youth. All staff shall adhere to the Florida Administrative
Code for the reporting of incidents as well as outlined procedures required for internal incident
reporting which may not be required to be called into the CCC. The PD shall ensure all
designated reportable incident types are reported to the CCC within two hours of the incident, or
within two hours of becoming aware of the incident. The PD shall ensure the program maintains
a separate file of all incident reports and has a system in place for tracking of incidents. The PD
added the program has postings throughout the facility with all pertinent information regarding
contacting the Florida Abuse Hotline and CCC. All incidents are tracked in the program incident
report tracker and all calls to the CCC and Florida Abuse Hotline are discussed daily in
management meetings and shift briefings for all staff.
1.04 Management Response to Allegations (Critical) Non-Applicable
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had no allegations of physical, psychological, and emotional abuse during the
annual compliance review period; therefore, this indicator is rated non-applicable.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a policy and procedures addressing the process for contacting the
Department’s Central Communications Center (CCC). The program reported fourteen incidents
to the CCC during the annual compliance review period. A review of five reportable CCC
incidents during the annual compliance review period revealed all five incidents were reported to
the CCC within the required time frame, and each incident was documented in the center’s
logbook. There were no additional internal incidents or grievances during the annual compliance
review period which should have been reported to the CCC and were not. The program
experienced an increase of seven reportable incidents to the CCC. The program director
attributed the increase in reportable incidents to the increase of medically complex youth at the
program in 2024.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 70 (Revised September 2022)
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program has a policy and procedures naming Right Interactions (RI) as the Department
approved Protective Action Response (PAR) curriculum. A RI Incident Report will be completed
and filed in accordance with the Florida Administrative Code any time staff use a physical
intervention technique such as countermoves, control techniques, takedowns, or application of
mechanical restraints other than for regular transports. The program had one RI incident during
the annual compliance review period. A review of the one RI incident confirmed the report was
completed by the end of the staff’s workday and included statements from all staff involved. The
incident did not require the use of mechanical restraints, result in injury to the youth or staff, nor
did the youth allege abuse. The RI Report was reviewed by a supervisor, a RI instructor, and
the program director (PD) within seventy-two hours of the incident. The post-RI interview
indicated the need for a RI medical review, which was conducted. Monthly summaries of all RI
incidents were submitted to the Department’s regional office by the fifteenth of each month and
are maintained by the program. The program last updated the RI plan on January 26, 2024, and
the Department approved the plan on February 6, 2024. The program had no RI incidents
during the previous annual compliance review. The program’s RI rate during the previous
quarter was 0.83, which is below the statewide Residential RI rate of 1.81. The PD was
interviewed and advised RI incidents and use of force incidents are reviewed daily during the
morning meetings. The PD added all use of force incidents are to be communicated with
supervisory and administrative staff immediately and the program keeps an internal monitoring
process to address all trends in regard to RI and use of force. Seven staff were interviewed and
all were able to articulate the program’s RI process.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has a policy and procedures outlining the pre-service training and certification
requirements for all new staff. Seven staff training records were reviewed for pre-
service/certification requirements. All seven staff completed all required essential skills trainings
prior to contact with any youth. Five of the seven staff completed all additional required
trainings, while the remaining two staff were still within their first 180 days of hire. The program
indicated both staff have been under the direct supervision of fully trained staff until the pre-
service training is completed and both staff are also signed up to attend Motivational
Interviewing (MI) on December 9, 2024. All seven staff completed trainings as required by other
Rules or manuals. Five of seven staff completed specialized training on Juvenile Sex Offenders;
however, two of the five completed the training late on October 30, 2024. The remaining two
staff were still within their first 180 days of hire. There were multiple trainings which were not
documented in the Department’s Learning Management System (SkillPro), due to Department-
wide system outages during the annual compliance review period.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 70 (Revised September 2022)
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a policy and procedures outlining the in-service training requirements for staff.
Seven staff training records were reviewed for in-service trainings including four direct care staff
and three supervisory staff. All four direct care staff completed all required in-service trainings.
Two supervisory staff training records were both lacking a two hour suicide awareness and
prevention training and one of the two supervisory staff was also missing active shooter
preparedness and mental health and substance abuse in-service training. Two of the
supervisory staff records reflected the required eight hours of supervisor trainings in the areas of
coaching, leadership, and personal accountability, however, the remaining record was missing
the supervisory training in coaching. All seven staff completed trainings as required by other
Rules or manuals. Six of seven staff completed specialized training on Juvenile Sex Offenders
and one supervisory staff did not complete the specialized training. All completed trainings were
entered into the Department’s Learning Management System (SkillPro). All instructors were
qualified to deliver the trainings provided. The program maintains an annual in-service training
calendar which is updated as changes occur. The program submitted a list of in-service training
to the Department’s Office of Talent, Leadership, and Culture and the training plan was
approved and signed by the director of Talent, Leadership, and Culture on September 30, 2024.
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 which include training requirements for the grievance
process, as well as the informal, formal, and appeal phase. Youth are encouraged to resolve
issues and complaints through informal communication with program staff. Staff are directed to
use active listening skills, respectful conversation and give youth the opportunity for full
expression of feelings regarding the conflict, with the ultimate goal of encouraging and
promoting open communication, and to assist the youth in the development of improved
problem resolution skills. Informal complaints should be handled within twenty-four hours. The
program maintained grievance logs for each month of the annual compliance review period;
however, there were no formal grievances filed during the annual compliance review period. A
review of five informal grievances confirmed each grievance was resolved during the informal
phase and documentation reflected the program’s process. All seven youth interviews indicated
they knew where to find a grievance form and each youth knew what to do with the form upon
completion. All seven youth stated they could ask for assistance in completing a grievance form.
All seven staff were able to accurately describe the grievance review process, indicated
grievance forms are placed throughout the program, and the process had three phases. Six of
seven staff interviews indicated each phase has associated time frames, and the supervisor and
program director (PD) review grievances; two staff stated youth can request assistance in
completing the forms. The PD interview indicated the program's transition services coordinator
is the grievance officer who monitors the grievance process. The informal phase is an attempt
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Office of Accountability and Program Support Page 14 of 70 (Revised September 2022)
for the youth to process the situation with staff and an opportunity to learn pro-social
communication skills. During the formal phase, the supervisor will attempt to provide a
resolution and the appeal phase includes a meeting with the program director or director of
operations to conclude the matter.
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures ensuring life and social skills interventions are being
provided to youth. The interventions include evidence-based Life Skills Training (LST),
Aggression Replacement Training (ART), Pathways: A Guided Workbook for Youth Beginning
Treatment, and Skillstreaming the Adolescent. These services are provided through treatment
team planning by clinical staff. Non-clinical staff/direct care staff model pro-social behaviors
through daily interactions with youth to help youth function responsibly and successfully in
everyday life situations. The services address communication, interpersonal relationships and
interactions, non-violent conflict resolution, anger management, and critical thinking skills
including problem-solving and decision making. The Health Education Record of seven youth
confirmed the program incorporates additional life skills interventions to include dental hygiene,
nutrition basics, personal hygiene, and physical fitness, provided by medical staff. In addition to
the life skills intervention services, the program works with each youth to create a portfolio to
include a résumé, cover letter, practice job applications, determining career choices, finances,
and budgeting. Seven youth were interviewed, and each youth was able to provide examples of
groups and/or activities they have participated in while at the program. The program director
(PD) interview indicated youth participate in Pathways, Juvenile Sex Offender (JSO) process
group, anger management, Seeking Safety, Impact of Crime, and Skillstreaming the
Adolescent. The PD also indicated the program uses The Council for Boys and Young Men as
the gender specific group. The designated mental health clinician authority (DMHCA) interview
results indicated the youth have the opportunity to practice skills learned in group during daily
interactions with staff, peers, and teachers, as well as during interactions with
parents/guardians, juvenile probation officers, and outside visitors.
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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 provides restorative justice awareness to youth through Impact of Crime (IOC).
IOC is designated as a Standardized Program Evaluation Protocol (SPEP) primary service at
the program. For details related specific to IOC delivery, please refer to the annual SPEP report.
Restorative justice groups/activities are provided twice a week, in accordance with the program
schedule, and are designed to assist youth in accepting responsibility for harm caused and
impact of their offense, expose the youth to victims’ perspectives, and provide opportunities to
participate in restoration activities. The youth have an opportunity to participate in the Social
Justice Alliance through The Throw Away Kids Network and Hope for the Hood Network, who
come on-site quarterly to provide discussions on gun violence, suicide, and bullying. The
program director interview indicated clinical groups are provided to the youth which include
victim empathy. Restorative justice groups/activities were confirmed with evidence provided
from the program of a Restorative Justice/Education Fair on May 30, 2024 and June 25, 2024.
Observations of handouts confirmed activities were conducted during the annual compliance
review period. The program also provided the Positive Skill Development (PSD) Group brochure
for youth and group facilitator guides. The youth perform community service at the program.
Seven youth interviews confirmed they complete community service hours cleaning around the
program and youth were observed to be engaged in these services during the annual
compliance review week. The program director confirmed youth complete community service
projects where they are able to make reparation to their communities and victims.
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 to determine how new alerts are identified,
documented, updated, and communicated to staff. Any staff can identify and place a youth on
alert status. All alerts will be entered and updated in the Department’s Juvenile Justice
Information System (JJIS). Suicide alerts will be updated or closed by the mental health clinical
staff or a licensed mental health professional. The program has a color-coded alert board
displaying the alert status of each youth. Additionally, the program utilizes shift briefings and the
logbook to help communicate alerts to staff. Only medical staff will enter or update medical
alerts. No youth were identified with alert risks during the annual compliance review week.
Seven youth records were reviewed to address the program entering alerts into JJIS. Six
applicable youth records reflected fifteen alerts were entered into JJIS, updated, or closed, if
required, recorded on the alert board, and in the logbook, if applicable, and the remaining youth
was non-applicable for alerts. The program director’s interview confirmed the policy and
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procedures for entering and removing alerts. The nursing staff interview confirmed the nursing
staff are responsible for entering and updating medical alerts upon each youth admission and
as needed, thereafter. Seven staff were interviewed, each was able to describe ways alerts are
shared with staff including shift briefings, alert board, and emails from medical staff.
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 an official case record for each youth, which consists of three separate
records for each program area to include case management, healthcare, and mental health and
substance abuse services. All reviewed individual management records contained the youth’s
name, Department identification number (DJJID), date of birth, county of residence and
committing offense. Each individual management record contained the required sections to
include legal information, demographics and chronological information, correspondence, case
management and treatment team activities, and a miscellaneous section. All youth records were
labeled “Confidential” and secured in a locked room or file cabinet and inaccessible to youth.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has an advisory board consisting of a law enforcement member, a judiciary
member, a community business member, a member representing the school board, faith
community, LGBTQIA+, victim advocate and a parent/guardian of a graduated youth. Meetings
have been held quarterly since the last annual compliance review on December 21, 2023,
March 21, 2024, and June 20, 2024. The meeting scheduled for September 26, 2024, was
postponed to December 19, 2024, due to hurricane Helene. A review of the meeting invites
found all members of the advisory board were invited to all four meetings. The meetings held on
December 21, 2023, and March 21, 2024, were attended by program staff only. The meeting
held on June 20, 2024, was held through an online meeting platform and all board members
were involved in the meeting. The final advisory board meeting has been scheduled and all
invites have been sent. The interview with the program director (PD) indicated there is an active
community advisory board, which meets quarterly, generally at 11:30 A.M. on the third Thursday
of the designated month. The PD added the members of the community advisory board assist
the program with the planning of activities and speakers, as well as providing mentor services to
youth. A board member was contacted, and they stated they are involved with the program
advisory board and would like to see better participation by board members.
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1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures for evaluating staff performance standards. The
program’s policy has an established system for evaluating staff at least annually based on
established performance standards. A review of five position descriptions to include coach
counselor, recreation manager, night coach counselor, transition service manager, and shift
supervisor found performance standards were clearly identified and matched the job description
for each staff and whose job function included implementation of the program’s behavior
management system. During the annual compliance review period, the program received a
deficiency for a therapist vacancy in a key position. The deficiency was closed on August 14,
2024. The program indicated, during the entrance meeting for the annual compliance review,
the part-time registered nurse recently resigned. The program director (PD) interview confirmed
the annual performance evaluation process. The PD also indicated the program has a staff
suggestion box where staff are able to submit suggestions on a daily basis, which the program
reviews. The program has a morale committee to address the needs of the staff and the
program has been able to maintain a solid core of staff for the most part. The program staff
partake in pro-social activities off-campus as well as staff appreciation activities during the All
Campus Meetings. All seven interviewed staff confirmed they receive yearly performance
evaluations.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program 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. The program’s contract with the Department includes a Memorandum of
Negotiation (MON), Summary of Negotiated Points, or Secretary letter. There are five special
contract conditions not covered by the Monitoring and Quality Improvement indicators.
The first special contract condition states graduates may qualify to receive a scholarship from
Rite of Passage’s Passageway Scholarship Foundation. The foundation provides graduates
with funding for post-secondary education and training. This funding is available to all graduates
who have earned a high school diploma or a high school equivalency diploma. Initial
scholarships may be up to $1,500.00, and recipients are eligible for scholarship increases each
semester if they maintain a grade point average of 2.0 or greater. Working with Project Anchor,
the transition services coordinator and teachers will conduct workshops with post-secondary
youth regarding how to complete scholarship applications to include passageway scholarships
and completing the Free Application for Federal Student Aid (FAFSA) application. No youth
applied for the scholarship during the annual compliance review period.
The second special contract condition requires the program to sponsor on-site Career Day
events twice a year to offer additional career choices to youth. During the annual compliance
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review period, the program sponsored on-site career days with the assistance of the Volusia
County School Board, which took place on May 30, 2024, and June 25, 2024.
The third special contract condition requires youth to have the opportunity to participate in the
Social Justice Alliance. The program indicated all youth have an opportunity to take part in
Social Justice Alliance through The Throw Away Kids Network and Hope for the Hood Network,
who come on-site quarterly to provide discussions on gun violence, suicide, and bullying.
The fourth special contract condition requires the program to provide nutritious, well-balanced
meals and three snacks a day, which are prepared and served in a manner ensuring each youth
are taken into consideration. The program indicated all meals are delivered from their sister
program, Hope Forest Academy. A snack is provided along with each of the three meals, as
required.
The final special contract condition requires the program to employ a community liaison to
ensure its visibility in local and surrounding communities. The program employs a recreation
therapist whose job duties include identifying guest speakers from the community, and recruiting
and training volunteers and community members to bring additional opportunities to youth
through art, drama, and faith-based opportunities. The program director (PD) interview
confirmed the special contract conditions.
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 policy and procedures for reviewing and analyzing data trends to utilize in
decision-making practices. The program’s trend analysis and data-driven decision making are
strengthened through an internal database which captures trend analysis for youth restraints,
assaults and fights, runaways, total incidents, intakes, length of stay, workers compensation,
referrals and trainings, staff exits including terminations, and turnover rate. Every program is
required to input the data weekly so corporate can compile the information for the monthly
report. This weekly process and outcome information is aggregated into monthly totals, which
are displayed in a statistical report specific to each program, and are provided to the corporate
regional team and program management for the purposes of tracking trends and informing risk
management. The program shares the data trend analysis in weekly management meetings and
discusses ways to fix any issues noted. Corporate has a weekly call with all administration
teams from each program who discuss data trends and ways they can improve areas of
concern. Information is discussed in daily meetings with administrative staff. Staff are updated
throughout the month during the daily staff meetings, weekly staff meetings, and monthly staff
meetings. The program sends the monthly data report to the Department monthly. The program
participates in quarterly advisory board meetings and corporate senior management meetings
are held monthly. The findings from trend data analyses are utilized to determine recruitment
strategies, positive morale approaches, policy and procedures, youth supervision techniques,
restorative justice programs, and individual and family services.
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Office of Accountability and Program Support Page 19 of 70 (Revised September 2022)
Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures in place to address initial contact to the youth’s
parent/guardian as well as the committing court. The program’s policy states case management
staff will contact the parent/guardian by telephone to notify them of placement, within twenty-
four hours of the youth admission to the facility. Within forty-eight hours, the case manager
sends written notification of the youth’s placement to the parent/guardian. The assigned case
manager notifies the committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager, as applicable within five working days. The program often
exceeds this and sends within forty-eight hours. Seven youth case management records were
reviewed, and all records contained documentation the parent/guardian was contacted by
telephone on the day of admission. All records indicated parents/guardians were mailed an
admission letter on the day of admission which spoke about length of stay, visitation, and the
performance planning process. Along with the admission letter, parents/guardians also received
supplemental information to include a Parent Intake Survey; and a parent/guardian handbook
outlining facility rules. All reviewed records contained a copy of the Judge Notification of
Admission Letter sent to the committing court informing them of each youth placement, which
was mailed on the day of admission. The documentation of all reviewed records further
indicated the assigned JPO was copied on the notification and the youth’s post release
counselor, if known at the time of admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures in place to address youth orientation. Seven youth
case management records were reviewed, and all contained documentation showing each
youth participated in an orientation on the day of admission. The assigned case manager
completes the Orientation Checklist which addresses the program’s rules, expectations, and
goals, as well as services applicable to the youth. The orientation includes a review of the
assignment to a treatment team, introduction to key staff and their roles, assignment of a living
unit, group leader, and primary counselor, review of the program goals, services,
responsibilities, and expectations, review of the behavior management system and disciplinary
actions, access to the Florida Abuse Hotline or, if the youth is eighteen years of age or older,
the Department’s Central Communications Center, review of disaster preparedness procedures
and emergency building evacuation procedures and routes to include advising youth of areas
which are off-limits, youth area search procedures, contraband policy and consequences for
possession, review of the daily facility schedule guidelines, with a copy provided to the youth,
dress code and hygiene expectations, review of resident rights, with a copy provided to the
youth, grievance and abuse reporting, access to emergency medical, dental, and mental
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health/substance abuse services including hours of sick call, performance planning and
eligibility for release criteria, visitation schedule, telephone and correspondence policy and
procedures, release criteria and anticipated length of stay, review of personal property/valuables
guidelines, criteria for off-campus activities, rules and regulations regarding youth conduct,
review of the program’s gang pamphlet, with a copy provided to the youth, and a review of the
youth handbook. Information contained on the orientation checklist is discussed with the youth
by the therapeutic manager on the day of admission. Once all information is reviewed,
completed forms are signed and dated by the youth and the case manager. All records
contained a signed acknowledgement confirming each youth received a copy of the program’s
handbook for youth. Additional information reviewed with the youth at admission included a
review of rewards and consequences, Prison Rape Elimination Act (PREA) information,
information on how to access outside victim advocates for emotional support services related to
sexual abuse, the program’s zero-tolerance policy regarding sexual misconduct, including how
to report incidents or suspicions of sexual misconduct, the right to be free from sexual
misconduct, and items deemed unauthorized when in possession of youth. During the annual
compliance review week, the program had an admission where orientation practices were
observed and confirmed. Seven youth were interviewed, and all indicated they participated in
the orientation process on the day of their admission and were provided with the
aforementioned materials.
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 which address written consent of any youth eighteen
years of age or older before providing or discussing any of the youth’s information with the
parent/guardian, which is contained within the orientation policy. Seven youth case
management records were reviewed to determine if the program obtained written consent for
providing youth information to the parent/guardian, Department of Children and Families, or
other applicable agencies. Seven records were reviewed, and only one record was applicable
as the remaining six youth were under the age of eighteen. Two additional case management
records for youth over the age of eighteen were requested and reviewed. All three records
contained an authorization to release information form which was signed by the youth on their
eighteenth birthday or upon admission to the program for those youth who were already
eighteen years of age at the time of placement. All authorization to release information forms
were signed and dated by each youth as well as a witness.
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.
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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 in place which address a classification system to be
implemented in accordance with Florida Administrative Code to promote safety and security as
well as the effective delivery of treatment services. The system is designed to ensure the safest
room and dorm assignment for the arriving youth. Upon being admitted to the program the youth
is assessed for a myriad of areas to include youth demographic information, physical
characteristics, level of maturity, background information, key indicators or abnormal behaviors,
such as medical needs and mental health/substance abuse needs, suicide risk, escape risk,
youth’s skill level, current committing offense(s), demonstrated behavior at intake, the youth’s
prior history of violence, security risk, gang affiliation/involvement, and internal alert
classification including vulnerability to victimization and/or level of sexual aggression, youth’s
history of potential or verified human trafficking. All data is formulated into one classification
form which is reviewed during the youth’s admission classification meeting and signed by
required treatment team members including the youth’s parent/legal guardian and JPO. Seven
youth case management records were reviewed. Each record contained a classification form
completed on the day of the youth’s admission to the program which addressed all
requirements. In all instances, hard copies of the Vulnerability to Victimization and Sexually
Aggressive Behavior (VSAB) were completed by mental health staff on the day of each youth’s
admission to the program and reviewed with the treatment team during the classification
process. All seven youth were identified with a suicide risk and other risk factors, and one of the
seven youth was identified with a medical risk. Six of the seven records reviewed did not
accurately capture the youth’s alert status on the program’s classification form; however, had all
other requirements met. A review of the Department’s Juvenile Justice Information System
(JJIS) Alert List for any issues affecting classification was completed for all seven youth and
each youth was classified for purposes of assigning to a living area, sleeping room, and youth
group or staff advisor. The medical, mental health, substance abuse, security risk factors,
and/or special needs identified during or subsequent to the classification process were
immediately entered into the program’s internal alert system and JJIS for three of the seven
youth. The alerts for the remaining four youth were not entered into JJIS due to Department-
wide system outages; however, were immediately entered into the program’s internal alert
system. An interview with the program director confirmed factors such as physical health status,
level of aggression, age, and home county are all considered when classifying a youth and
assigning them to a dormitory and sleeping room. The program has a system in place for
reassessing youth 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 off-campus activities. As
warranted, reassessments are completed and filed in the youth’s case management record. All
seven reviewed records contained evidence of an initial classification, and three out of seven
had reclassification sheets which were signed and dated by members of the treatment team.
Seven case management records were reviewed for risk assessments. All seven youth had a
monthly risk assessment completed during their formal treatment team meeting.
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Office of Accountability and Program Support Page 22 of 70 (Revised September 2022)
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 in place which outline notification of law enforcement
regarding youth entering the program with suspected gang affiliation, or documented gang
membership, as well as for youth who are observed engaging in gang activities during their
commitment to the program. Seven youth case management records were reviewed; however,
none of the youth in the sample size were applicable for gang affiliation or membership. The
program was able to provide one additional record for review of gang identification and
notification. The identified youth was also confirmed in the Department’s Juvenile Justice
Information System (JJIS) as the only youth with a gang alert. A review of the youth’s record
demonstrated it contained a security threat questionnaire which was completed at the time of
admission to the program in order to gauge the youth’s level of gang involvement, if any.
Additionally, the program ensured timely notification to law enforcement, the school system, and
the youth’s juvenile probation officer. All documentation was maintained in the youth’s individual
record as well as in a gang binder.
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 in place which address the implementation of gang
prevention and intervention strategies. During the admission process, youth are screened for
gang involvement through the security threat group questionnaire and cross referencing the
youth’s face sheet and alerts page. Youth identified as having gang involvement have an alert
entered into the Department’s Juvenile Justice Information System (JJIS) as well as the
program’s internal alert board. Youth identified as being criminal street gang members, are
affiliated with any criminal street gang, or who are at a high risk of gang involvement are
required to participate in gang prevention and intervention activities. The program uses Gang
Resistance and Drug Education as their main gang curriculum. The program also uses Impact
of Crime (IOC) as part of their gang prevention and intervention strategies. Seven youth case
management records were reviewed; however, none of the youth in the sample size were
applicable for gang affiliation or membership. The program was able to provide one additional
record for review. A review of the record confirmed the youth was identified as a gang member
or affiliated gang member and showed the youth had a gang goal listed on their Individualized
Performance Plan (IPP). A review of the program’s gang binder found this youth participated in
monthly gang intervention sessions with their assigned case manager as evidenced by
observed sign in sheets. Lastly, the programs policy as well the program director’s interview
both indicated a youth will be provided the opportunity to dis-affiliate from their identified criminal
street gang should they choose to.
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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 in place to ensure a Residential Assessment for
Youth (RAY) is completed within thirty days of the youth’s admission to the program, and RAY
Reassessments are completed within ninety days after completion of the initial RAY. Seven
youth case management records were reviewed, and all records contained an initial RAY
completed within the required time frame. Several of the records demonstrated they were
completed when there were Department-wide system outages; however, each of those
instances showed the program had sent the initial RAY to the assigned Department staff to
score within the required time frame as evidenced by the attached email print out. Each youth
also had a copy of their RAY Overview Report filed within their individual record. Seven youth
case management records were reviewed to determine whether or not a RAY Reassessment
was completed within ninety days. All were applicable for RAY Reassessments. All seven
records contained the required RAY Reassessment documentation. In total, twenty five RAY
Reassessments were reviewed, with only one being two days late.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures in place to ensure the Youth Needs Assessment
Summary (YNAS) is conducted within thirty days of the youth’s admission to the program. The
youth’s assigned case manager is responsible for gathering information from all members of the
treatment team as well as collateral documents and incorporating this information into the
YNAS. Seven youth case management records were reviewed, and seven records contained a
YNAS which was completed with the required time frame. All YNASs were completed prior to
the youth’s Individualized Performance Plan (IPP) and were documented in the Department’s
Juvenile Justice Information System (JJIS).
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
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Office of Accountability and Program Support Page 24 of 70 (Revised September 2022)
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 in place to ensure all members of the treatment team,
youth, juvenile probation officer, and parent/guardians are involved in the development of the
youth’s performance plan within thirty days of admission to the program. The findings of the
initial assessment completed on each youth, along with information/feedback from the
intervention and treatment team, is utilized by the assigned case manager in order to create the
youth’s performance plan. In addition, information provided by the youth’s parent/guardian on
the Parent Input form sent at admission is incorporated into the performance plan. Seven youth
case management records were reviewed. All seven records contained documentation of the
Individualized Performance Plan being developed within the required time frame, following the
youth’s initial needs assessment and the completion of the initial Residential Assessment for
Youth (RAY), as required. The youth’s intervention and treatment team were present during the
development of the performance plan and included participation from the treatment team leader,
youth, program administration, direct care/living unit representative, mental health treatment
staff, education/vocation staff, and medical staff. Two of the seven case management records
were applicable for and included the Department of Children and Families (DCF) caseworker or
Agency for Persons with Disabilities (APD) waiver support coordinator; the remaining five
records were not applicable. In all seven records, there was documentation sent to the youth’s
parent/guardian from the assigned case manager requesting they review and sign the signature
sheet and return it in the stamped envelope provided by the program; however, only one of the
reviewed case management records contained an Individualized Performance Plan signature
sheet signed by the youth’s parent/guardian. All performance plans contained individualized
goals based on the prioritized needs of the youth. The top three criminogenic needs were met in
each performance plan reviewed. Two of seven records did not address delinquency
interventions or court-ordered sanctions. The remaining five records met all required elements.
Each performance plan listed the transition activities targeted for the last sixty days of the
youth’s anticipated stay, responsibility of staff in completing the goal, responsibility of youth in
completing the goal, start date, and projected completion/end date. Upon development of the
performance plan, and after signature by required parties, a transmittal letter and a copy of the
plan are mailed to the committing court, juvenile probation officer, parent/guardian, and DCF
counselor, as applicable. In all seven youth case management records, transmittal letters were
distributed to these parties within ten working days. All seven interviewed youth revealed they
participated in the development of their performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a policy and procedures in place which address performance plan revisions.
After creation of the Individualized Performance Plan, at thirty-day intervals, the assigned
treatment team meets to formally review the youth’s performance plan goals and determine
whether or not revisions are necessary. In addition, every ninety days after completion of the
initial Residential Assessment for Youth (RAY), case management staff complete a RAY
Reassessment and, should the results warrant, will revise the youth’s performance plan goals.
Seven youth case management records were reviewed. All seven were applicable. Of the seven
youth reviewed, each had at least one RAY Reassessment completed. Two of the seven
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records reviewed did not reflect any revisions were made based on the risk and protective factor
findings. In each instance the two youth demonstrated an increase in risk factors which were not
reflected on the youth’s formal treatment team review. The remaining five records reflected the
treatment team made necessary revisions when warranted. Of the seven records reviewed, five
reflected incorporation of both academic and treatment plans within the youth’s performance
plan. Two youth in the sample size warranted inclusion of their DCF plans and each
demonstrated they were incorporated into their respective performance plans. Three of the
seven records contained documentation showing the youth’s performance plan was updated to
facilitate transition activities during the last ninety days of the youth’s commitment, while the
remaining four records were not applicable due to length of stay.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a policy and procedures in place to ensure Performance Summaries and
transmittals are completed within required time frames. At each ninety-day interval, beginning
ninety days from the signing of the youth’s performance plan, the intervention and treatment
team meets to create a Performance Summary. In addition, prior to the youth’s release,
discharge, or transfer from the program, the intervention and treatment team will meet in order
to create the Performance Summary. Seven youth case management records were reviewed for
the completion of Performance Summaries. All seven youth case management records were
applicable for this indicator. A review of the seven records validated each youth received a
Performance Summary which was completed at least every ninety days following the signing of
their initial performance plan. All Performance Summaries included the youth’s status on each
performance/treatment plan goal, the youth’s overall adjustment/progression in the residential
commitment program, the youth’s overall progress during the rating period, educational and
vocational progress, including credits earned and behavior in school, transition/discharge
information, and youth comments. A total of twenty Performance Summaries were reviewed. All
twenty noted the youth’s interaction with peers, interaction with staff, overall behavior
adjustment to the program, and significant positive and negative events. Three of the twenty
summaries failed to denote the youth’s level of motivation/readiness to change. In all reviewed
Performance Summaries, the assigned case manager completed the Performance Summary,
each document was signed and dated by the staff member preparing the Performance
Summary, the treatment team leader, program director or designee, and the youth. There was
documentation in all applicable records showing the youth could read and add comments to
each Performance Summary prior to signing them. All reviewed case management records
contained the original Performance Summary. In all instances, within ten working days, a copy
of the original Performance Summary, along with a transmittal letter, were sent to the
committing court, juvenile probation officer, parent/guardian, and Department of Children and
Families (DCF) counselor, as applicable. Two of seven records did not support any findings the
youth received copies of their summary; however, the remaining five records did and supporting
documentation was maintained in each of the five youth case management records. Three
closed records were reviewed for discharge and release summaries. All three records contained
the original release summary which included the justification for the youth’s release from the
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program. Two of the three records contained a Pre-Release Notification (PRN), completed at
least forty-five days prior to the youth’s release; however, the remaining youth was civilly
committed from court preventing the program from completing all required release procedures.
All summaries and PRNs for the two youth were signed by the appropriate parties and
maintained in the youth’s closed case management record. The two applicable youth records
contained notification to the parent/guardian confirming the youth’s release date once the
program received the approved PRN from the committing court. All three closed records
contained documentation supporting the Exit Residential Assessment for Youth (RAY) was
completed for each youth following approval of their release. All three of the youth reviewed
were applicable for the Sexually Violent Predator Program (SVPP) and demonstrated the
required documentation was completed and the youth’s assigned JPO was notified. Each
contained the required checklist, Individualized Performance Plan, Performance Summary,
physical health summary, psychiatric evaluation, transition plan, and psychiatric records. Two of
the three records were applicable for victim notification, and both demonstrated the program
sent the Victim Notification of Release letter to the victim within the required time frame.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to encourage and facilitate the involvement of the
youth’s parent/guardian in the case management process. The program encourages
parent/guardian involvement throughout the entire youth’s length of stay in the program, and
notably during the assessment process, in the participation of the performance plan, during
progress reviews, during treatment team meetings, and during transition planning. If the
parent/guardian is unable to attend any of these meetings in person, they are given the
opportunity to participate by telephone and can provide verbal or written input as well. During
the annual compliance review week a formal treatment team was observed. All required
treatment team members were present with the exception of the living unit representative;
however, reviewed records demonstrated this is not standard. Seven youth records were
reviewed and reflected the parent/guardian is encouraged to participate in all aspects of
programming and is provided with information on all treatment dates and visitation. The program
provides family visitation, and the case managers and therapists encourage parents/guardians
to visit whenever they speak to them during treatment team meetings. The interview with the
program director advised parents/guardians are encouraged to attend and are invited to
participate in all aspects of the youth’s treatment in the program. The program director stated
there are several ways such as welcome letters, weekly calls, treatment teams, and monthly
family days where family members are encouraged to participate in their youth’s treatment.
Seven youth were interviewed, and all said their parents/guardians are contacted during their
formal treatment teams.
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2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a policy and procedures in place to ensure each youth and their intervention
and treatment team meet on a bi-weekly basis, alternating formally and informally, to review the
youth’s performance to include Residential Assessment for Youth (RAY) Reassessment results,
progress on Individualized Performance Plan (IPP) goals, positive and negative behavior
including behavior resulting in physical interventions, and treatment plan progress. Seven youth
case management records were reviewed. All the reviewed records reflected the program
exceeds requirements by completing two informal and one formal treatment team within each
month. Each record contained evidence the youth’s parent/guardian, juvenile probation officer
(JPO), and other pertinent parties including the case manager, transition specialist/transition
services manager, medical/health services, education, administration, mental health therapist,
and youth counselor/living unit representative are actively participating in these formal treatment
team progress review meetings. Formal reviews were conducted at least every thirty days and
were appropriately documented in each youth’s case management record. Each formal review
included a review of the performance plan progress report, status of performance plan goals
and objectives, contact with parents/guardians and JPO, performance plan goal focus for the
month, stage of change, physical and medical progress report, education progress report,
mental health/substance abuse progress report, issues/concerns with peers or staff, overall
program adjustment, and program behavior and performance progress report. Two of the seven
records did not fully capture the RAY Reassessment findings when warranted, only the
protective factors were noted. Each record contained informal treatment team meetings held
twice a month, before and after each formal meeting. During the program’s annual compliance
review, the reviewer was able to observe a treatment team meeting which demonstrated a
review of necessary areas and included all treatment team members with the exception of the
living unit representative. Seven youth were interviewed and all youth confirmed the information
reviewed with them during treatment team meetings. In addition, all seven youth stated their
parent/guardian is contacted during treatment team meetings.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a policy and procedures in place addressing the program’s transitional
planning process, to include participation of the program and the youth in the Community Re-
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Entry Team (CRT) meeting. A review of three closed youth case management records found
documentation of the treatment team planning for the youth’s successful transition to the
community upon release from the program. Each record also contained evidence of a transition
conference summary being completed at least ninety days prior to the youth’s targeted release
date. Documentation confirmed each transition plan was developed by the youth, treatment
team leader, administrative representative, clinical services representative, education
representative, medical representative, juvenile probation officer (JPO), and the youth’s
parent/guardian. Documentation in all three closed records verified all attendees signed and
dated the transition plan. During the transition conference, the treatment team members
reviewed transition activities listed on the youth’s Individualized Performance Plan, identified
additional transition activities, identified target completion dates, and the person/persons
responsible for completion. Each of the three closed records showed evidence of the plan being
sent with a request for return with signature to the parent/guardian and JPO. None of the
youth’s plans included a returned signature page from their JPO or parent/guardian. Two of the
three youth records contained evidence the youth and assigned case manager participated in
the CRT meeting held prior to the youth’s release. The remaining closed record documented the
youth was released from a court appearance prior to the scheduled CRT meeting. The two
applicable records reflected both the youth and case manager participated by telephone
conference. Email invites were present in both closed records, with documentation of the CRT
meetings recorded on the case management chronological record along with the date and the
name of the staff member making the entry.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures in place addressing the program’s exit process to
include assembling an exit portfolio for each youth to assist the youth once they are released
back into their home community. A review of three closed youth case management records
found all records contained an exit portfolio. Each exit portfolio was discussed and initiated for
the youth at the transition conference, and then verified during the exit conference with the
exception of one youth who was released from court prior to their exit conference. Each of the
three records reflected numerous attempts throughout the youth’s length of stay to solicit the
parent/guardian to provide the youth’s birth certificate and Social Security card beginning at
admission. Each exit portfolio included the youth’s transition plan and a calendar containing the
dates and times of follow-up appointments for the youth to attend in their home community. Two
youth portfolios contained copies of their birth certificates. One portfolio contained a state-
issued identification card and none of the portfolios contained Social Security cards; however,
as mentioned, each record had noted various attempts to procure these items. One record
contained requisite education and vocational documents earned while in the program, the
remaining two youth had a high school equivalency diploma (GED). All three records contained
examples of completed résumés and employment applications. The program’s contract did not
stipulate any additional portfolio requirements. For youth who were required to complete
community service hours, they were documented and included as part of the exit portfolio. Upon
release from the program, the completed exit portfolios were provided to the youth and
documented on the acceptance of custody form. In addition, case management staff forwarded
the exit portfolio information to the juvenile probation officer.
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2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures in place which address participation of the youth and
treatment team in the exit conference. Three closed youth case management records were
reviewed for the completion of an exit conference. Two of the three records contained
documentation an exit conference was conducted after the juvenile probation officer (JPO) was
notified of the youth’s release. One record did not contain documentation of an exit conference
due to the youth being released from court prior to the scheduled exit conference. Both of the
records had completed exit conferences which reflected the meetings were conducted at least
fourteen days prior to the youth’s release in which the status of goals developed at the transition
conference were reviewed and release plans were finalized. Additionally, both records included
provisions for continuation of education and/or employment, documentation the parent/guardian,
case manager, and JPO of each youth were aware of the vocational plan and post-release
discharge plans for both youth. A summary of the conference was found in both records and
included the date, signatures, names of participants by telephone, and a summary of pending
transition goals. As required, both exit conferences noted the required treatment team members
participated in person or by teleconference. Exit conferences were held separately from the
transition meeting and Community Re-Entry Team (CRT) meeting for both youth.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures which promote constructive input by youth. The
program uses informal “speak out” forms, grievance procedures, community meetings, and the
student council meetings (youth advisory board). Youth advisory board meeting agendas,
minutes, and notes, speak out forms, and grievance logs were reviewed during the annual
compliance review week. Documentation confirmed the youth advisory board meetings are held
regularly at the program. The program’s policy did not specify frequency of meetings; however,
there were minutes demonstrating they were held at least monthly and sometimes more. Seven
youth were interviewed and all indicated there were avenues, both formal and informal, for them
to provide input into programming, including the aforementioned “speak out” forms and
community meetings. The program director was interviewed and confirmed the program has a
myriad number of ways for youth to provide input into programming, including daily meetings
with the youth.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program has a policy and procedures which provide for a single licensed mental health
professional to act 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 DMHCA is a licensed mental health counselor (LMHC) with a clear
and active license which expires on March 31, 2025. There have been no other DMHCAs during
the annual compliance review period. The back-up DMHCA is a LMHC with a clear and active
license which expires on March 31, 2025. DMHCA is on-site forty hours a week and on-call
twenty-four hours a day for emergencies. A review of position description confirmed the DMHCA
is to provide services for the required hours . An interview with the DMHCA confirmed the
DMHCA is responsible for coordination, implementation, and oversight of mental health and
substance abuse services at the program. The DMHCA provides weekly supervision for non-
licensed clinical staff.
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 to ensure mental health and substance abuse
services are provided by staff with the appropriate qualifications. The program has no licensed
clinical staff with the exception of the DMHCA.
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 to ensure mental health and substance abuse
services are provided by staff with the appropriate qualifications. The designated mental health
clinician authority (DMHCA) must ensure clinical staff working under their supervision are
performing services the staff are qualified to provide based on education, training, and
experience. An informal interview with the DMHCA confirmed these procedures were being
followed. The program has three non-licensed master’s-level therapists who provide mental
health and substance abuse services to the program. The Department’s Licensed Mental Health
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Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision Log
was reviewed which verified each non-licensed mental health clinical staff working under the
direct supervision of the DMHCA received a minimum of one hour a week of on-site, face-to-
face direct supervision, by a licensed mental health professional, for the purpose of overseeing
and directing the mental health services provided in the program during the annual compliance
review period. The program had an active Chapter 397 license, which expires on March 22,
2025. This license is posted in the administration building hallway. Non-licensed clinical staff
provide mental health and substance abuse services seven days a week for forty hours each.
The program had a non-licensed therapist vacancy from May 26, 2023 until June 17, 2024. The
program received a minor deficiency for this key position vacancy, which was successfully
closed on August 14, 2024. A review of credentials for the three non-licensed therapists verified
two hold a master’s-level degree from an accredited university or college in the field of
counseling and the remaining therapist holds a master’s-level degree in social work. The non-
licensed substance abuse clinical staff providing substance abuse services in the program,
which is licensed under Chapter 397, are working under the direct supervision of a qualified
professional. Documentation confirmed two of the three non-licensed clinical staff 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 five Assessments of Suicide Risk (ASRs) conducted on-site in the physical
presence of a licensed mental health professional. The remaining non-licensed clinical staff
member has not yet completed training to conduct ASRs.
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 to ensure 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 screens all youth utilizing the Massachusetts Youth
Screening Instrument, Second Version (MAYSI-2) in the Department’s Juvenile Justice
Information System (JJIS). Seven youth mental health and substance abuse records were
reviewed. All seven records reflected a MAYSI-2 was completed for each youth in full on the
day of admission by a staff member qualified to complete screening. Documentation confirmed
staff reviewed all available information for each youth to include the youth’s commitment packet,
and reports and/or records for existing documentation of mental health or substance abuse
problems or history of human trafficking. Three out of seven reviewed records were completed
in JJIS on the day of admission. The remaining four youth’s MAYSI-2s were not completed in
JJIS on the day of admission due Department-wide system outages during the annual
compliance review period. Five out of seven reviewed youth’s MAYSI-2s indicated further
assessment was needed; however, all seven youth were referred for an Assessment of Suicide
Risk (ASR) and comprehensive evaluation as the program’s policy requires all youth have an
ASR and comprehensive evaluation completed upon admission to the program. The program
director (PD) and designated mental health clinician authority (DMHCA) were notified of the
need for an assessment in each youth record as documented on the mental health and
substance abuse referral form. An ASR was completed on the day of admission for each youth.
None of the seven reviewed youth were applicable for needing to be placed on precautionary
observation. An interview with the program director confirmed program utilizes the MAYSI-2,
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ASR, and comprehensive evaluation to screen youth for mental health and substance abuse
needs.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a policy and procedures to ensure youth identified by screenings, staff
observations, or behaviors post-admission as in need of further evaluation will be referred for a
combined Comprehensive Mental Health and Substance Abuse Evaluation. Seven youth mental
health and substance abuse records were reviewed. All seven youth had a new combined
comprehensive evaluation completed within thirty calendar days of admission. Each record
contained a substance abuse consent for services signed by the youth. Two out of seven
reviewed youth were applicable for completion of their comprehensive evaluation by non-
licensed clinical staff. In both records, the licensed clinical staff reviewed and signed the
comprehensive evaluation within ten calendar days. Each youth’s comprehensive evaluation
contained all required elements. None of the reviewed youth were applicable for needing an
updated comprehensive evaluation.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures to ensure youth determined to have a mental disorder
or substance abuse impairment and are receiving mental health or substance abuse treatment
have an Initial or Individualized Mental Health or Substance Abuse Treatment Plan. Seven
youth mental health and substance abuse records were reviewed. Each record had an initial
treatment plan completed on a program form which contained all required elements within
seven days of the initiation of treatment. The initial treatment plan was signed by the mental
health clinical or substance abuse clinical staff completing the form. Six out of seven initial
treatment plans were signed by all members of the treatment team who participated in the
development of the plan, except for the parent/guardian who participated on the telephone
which was noted on each initial treatment plan. The remaining youth was nineteen years of age
and did not have their parent/guardian participate. Two of seven initial treatment plans were
completed by a non-licensed mental health clinical staff, and each was signed by the licensed
clinical supervisor within ten days of completion; the remaining initial treatment plans were
completed by the licensed clinical supervisor. Two of seven initial treatment plans included the
youth’s psychiatric needs, including medication and frequency of monitoring by the psychiatrist;
the remaining five were not applicable; however, two of the remaining youth did have psychiatric
services added to their individualized treatment plans after completing a psychiatric interview.
Each youth had an individualized treatment plan completed on a program form which contained
all required elements. Treatment plan reviews were completed for each youth at minimum every
thirty days. All seven youth had individualized treatment plans signed by all required parties,
except for parent/guardian and juvenile probation officer who participated by telephone, and this
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was documented on each treatment plan. A review of video camera observations of three
groups compared to logbooks and sign-in sheets confirmed groups were being held as
scheduled.
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 which direct treatment and discharge planning.
Seven youth mental health and substance abuse records were reviewed. Each youth was
assigned to a treatment team upon admission to the program, which contained all required
members. Six out of seven reviewed youth had a properly executed Authority for Evaluation and
Treatment (AET) in their record. The remaining youth was nineteen years old; therefore, an AET
was not required. Each record contained a signed consent for substance abuse treatment
services. All seven records contained treatment progress notes which contained all elements of
the Department’s form. Documentation confirmed each youth was receiving individual therapy
and psychosocial skills training. Five out of seven reviewed youth received all services as
stipulated on their treatment plan. One of the remaining youth missed a family therapy session
in June and July 2024 and the remaining youth missed both family therapy sessions in February
2024. Three closed youth mental health and substance abuse records were reviewed for
discharge planning. Each record included a discharge plan on the Department’s Mental
Health/Substance Abuse Treatment Discharge Summary form which documented future
services needed. None of the reviewed youth were released while on suicide
precautions/mental health alert. Documentation confirmed the discharge plan was discussed
with each youth, parent/guardian, and juvenile probation officer (JPO) during the exit
conference. A copy of the Mental Health/Substance Abuse Treatment Discharge Summary was
provided to each youth, parent/guardian, and JPO.
3.08 Specialized Treatment Services (Critical) Limited 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 a policy and procedures which require specialized treatment services to be
provided to youth. The program’s required clinical groups according to the contract are
Pathways: A guided workbook for youth beginning treatment, Footprints: Steps to a healthy life,
as needed, Aggression Replacement Therapy, Cannabis Youth Treatment, and Sexual
Education/Healthy Sexuality and Healthy Boundaries. Seven youth were interviewed. All
confirmed they participate in individual and family therapy. Six out of seven interviewed youth
stated they attend individual therapy once a week, the remaining youth stated they had
individual therapy three times a month. Five out of seven interviewed youth stated they receive
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family therapy once a month, one stated they receive family therapy bi-weekly, and the
remaining youth did not state how often they received family therapy. Seven staff were
interviewed. All staff confirmed they do not facilitate any clinical groups. An interview with the
designated mental health clinician authority (DMHCA) confirmed all youth receive juvenile
sexual offender treatment services (JSO) and clinical services according to their individualized
treatment plan. An interview with the program director confirmed Pathways: A guided workbook
for youth beginning treatment is the primary JSO clinical group provided by the program. The
DMHCA is on-site forty hours a week and clinical staff are on-site seven days a week. A review
of clinical staff caseloads confirmed clinical staff have no more than ten youth to one therapist.
All non-licensed clinical staff have a master’s degree in social work or counseling. A review of
documentation confirmed the program provides weekly individual therapy, bi-weekly family
therapy, and the psychiatrist is on-site every other week. The program provides group services
five times a week, with a minimum of three JSO groups weekly. The program employs a
DMHCA and three non-licensed clinical staff. All non-licensed master’s level therapists are
required to completed training listed in Florida Administrative Code before providing JSO and
must receive approval from the Department’s Office of Health Services (OHS). OHS notified the
program on August 9, 2024, of these requirements. Two of the program’s non-licensed
therapists do not meet these requirements; however, they have been providing JSO during the
annual compliance review period. Documentation confirmed one of the non-licensed therapists
had been approved by OHS to provide JSO services in 2022; however, they were overdue for a
recertification. The remaining therapist was denied approval to provide services in 2021 by OHS
and there is not documentation the therapist was subsequently approved. The program has
indicated to OHS and the annual compliance review team the two therapists will complete
required training before the end of November 2024. The program did not have any youth
applicable for needing services during medical quarantine.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a policy and procedures to ensure the provision of psychiatric services which
include psychiatric evaluation, psychiatric consultation, medication management, and medical
supportive counseling provided to youth with a Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) mental disorder and each youth receiving psychotropic
medication in the program. The program employs a psychiatrist through an independent
contractor agreement. The psychiatrist is scheduled to be on-site every two weeks, for a
minimum of two hours, and on call for emergencies during the evening and on weekends and
holidays. The psychiatrist has a clear and active license which expires on January 31, 2025.
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 also incorporated into the
mental health clinical staff’s evaluations of the youth and the youth’s Individualized Mental
Health or Substance Abuse Treatment Plan (ITP). The program does not use a psychiatric
advanced practice registered nurse. A review was conducted of the sign-in/out logs for the
psychiatrist’s bi-weekly visits, which confirmed the psychiatrist was at the program as required
by the agreement with the program and program’s contract with the Department. Documentation
confirmed the psychiatrist actively participates in, manages, and supervises psychotropic
medication services at the program. The program has a back-up psychiatrist who is a medical
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doctor with a clear and active license; however, the program did not utilize the back-up
psychiatrist during the annual compliance review period. The program does not utilize
telepsychiatry. An interview with the psychiatrist confirmed the psychiatrist oversees psychiatric
interventions, medication management, and completes psychiatric evaluations for youth. The
psychiatrist stated they are on-site bi-weekly and meets with medical and mental health staff to
discuss youth receiving services prior to seeing youth. The psychiatrist has no concerns with the
mental health and substance abuse services at the program. An interview with the designated
mental health clinician authority (DMHCA) confirmed the program’s practice. Seven youth
mental health and substance abuse records were reviewed. Two of the seven youth were
applicable for entering the program on psychotropic medication and received a psychiatric
interview within fourteen days of admission; however, it is the program’s practice to refer all
newly admitted youth for a psychiatric interview. Documentation confirmed all seven youth had
a psychiatric interview conducted within fourteen days of admission. The initial diagnostic
psychiatric interviews included history of the youth, Mental Status Examination, diagnoses and
ensuring each diagnosis is consistent with the treatment plan, treatment recommendations,
prescribed medications, 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. The initial psychiatric evaluations were completed on a
form developed by the program which contains all required elements of the Department’s
Clinical Psychotropic Progress Note (CPPN). The form was clearly identified as an initial
psychiatric interview. Two of the seven youth entered the program on the psychotropic
medication and an additional youth was prescribed psychotropic medication during the initial
psychiatric interview and one youth was prescribed psychotropic medication several months
after admission, for a total of four youth requiring psychiatric medication management. The four
applicable youth records confirmed each youth received the prescribed psychotropic
medications and included documentation of face-to-face medication monitoring reviews being
conducted every thirty days. The psychiatric evaluations were documented on a form developed
by the program which contained all the required elements within the CPPN. The reviews were
completed, signed, and dated by the psychiatrist; and included identifying youth information,
diagnosis, target symptoms of each medication, evaluation, description of effects of prescribed
medication on target symptoms, the name, dosage and quantity of the medication, side effects,
youth’s adherence to the medication regimen, height, weight, blood pressure, and most recent
serum drug levels or laboratory findings. Two of the four applicable youth records with
prescribed psychotropic medications requiring monthly monitoring of Tardive Dyskinesia, and
reviewed documentation supported the monitoring was conducted monthly.
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 ensuring the program follows a suicide prevention
plan to safely assess and protect youth with elevated risk of suicide in the least restrictive
means possible. The program has a suicide prevention plan including 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 program’s review process for suicide attempts and mortality review includes
circumstances surrounding the event, program procedures relevant to the incident, all relevant
training received by involved staff, pertinent medical and mental health services involving the
victim, possible precipitating factors, and recommendations. The suicide prevention plan was
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reviewed annually as required, on September 19, 2024, by the designated mental health
clinician authority and on September 20, 2024, by the program director.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
The program has a policy and procedures which govern suicide prevention services. This policy
defines suicide precautions as methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. It requires any youth exhibiting suicide risk behaviors to be placed on
suicide precautions, and a minimum of constant supervision. Seven youth mental health and
substance abuse records were reviewed. None of the seven reviewed youth were applicable for
suicide prevention services. Three additional records were requested for a minimum sample of
three. Each applicable youth was determined to be at risk during their admission screening.
Each youth had an Assessment of Suicide Risk (ASR) completed on the Department’s form
within twenty-four hours of each youth being determined to be at risk. Each youth was
maintained on constant supervision. Each record reflected the parent/guardian and juvenile
probation officer were notified about the youth’s potential suicide risk as indicated on the ASR.
Documentation confirmed each youth was provided supportive services by mental health clinical
staff and each ASR was completed by a licensed clinical staff member, or by non-licensed
clinical staff under the supervision of a licensed mental health professional. One of the three
reviewed youth had an ASR completed by a non-licensed therapist which was reviewed by the
designated mental health clinician authority (DMHCA) within twenty-four hours. The remaining
two youth’s ASRs were completed by the DMHCA. All three youth were continued on constant
supervision after the completion of the ASR. Documentation confirmed each record contained
the actual date/time the clinician conferred with program director or designee and licensed
mental health professional recorded on the ASR in the date/time sections. Each record
contained a Follow-Up ASR on the Department’s form completed prior to the removal of the
youth from precautionary observation. Each youth was maintained on constant supervision until
the completion of a Follow-Up ASR and was stepped down to close supervision once it was
determined the youth could be discontinued from suicide precautions. Each youth was
maintained on close supervision until it was determined no longer necessary by the DMHCA,
and a conference was held between DMHCA and program director. A review of the
Department’s Juvenile Justice Information System (JJIS) reflected a suicide alert was initiated
for each youth and closed upon the recommendation of the Follow-Up ASR. A review of the
program logbooks confirmed evidence indicating administration or supervisory staff provided
instructions related to the suicide risk assessment findings and suicide precaution decisions for
each youth. While on precautionary observation, each at-risk youth was allowed to participate in
select activities with other youth in designated safe housing/observation areas of the program. A
review of video footage for two of the applicable reviewed youth placed on precautionary
observation was unable to be completed due to video footage being maintained a maximum of
thirty days; however, a review of video camera observation for the remaining youth and one
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additional youth on precautionary observation confirmed staff were always with each youth
while youth were on precautionary observation.
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program’s Suicide Prevention Plan requires staff to maintain one-to-one or constant
supervision of youth placed on suicide precautions. Seven youth mental health and substance
abuse records were reviewed. None of the seven reviewed youth were applicable for suicide
prevention services. Three additional records were requested for youth applicable for suicide
prevention services for a minimum sample of three. Documentation confirmed Suicide
Precaution Observation Logs were maintained for each youth for the duration the youth was on
suicide precautions. Each Suicide Precaution Observation Log documented the appropriate
level of supervision and observations of each youth’s behavior in real time, not exceeding thirty-
minute intervals. Each log was reviewed and signed by each shift supervisor and mental health
clinical staff. Each log documented safe housing requirements. In one of the three records,
warning signs were observed and the program director/designee and mental health clinical staff
were notified, which was documented on the log.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a policy and procedures which ensure 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. Seven pre-service and seven in-service staff training
records were reviewed for the completion of suicide prevention training. All seven pre-service
staff and five of seven in-service staff completed the required training. The remaining two in-
service staff were missing two hours of the required suicide prevention training. The program
has two suicide response kits which are co-located with first-aid kits in the administration break
room and in master control on the dormitory. The suicide response kits each contain a knife-for-
life, a needle nose plier, and wire cutters. A review was conducted of the program’s mock
suicide drills which confirmed the program completed the required quarterly drills on each shift.
An observation of video confirmed drills were simulated. The program exceeded the required
semi-annual training on emergency response procedures which include “mock” training in
emergency response to a suicide attempt or incident of serious self-inflicted injury to include
cardiopulmonary resuscitation. All staff who were not present during a quarterly drill had the
opportunity to review each drill scenario and procedures in an effort to understand the process
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and receive the necessary training to respond to an incident of a suicide attempt or incident of
serious self-inflicted injury in the program. An interview with the program director confirmed the
program has monthly medical and mental health drills. Seven staff stated they would notify
mental health clinical staff, place youth on sight and sound supervision, and document
supervision if a youth expresses suicidal thoughts. Two of seven interviewed staff also stated
they would search the youth and their room for sharp objects. One staff stated they would notify
their supervisor. All interviewed staff stated suicide response kits are located in master control
and the medical office. Three of seven staff stated a suicide response kit was also located in the
administration break room. Six interviewed staff stated medical and suicide drills are held
monthly. The remaining staff member stated they were held twice a month.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a policy and procedures which require a response 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 program. The program has a written combined crisis intervention and
emergency response plan which includes a notification and an alert system, means of referral,
youth self-referral, communication, supervision, documentation, and review.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a policy and procedures ensuring the program responds 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 program. 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. Seven youth mental health and substance abuse records were reviewed.
None of the reviewed youth records were applicable for requiring a Crisis Assessment. Three
additional records were requested for a minimal sample of three. All three reviewed youth had a
Crisis Assessment completed on the same day each youth was identified as being in crisis.
Each Crisis Assessment included reason for the assessment, Mental Status Examination and
interview, determination of danger to self and/or others, initial clinical impressions, supervision
and treatment recommendations, and recommendations for follow-up or further evaluation. Two
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of three youth were applicable for parent/guardian notification of follow-up treatment and both
applicable youth had documentation confirming their parent/guardian was notified. The
remaining youth was eighteen years old and did not require parent/guardian notification. Each
youth had a Crisis Assessment completed by mental health clinical staff. Two of the three youth
were applicable for requiring a mental health alert to be placed in the Department’s Juvenile
Justice Information System (JJIS) due to being placed on precautions after completion of the
Crisis Assessment. Both applicable youth had a mental health alert entered into JJIS. The
remaining youth did not need to be placed on precautions as determined by the Crisis
Assessment. Two out of the three reviewed youth were applicable for their Crisis Assessment
determining the youth posed a safety and security risk, and each youth remained on alert until a
follow-up Crisis Assessment and/or follow-up Mental Status Examination was completed. Both
youth were maintained on constant or one-on-one supervision which was documented on the
Department’s form. Only one of the three youth were applicable for returning from an off-site
Crisis Assessment as this youth was Baker Acted. The youth who returned from being Baker
Acted was placed on constant supervision until a mental health clinical staff reviewed the off-site
assessment documents and provided a Follow-Up Crisis Assessment. None of the three
reviewed records were applicable for having a Follow-Up Crisis Assessment completed by a
non-licensed therapist. One youth was applicable for being the alleged victim of a Prison Rape
Elimination Act (PREA). Documentation confirmed a Mental Health and Substance Abuse
Referral Summary was submitted immediately for a Crisis Assessment and youth was offered
ongoing mental health services.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a policy and procedures which govern 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 Florida Administrative Code
and the program’s emergency response plan. The program has a written combined crisis
intervention and emergency response plan which includes immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health and substance abuse services, transport for Baker and Marchman Acts, documentation,
training, and review.
3.18 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program has a policy and procedures to ensure individuals who are believed to be an
imminent danger to themselves or others because of mental illness or substance abuse
impairment receive emergency mental health or substance abuse services. Seven youth mental
health and substance records were reviewed. None of the reviewed youth were applicable for
requiring a Baker or Marchman Act. The program had two Baker Acts and no Marchman Acts
during the annual compliance review period. The two youth records for the incidents of Baker
Act were reviewed. Each youth was referred to mental health clinical staff immediately upon
staff determining each youth was at risk. Documentation confirmed each youth was placed on
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one-on-one supervision at the time of discovery of risk. Both youth were assessed by mental
health staff and a Baker Act was authorized by the designated mental health clinician authority
(DMHCA) and program director. Each youth was then transported to a local receiving facility by
law enforcement. Upon return to the program, both youth were placed on constant supervision
and a referral was completed indicating a Mental Status Examination was to be conducted.
Supervision was maintained until the DMHCA completed a Crisis Assessment.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedures to conduct an on-going safety planning process for
each youth. The safety plan shall be designed to identify stimuli which have both positive and
negative effects on the youth. Seven youth mental health and substance abuse records were
reviewed. All seven youth had a safety plan completed within fourteen days of admission which
contained all required elements. Each youth’s plan was jointly prepared by the youth,
parent(s)/guardian(s) or family member, and the program’s clinical staff, except for one youth
who did not have parent/guardian involvement in the initial safety plan preparation.
Documentation confirmed each safety plan incorporated any recommendations from previous or
current clinical assessments or screening instruments and incorporated trauma responsive
practices. Six out of seven youth had their safety plan reviewed and updated at least every thirty
days. One youth had one plan review which was three days late. Each plan was reviewed and
updated as necessary following any significant behavioral or mental health event identified by
the youth’s intervention and treatment team. Safety plans are located in a binder in the
administration break room for direct care staff to review as well as in the youth’s mental health
and substance abuse record. Seven youth were interviewed. All confirmed they participated in
the development of their safety plan. An interview with the program director confirmed safety
plans are updated monthly and on an as needed basis.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a policy and procedures stating the designated health authority (DHA) shall be
clinically responsible for the medical care of all youth at the program. The program’s DHA is an
osteopathic physician who holds a clear and active license with an expiration date of March 31,
2026. The physician’s specialty training is in family practice. The DHA does not have any
disciplinary cases or public complaints on record. The program does not utilize a physician’s
assistant or advanced practice registered nurse. Reviewed sign-in/out logs for the last year
confirmed the DHA was on-site for two hours each week, as required by contract. The program
has a back-up physician in the event of the DHA’s absence who holds a clear and active license
with an expiration date of January 31, 2026; however, the DHA has not been absent in the last
year. A review of the program’s contract found the program does not utilize telemedicine or
telehealth for medical services. The DHA was interviewed and stated they are on-site weekly to
conduct intake physicals, periodic evaluations, sick call, and refer youth off-site as needed. The
DHA indicated there is a tracking system in place to ensure all off-site findings, instructions, and
information are reviewed. The information is placed either in the youth Individual Healthcare
Records or the DHA’s folder. The DHA stated they are available to review important medical
issues with nursing staff by telephone or when on-site. The DHA stated if they are on a
scheduled absence, they notify the regional nurse to assist with coverage. The DHA stated they
have no concerns with healthcare at the program.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a policy and procedures indicating the designated health authority is clinically
responsible for all healthcare services provided to youth at the program. Daily clinical care shall
be performed by licensed medical staff, according to developed and authorized protocols. The
program’s contract indicates they will have a full-time health services administrator (HSA), who
works forty hours a week, one full-time registered nurse (RN), who works forty hours a week,
and one part-time RN, who works twenty hours a week. The program does not utilize any
licensed practical nurses. At the time of the annual compliance review, the program had one
full-time RN, who serves as the HSA, who had been out on Family and Medical Leave Act
(FMLA) since September 4, 2024, and one part-time RN. The program had one additional part-
time RN who resigned on October 27, 2024. Prior to September 4, 2024 the three RNs were
meeting the required nursing hours. Between September 4 and October 27, 2024, the two part-
time nurses were working additional hours and meeting the required nursing hours. Between
October 24, 2024 and the week of the annual compliance review, the part-time RN was working
approximately eighty hours a week; however, the program was not meeting their required hours.
The program had a full-time RN start on November 7, 2024, during the annual compliance
review week, and indicated they will be able to cover their required hours with the new RN. A
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review of nursing licensure credentials confirmed each RN’s license was clear and active. Each
nurse has a current cardiopulmonary resuscitation certification card.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The medical FOPs and healthcare protocols were signed by
the designated health authority (DHA) and the program director (PD) on January 10, 2024. The
psychiatrist signed both on January 13, 2024. A cover page indicating all FOPs were reviewed
was signed by the program’s health services administrator (HSA) and one registered nurse (RN)
on January 10, 2024, and by the other RN on January 13, 2024. There was one FOP which had
been revised since January 10, 2024, and each nurse signed and dated the FOP following the
revision. A cover page indicating the healthcare protocols were reviewed was signed by the
HSA and both RNs on February 14, 2024. The program did not have any newly hired RNs over
the last year, aside from the one who started during the week of the annual compliance review.
Approval of treatment protocols and standing procedures were written and authorized by the
DHA and were not delegated 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.
The program has a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET), authorizing specific treatment for youth in the custody of the
Department. Seven youth Individual Healthcare Records (IHCRs) were reviewed. Six IHCRs
contained a valid AET form. Each AET was a copy and was stamped with the word “copy.” Each
AET was signed by a parent/guardian and a Department representative; however, one of the six
did not have a date on it, only the month and year. One youth was eighteen years of age, and
had a documented release of information in their IHCR. During an interview with nursing staff, it
was stated nursing staff review all projected intakes in the Department’s Juvenile Justice
Information System and validate each AET. New admissions are discussed with case
management and, if needed, a case manager will contact the juvenile probation officer to obtain
a new AET. Nursing staff indicated a release of information is signed by each youth when they
turn eighteen, or if they are eighteen when they arrive to the facility.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure parents/guardians are informed of
significant changes in youth’s conditions and to obtain consent when new medications and
treatments are prescribed. Seven youth Individual Healthcare Records (IHCRs) were reviewed.
Six were applicable for parent/guardian notification, as the remaining youth was eighteen years
of age at the time of admission. Two youth IHCRs were applicable for parent/guardian
notifications for over-the-counter (OTC) medications beyond those covered by the Authority for
Evaluation and Treatment (AET). Both IHCRs contained documentation of parent/guardian
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notification and consent for each OTC medication. The remaining four youth did not receive any
OTC medications beyond those covered by the AET. New medication was ordered for all six
applicable youth. Documentation of notification to the parent/guardian for each new medication
was in each youth’s IHCR. All written notifications were sent utilizing the correct forms. Two
youth were taking psychotropic medications at the time of admission, and two additional youth
were prescribed psychotropic medications while at the facility. Three of the four youth had a
new psychotropic medication prescribed, discontinued, or had the dosage significantly changed
while at the program. Documentation in two of the three IHCRs found parent/guardian verbal
consent was documented on page three of the Clinical Psychotropic Progress Note (CPPN). A
signature indicating a staff witnessed telephone conversations for psychotropic medications was
located on page three of the CPPN for one of the two youth. The remaining IHCR contained five
CPPNs requiring a witness signature in which there was no witness signature. The remaining
youth was not applicable due to being eighteen years of age. All seven reviewed youth had their
vaccinations verified on the day of admission. None of the reviewed youth received a
vaccination at the program. None of the reviewed youth required an exemption for a
vaccination. An interview with nursing staff found parent/guardian verbal consent is obtained for
any OTC medication which has not been approved by the AET, for new prescriptions, any
significant dosage change, or when a medication is discontinued. Nursing staff stated
notifications are made within twenty-four hours with a written notification, and verbal consent is
obtained as soon as possible. If a youth needs emergency services, all attempts are made to
verbally contact a parent/guardian prior to the youth leaving for the emergency room.
Parents/guardians are also contacted upon a youth’s return to the facility with the results of the
emergency visit. Nursing staff indicated a witnessed verbal consent is obtained to initiate a new
psychotropic medication, significantly change the dosage, or discontinue the medication.
Nursing staff indicated vaccinations are not provided on-site. Immunization records are
reviewed prior to and at each admission. If a parent/guardian is requesting exemption from an
immunization, they must provide the appropriate documentation from the Department of Health.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures which ensure youth are screened upon admission for
healthcare concerns which may require a referral for further assessment by healthcare staff.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for completion of the
Department’s Facility Entry Physical Health Screening (FEPHS) form. Each youth’s IHCR
contained a FEPHS form completed by a registered nurse (RN) on the day of their admission.
The program only had one youth applicable for a change in physical custody for greater than
twenty-four hours. The program completed a new FEPHS form as required. An interview with
nursing staff found each youth is seen by a RN within thirty minutes of admission. Nursing staff
are notified of new admissions through the commitment manager. If there is a change in
custody, a new FEPHS form is completed upon the youth’s return to the program.
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4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program maintains a policy and procedures to ensure all youth are oriented to the general
process of healthcare delivery services at the program. Seven youth Individual Healthcare
Records (IHCRs) were reviewed for healthcare orientation. Each youth received a general care
orientation on the day of admission. The program’s healthcare orientation included all required
topics. Each youth’s IHCR included a signed Health Education Acknowledgment form indicating
they reviewed medical care education and were able to ask any questions. A Health Education
Record was also located in each youth’s IHCR. The program’s contract indicates they must
provide health education monthly. Documentation in each youth’s IHCR indicated they receive
monthly education on the required topics.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program maintains a policy and procedures to ensure the designated health authority
(DHA) is notified when a youth admitted requires emergency care or routine notification in
accordance with the Department’s requirements. The program’s practice is to notify the DHA of
each admission. Seven youth Individual Healthcare Records (IHCRs) were reviewed. Three
reviewed youth had a known or suspected chronic condition upon admission. None of the
reviewed youth were identified as in-need of an emergency response upon admission. Each
youth’s IHCR contained documentation of notification being made to the DHA within twelve
hours of admission. Two youth were taking psychotropic medication when admitted to the
program. Both IHCRs included documentation of the psychiatrist being notified. During an
interview, nursing staff stated a nurse notifies the DHA, by telephone, of all admissions. The
notification includes each youth’s history and any chronic conditions, and is completed once the
initial nursing assessments are complete and IHCRs are reviewed. All notifications are
documented in the nursing admission note.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program maintains a policy and procedures to ensure the standard Department’s Health-
Related History (HRH) form is used for all youth admitted into their physical custody. Seven
youth Individual Healthcare Records (IHCRs) were reviewed for completion of a HRH form. A
new HRH form was completed on the day of admission for each youth. Each reviewed HRH
form was completed prior to the Comprehensive Physical Assessment and reviewed by the
designated health authority. Nursing staff stated a nurse completes a HRH form during the initial
nursing assessment for each youth. HRH forms are completed annually, as needed, or anytime
there is a significant medical event or change.
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4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the standardized Comprehensive Physical
Assessment (CPA) form is used for all youth admitted into the program. A review of seven youth
Individual Healthcare Records (IHCRs) found a new CPA form was completed by the
designated health authority (DHA), on the Department’s CPA form, within seven days of
admission for each youth. Each youth’s Medical Grade was documented on their CPA. Three
youth were identified as Medical Grade one, two youth were identified as Medical Grade three,
and two youth were identified as Medical Grade five. All sections of each CPA were marked with
an “O” or an “X.” Those sections marked with an “X” had comments by the DHA in the
comments section of the form for each youth. Each youth refused a portion of the exam. Each
youth’s IHCR included a signed refusal form reflecting the refused portion and was dated the
date of the exam. The Department’s Problem List was updated, as required, for each youth. All
seven youth had at least one verified Tuberculosis Skin Test (TST) completed and documented
within the last year. Each youth’s results were documented on their CPA and Infectious
Communicable Disease (ICD) form, and each youth’s test results matched on both forms. An
interview with nursing staff found CPAs are conducted by the DHA within seven days of
admission and annually thereafter. Nursing staff stated they review the Department’s Juvenile
Justice Information System for TST status prior to admission. A tuberculosis screening is
completed during the initial nursing assessment and a medical tracker is maintained to monitor
for TST due dates. Nursing staff stated TST documentation is located on the Facility Entry
Physical Health Screening form and the ICD form.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program maintains a policy and procedures ensuring all youth are evaluated and treated, if
necessary, for sexually transmitted infections (STIs). Seven youth Individual Healthcare
Records (IHCRs) were reviewed. Each youth’s IHCR contained documentation showing they
were screened and evaluated for STIs on the day of admission. Further evaluation was not
required for any youth; therefore, testing was not ordered for any youth. None of the reviewed
youth were out of the Department’s physical custody or required a rescreen for any reason.
Consent forms in all seven reviewed IHCRs reflected each youth was offered counseling,
testing, and if indicated, treatment/referral for human immunodeficiency virus (HIV). Each youth
refused HIV testing and a refusal was documented. The program’s policy and procedures
indicate youth HIV test results are only disclosed to entities as outlined in Florida Administrative
Code. The program has a provider with a 500/501 certification by the Department of Health,
which expires on April 30, 2025, who provides their HIV pre-test and post-test counseling
services. Seven interviewed youth indicated they can ask for a HIV test. An interview with
nursing staff found each youth is screened for STIs. Each youth is interviewed during the initial
nursing assessment to obtain their history. If further evaluation is required, they are referred for
an off-site evaluation. All screenings, evaluations, referrals, and test results are documented on
the Infectious Communicable Disease (ICD) form. Lab results are filed in the laboratory section
of each IHCR. Nursing staff stated HIV test results are sealed, marked confidential, and filed in
the lab section of each IHCR. Results are given to youth upon discharge from the program.
Nursing staff stated youth are asked if they want HIV testing during intake. A log is maintained
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identifying each youth who has requested testing. Youth sign a consent and then receive
testing. Youth can request to be tested at any time and a community provider comes monthly to
provide education and testing. All pre and post-test counseling is documented on the Health
Education Record.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program maintains a policy and procedures to ensure all youth can submit sick call
requests and have their complaints treated appropriately through the program’s sick call system.
Seven Individual Healthcare Records (IHCRs) were reviewed, and three were applicable for sick
calls. None of the three applicable youth presented with a similar sick call complaint three or
more times within a two-week period. There was a total of ten sick calls documented for the
three applicable youth. Each Sick Call Request form was completed by the youth requesting a
sick call and the nurse conducting the sick call. Reviewed documentation found each sick call
was completed by a registered nurse (RN). Each youth’s Sick Call Request forms were filed in
their IHCR in reverse chronological order. Each Sick Call Request form was documented in
accordance with Florida Administrative Code. Each youth’s sick calls were documented on their
Sick Call Index in their IHCR. Each sick call was documented on the program’s Sick Call
Referral Log. All dates listed on the Sick Call Indexes corresponded to the completed Sick Call
Request forms located in the IHCRs. None of the youth were in restricted housing. A review of
the daily schedule, posted schedule, and nurse interview found sick call is held Monday through
Friday from 7:30 a.m. to 8:00 a.m., and on Saturday and Sunday from 1:00 p.m. to 1:30 p.m.,
which meets the contract requirement of providing sick call seven days a week. Sick call hours
are posted outside of the medical office. An exam table is located in the medical clinic to utilize
during sick calls and only RNs conduct sick call. Sick Call Request forms are available to youth
on the dorm and in the group room. If there are no nursing staff on-site, the program’s policy
indicates Sick Call Request forms should be reviewed by a supervisor within two hours. Seven
youth were interviewed. Two youth stated they see a nurse immediately when requesting a sick
call, four youth stated they see a nurse within one day, and one youth stated they see a nurse
within three days. During an interview, nursing staff indicated youth can submit a sick call at any
time by completing a form and placing it in the sick call box. The box is monitored by nursing
staff once a day, and all youth are seen within twenty-four hours of making a request. A referral
is completed if a youth has the same complaint three times within fourteen days or if the
treatment protocol appears to be ineffective. Nursing staff indicated the program does not utilize
room restriction. A sick call was not observed, as no sick calls took place during the annual
compliance review 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.
The program maintains a policy and procedures showing they have a comprehensive process
for the provision of episodic care and first-aid care. Seven youth Individual Healthcare Records
(IHCRs) were reviewed and four were applicable for episodic care. A total of seven episodic
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care or first-aid care events were reviewed for the four youth. On-site care was provided by
licensed healthcare staff for each event. Each event was documented in the required subjective,
objective, assessment, and plan (SOAP) format. An episodic care event was not observed, as
one did not take place during the annual compliance review week. During an interview, nursing
staff stated they document episodic care on their nursing progress notes and on the Episodic
Care Log. Non-licensed staff can complete the Department’s required form to document and
notify nursing staff of youth who received episodic care while nursing staff were off-site. Off-site
emergency care is documented on the Episodic Care Log.
The program maintains seven first-aid kits. The kits are kept in the maintenance office,
administration, master control, one for transport, kitchen one, kitchen two, and case
management. Nursing staff regularly inventory the contents and restock if needed. If staff
determine a kit needs to be restocked, they shall bring it to nursing staff to restock. Four first-aid
kits were checked. Three of the first-aid kits were fully stocked with designated health authority
(DHA) approved items; however, the master control first-aid kit was missing adhesive tape. A
review of documentation for the last year found first-aid kits were inspected monthly by nursing
staff, as required. Nursing staff was interviewed and indicated there are eight first-aid kits;
however, the provider’s regional nursing director clarified one of the first-aid kits is no longer
there.
The program has two automated external defibrillators (AEDs), which are located in master
control and kitchen one. Instructions are located with both AEDs. On-site nursing staff check to
ensure the AED batteries and pads are operable. A review of documentation for the last year
found checks were conducted monthly. Nursing staff conducted a self-test on both AEDs during
the annual compliance review week, with no issues being noted. The green light was flashing on
both AEDs during the annual compliance review week. The batteries for the master control AED
were last changed in February 2023 and expire in February 2027. The batteries for the kitchen
one AED were last changed on May 17, 2023, and expire in April 2027. The pads on the master
control AED expire on March 28, 2025, and the pads on the kitchen one AED expire on June
14, 2025. Nursing staff confirmed in an interview there are two AEDs in the facility and
instructions are kept with both AEDs. Nursing staff also confirmed they check to ensure the
AEDs are operable and confirmed the expiration dates for the batteries and pads.
A review of emergency drill documentation for the last year found the program has conducted
drills, which simulate an episodic care event which calls for immediate first-aid and/or
administration of cardiopulmonary resuscitation (CPR) techniques and the initiation of the
emergency procedures to follow when a life-threatening emergency occurs, at least monthly on
each shift. A review of drill documentation found all direct care staff who have been at the
program for at least a year participated in a drill including the use of CPR during the past year. A
video review of emergency drills confirmed drills were simulated. The program has a list of
emergency numbers, inaccessible to youth, located in administration and in the program
director’s (PDs) office. A review of training logs found all six direct-care staff, who are trained to
assist in the administration of medication, were trained by a RN on the administration of the
epinephrine auto-injector. A review of seven pre-service and seven in-service staff training
records found each staff was trained in episodic, first-aid, and emergency care. Nursing staff
indicated drills are conducted monthly on each shift, with the use of CPR quarterly. Nursing staff
stated emergency numbers are inaccessible to youth and located in master control and the PD’s
office.
The program has a policy on the use, access, and inventory of Narcan. The policy indicates the
program will maintain at least one prescribed stock Narcan. Narcan must be maintained in a
designated, locked area which is accessible to trained supervisors. A perpetual and weekly
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inventory shall be kept, and the Narcan shall be stored at room temperature. If Narcan is utilized
on a youth, the youth must be transported by emergency medical services. The program stores
Narcan in the medication cart and in administration. Nursing staff and supervisory staff have
access to the Narcan. A review of training logs found all six staff who have been trained in
medical administration have been trained on the administration of Narcan. A review of
inventories found Narcan is inventoried daily and weekly.
Seven staff were interviewed, and each indicated they are able to call 9-1-1 for a medical
emergency. Seven interviewed youth stated they can see a doctor or dentist, if needed.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures ensuring the program provides for timely referrals
and coordination of medical services to off-site healthcare providers. Five of seven reviewed
Individual Healthcare Records (IHCRs) were applicable for off-site care. A total of nine off-site
care events were reviewed for the five youth. The Department’s Summary of Off-Site Care
Consultation Report form was utilized for each off-site care event. None of the off-site care
events were for emergency care; therefore, documentation on the Episodic Care Log was not
applicable. Documentation of parent/guardian notification was located for four of the five youth
off-site care events. The parent/guardian notification for the remaining youth was completed
following the event. The designated health authority (DHA) reviewed all off-site care findings,
instructions, and information and signed each Summary of Off-Site Care Consultation Report
form acknowledging their review. Two youth required follow-up care. Evidence indicating both
youth received appropriate follow-up care was provided, with one youth having one follow-up
appointment, and the other youth having two follow-up appointments. During an interview,
nursing staff indicated youth who are sent off-site for first-aid or emergency purposes are
tracked utilizing the Episodic Care Log. Nursing staff are notified of all off-site medical events
which occur after nursing hours. Nursing staff indicated they review all orders with the DHA
upon each youth’s return. A checklist is completed to ensure all steps are completed. The
DHA’s folder is utilized for weekly review, and required documentation is flagged in each youth’s
IHCR for the DHA to review during their next on-site visit. A healthcare tracker is utilized to track
any follow-up care.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program maintains a policy and procedures to ensure youth who have chronic conditions
receive regularly scheduled evaluations and necessary follow-up. Seven youth Individual
Healthcare Records (IHCRs) were reviewed. Three of the youth were applicable for chronic
conditions. All three reviewed youth were identified on the Department’s Facility Entry Physical
Health Screening (FEPHS) form as having a chronic condition. None of the reviewed youth had
a communicable disease. Two youth were taking prescribed medication on an ongoing basis. All
three youth had an identified chronic health condition, were undergoing treatment for a physical
health condition, and were classified with a Medical Grade two through four, or a Medical Grade
five for youth also taking psychotropic medications. Each youth was placed on the program’s
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chronic illness list. A review of progress notes found each youth received periodic evaluations at
least every ninety-days. There were no youth at the program who were taking anti-tuberculosis
medication. All periodic evaluations were conducted on-site, and periodic evaluations were
completed prior to renewing any prescription medications which expired for the two youth taking
prescribed medications. There were no instances of lapses in care or missed periodic
evaluations for any youth. The Department’s Problem List was updated, as required, for each
youth. The program director (PD) was interviewed and indicated administration meets with
medical staff daily to discuss any medical issues pertaining to youth. The PD indicated
discussions occur in morning management meetings and the previous day’s documentation is
reviewed. An interview with the designated health authority (DHA) confirmed periodic
evaluations are conducted every ninety days, or sooner, if needed. Nursing staff have a tracker
to ensure they are completed as required. Nursing staff stated youth are placed on the medical
tracker at intake, or once they are determined by the DHA to have a chronic condition. The
medical tracker monitors and tracks due dates for periodic evaluations.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program maintains a policy and procedures indicating they shall receive, store, inventory,
and provide medication in a safe and effective manner which shall be demonstrated by
observation, as well as review of documentation of procedures and processes. Seven youth
Individual Healthcare Records (IHCRs) were reviewed. Four youth were identified on the
Department’s Facility Entry Physical Health Screening (FEPHS) form and in the progress notes
as admitted to the program with medication. Documentation in each youth’s IHCR found each
youth’s medications were verified, utilizing the required Department form, prior to being admitted
into the program. The designated health authority (DHA) and/or psychiatrist was contacted to
obtain an order to resume the medication prescribed prior to admission for all four youth. Two
additional reviewed youth were prescribed medication after their admission. All medications for
all six youth were observed to have a current, valid order, and were given pursuant to a current
prescription. Each time a medication was continued, discontinued, changed, or a new one was
ordered, the DHA placed an order on a Practitioner Order form. None of the youth were in
restricted housing. Two youth were applicable for over-the-counter (OTC) medications not listed
on the Authority for Evaluation and Treatment form. All OTC medications for both youth were
administered in accordance with approved protocols or practitioner’s order. The program utilizes
a preprinted pharmacy Medication Administration Record (MAR), which includes all required
elements; however, one medication for one youth had an incorrect end date documented, and
one medication for another youth had an incorrect start date documented. A review of MARs
found youth and staff initialed each administered medication and side-effect monitoring was
documented at least weekly for each youth. There were no undocumented explanations for
lapses or errors in medication administration. Trained non-healthcare staff assisted in the
administration of medication for one reviewed youth when nursing staff were not on-site. Two
youth refused medication. Both youth signed a Refusal of Treatment form for each refusal, and
each refusal was clearly documented on their MAR. None of the reviewed youth required
parenteral medication. Two youth were prescribed psychotropic medication upon admission,
and the DHA and psychiatrist were notified the day of admission for both. The psychiatrist
conducted an Initial Diagnostic Psychiatric Interview with both youth within fourteen days of
admission. Two additional youth were prescribed psychotropic medication subsequent to
admission. All four youth received a medication monitoring/review every thirty days, as required.
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There were no standing orders, emergency treatment orders, or pro re nata orders for
psychotropic medications. Medication pass was observed for one youth during the annual
compliance review week. Medication delivery was the sole responsibility of the nurse during the
time of administration. The youth was escorted to medication pass by direct care staff and
approached the nurse administering medication individually. The nurse identified themself and
stated the youth was there for medication pass. The same staff prepared and administered the
medication. The nurse verified the youth’s allergy and alert status, and both the staff and youth
initialed the MAR. Staff observed the youth take their medication to ensure it was swallowed,
and the nurse had the youth cough and had direct care staff check to ensure the medication
was swallowed. The medication was not pre-poured from its original packaging and placed in
another container for subsequent administration. The six rights of medication
delivery/administration were verified by nursing staff. Seven youth were interviewed. Five youth
indicated they receive their medication from a nurse. The remaining two youth indicated they do
not take medication. All five youth were able to explain the process for receiving medication.
Nursing staff indicated medications are verified upon admission. Nursing staff confirmed the
program utilizes a pre-printed pharmacy MAR. All non-healthcare staff who administer
medications are trained by nursing staff. Nursing staff indicated medication pass takes place
daily from 8:00 a.m. to 8:30 a.m., 12:00 p.m. to 12:15 p.m., and 5:00 p.m. to 5:30 p.m.
Medications are ordered through a vendor and are procured within twenty-four hours. Nursing
staff confirmed there is a psychiatrist on-site for medication management.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program maintains a policy and procedures stating any medical equipment classified as
sharps, as well as stock medications, shall be secured and inventoried utilizing a routine
perpetual inventory descending count as each sharp is utilized and disposed of or when the
medication is administered. The program’s sharps are secured in a locked cabinet in the
medical clinic. A review of sharps inventories for the last year found weekly inventories are
conducted by healthcare staff. The program also utilizes a Sharps Add or Remove Sheet which
documents the date, item, number of items added or removed, and the reason; however, it does
not document the start or end count. During the week of the annual compliance review, the
program created a form including both a weekly and perpetual count, which they plan to start
utilizing. All medications were identified and secured in a locked area designated for storage of
medications in the medical clinic. Medications are kept in the locked medication cart, with all
overflow medications stored in a locked cabinet in the medical clinic. The medication cart was
found to be organized with stock items separate from youth specific medications and all
injectable, topical, drops, and liquids separated. Controlled medications are stored behind a
double lock in the medication cart. All controlled substances have a perpetual inventory and a
shift-to-shift count which is signed off on by two staff. The program has a dedicated refrigerator
for only medication requiring refrigeration. The program has a process for the destruction and
disposal or return of expired or discontinued medication. Medications which are not controlled
are inventoried and disposed of with a witness. Quarantined medications are disposed of at
least monthly. Controlled medications are inventoried until they are disposed of. They are
destroyed by two staff and a pharmacist. A review of over-the-counter (OTC) inventories for the
last year found a perpetual inventory is done whenever an OTC medication is utilized, and
weekly inventories are conducted by healthcare staff. Six staff training records were reviewed
for non-healthcare staff who may assist in delivery and oversight of medication self-
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administration. Each staff received training, delivered by a registered nurse (RN), on medication
administration. A nurse was observed counting three controlled medications, three OTC
medications, and three sharps. All counts matched the ending inventory numbers. Nursing staff
indicated if there is an inventory discrepancy they would notify their supervisor, and contact the
Department’s Central Communications Center if it was a controlled medication. An interview
with nursing staff confirmed all controlled medications are destroyed on-site with the pharmacist
and the program director or designee. Other medications are returned to the pharmacy for
destruction. Nursing staff indicated the controlled medications are maintained behind two locks
and are counted shift-to-shift, at least twice daily. Nursing staff stated the pharmacy consultant
is on-site monthly to conduct medication inventories, inspect the medication cart, and complete
controlled medication destruction.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has implemented infection control procedures which include prevention,
containment, treatment, and reporting requirements related to infectious diseases, as according
to Occupational Safety and Health Administration (OSHA) federal regulations and the Center for
Disease Control and Prevention (CDC) guidelines. The program’s Infection Control Plan and
Exposure Control Plan were reviewed and signed by the designated health authority, program
director (PD), and health services administrator on February 7, 2024. The program’s Infection
Control Plan includes all required topics. Hepatitis B immunizations are available for all staff and
staff have access to protective equipment, as needed. There were no instances in which the
local county health department, CDC, and/or the Department’s Central Communications Center
(CCC) should have been notified of an infectious disease or any facility or occupational
exposure in the last year. The program’s Exposure Control Plan was found to be written in
accordance with OSHA standards and is available to all staff in the medical office and the PD’s
office. The program has a comprehensive process for needle stick post-exposure evaluation.
The program is to document the route of exposure and circumstances of the exposure, identify
and document the source individual, collect and test the exposed individual with consent,
provide post-exposure prophylaxis when medically indicated, provide counseling, evaluate any
reported illness, and provide the OSHA standard, description of duties related to the incident,
documentation of the route of exposure and circumstances, results of blood testing, and medical
records relevant to treatment to the exposed individual. The PD was interviewed and indicated
the exposure control plan is located in the medical and maintenance offices and is reviewed
with staff annually. Nursing staff indicated the exposure control plan is available in medial and in
the PD’s office. Nursing staff provide infection control and exposure control plan training to staff
and youth receive infection control training annually.
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4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Limited 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 of youth,
including interacting positively with youth, engaging in a full schedule of constructive activities,
and closely observing behavior of youth, to include changes in behavior. Staff must also be able
to always account for the whereabouts of youth under their supervision. The program’s
contracted supervision ratio is one staff for every eight youth during daytime activities, and one
staff to ten youth during evening hours. Each day of the annual compliance review week,
program staff were observed supervising youth in school, during recreation, taking restroom
breaks from school, cleaning, and during an intake. At all times, staff were properly supervising
youth, and were within the contractually required ratio. Interactions were observed to be
positive. Three staff were informally interviewed during these observations, and all staff
immediately knew the number of youth they were supervising. The program’s procedures define
active supervision as the effective positioning of staff in an area suited for optimum sight and
sound supervision of youth. Staff are to position themselves in a manner to supervise and
interact with all youth they are supervising. The daily schedule is posted in the modular unit for
youth to review, and during the annual compliance review week, youth were observed to be
engaged in a full schedule of activities. The program had a recent deficiency in supervision
added on October 17, 2024 (# 52268-27042). This indicator is rated as limited compliance as a
result of the incident. No additional deficiency was added during the annual compliance review
week.
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 which require a detailed written description of the
collaborative behavior management system (BMS). The BMS must be conspicuously posted
and provided in a 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 uses the Measurable
Achievement Plan (MAP) as their BMS. The BMS was last reviewed in August 2023 to ensure
the appropriate parties were involved in the development, implementation, and on-going
maintenance of the BMS. The program has an agreement with the school related to the BMS.
All staff, including three education staff, were trained on the use of the BMS. Seven youth case
management records were reviewed, which confirmed the youth orientation included a review of
the program’s BMS. Five staff position descriptions were reviewed for staff whose job functions
include implementation of the program’s BMS, and all position descriptions included the
implementation of the program’s BMS. Seven staff training records were reviewed, and all
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contained documentation which confirmed they received training in the implementation of the
BMS. During the tour the week of the annual compliance review, the BMS was seen posted in
the modular unit, as well as on each youth room door, which contained the youth’s name,
picture, and progress level regarding the BMS, to allow staff and youth to be aware of their level
at any time. The BMS posting and youth handbook included rules and positive and negative
consequences. The BMS includes all the required elements, which included promoting safety,
respect, and fairness, promoting and protecting youth rights, opportunities for positive
reinforcement, recognition of accomplishments and positive behavior at a four to one ratio,
promoting socially acceptable means for youth to meet their needs, a process for explaining to
youth the reasons for any sanctions imposed, youth having the opportunity to explain their
behavior, opportunities for staff and youth to discuss the impact of behavior on others,
reasonable reparations for harm caused to others, discussion of alternate behavior, promoting
positive dialogue and peaceful conflict resolution, and minimizing separation of youth from
population. The BMS does not include any increase of length of stay, denial of youth’s basic
rights or services, promotion of group discipline, punishment of youth by other youth, or
disciplinary confinement. During the tour, staff and youth interactions were observed for
adherence to the required elements of the BMS, including rewards and negative consequences,
and staff were found to adhere to the required elements. During the annual compliance review
week, staff were observed providing expectations throughout the day, addressing unacceptable
behavior, and encouraging youth when displaying positive behavior. Seven staff were
interviewed, and all were familiar with the BMS to include rewards and incentives. All staff knew
basic rights cannot be taken away from a youth as a form of punishment, and explained youth
are able to discuss their behavior and consequences during treatment team. All interviewed
staff advised youth are not placed on room restriction. Seven youth were interviewed, and all
were familiar with the BMS. All youth were able to explain the different types of rewards,
consequences, and levels of the BMS. All youth said they are not allowed to punish other youth.
The program director (PD) was interviewed and advised the program uses the MAP as its BMS.
This is an incentive-based system which allows the youth to know their status in the program
daily, along with being provided incentives for all achievements made daily. The system
consists of five levels which youth must advance from through. The PD said rewards are
monitored by the recreational therapist to ensure consistency. The program ensures this takes
place by meeting with the youth daily at which time they have the opportunity to discuss with all
staff any issues or concerns they may have in or with the program. Youth can also file a
Request to Speak form or a grievance which will be addressed within the required time frames.
The recreational therapist monitors this process and tracks all consequences daily to ensure
consistency and fair treatment of youth. The PD said the program uses an internal fidelity check
tool to monitor this process. It is also monitored by the regional compliance director as well as
with the treatment team on a monthly and quarterly basis. Staff are evaluated annually on
administering this process fairly and consistently.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures requiring staff to observe youth at least every ten
minutes while the youth are in their rooms, either during sleep time or at any other times, such
as during an illness. The program has fifty-one cameras and forty-one were working at the time
of the annual compliance review. The program submitted a work order for repairs of the non-
operational cameras on November 1, 2024, and repairs were completed on November 7, 2024.
The program’s video recording system maintains thirty days of recordings. A sample of security
tapes and corresponding logs was reviewed to verify ten-minute checks. The sample included
nine samples of thirty-minute increments, at different times of the evening, covering both shifts.
The review confirmed checks were being conducted within the required ten-minute time frames.
As a practice, the program conducts these checks every eight-minutes. A comparison of the
checks viewed on video with the hard-copy check sheet revealed the checks were documented
in real time. Staff who completed the checks initialed the check sheet. All checks were met with
fidelity, and staff ensured to observe each youth while conducting these checks. A review for the
annual compliance review period was conducted by reviewing ten-minute check sheets for one
day each month on each shift. This review verified all checks were being conducted as required.
Seven staff were interviewed, and all said they conduct these checks every eight minutes.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program has a policy and procedures to ensure youth are always accounted for through a
system of physically counting youth at various times throughout the day. The program is
required to conduct and document youth counts at the beginning of each shift, after each
outdoor activity, and during emergency situations such as escapes or riots. The program must
maintain a chronological record of events as they occur. If an event disrupts the safety and
security of the program, the chronological record of events must be updated as soon as it is
feasible after order has been restored. The program tracks daily census information including
the total daily census count, new admissions, releases or direct discharges, transfers, and youth
temporarily away from the program. The program's Continuity of Operations Plan (COOP)
requires staff to always account for the whereabouts of youth. This includes the need for
continual headcounts to be conducted minimally at the beginning of each shift, during any
emergency, and at regular intervals. Headcounts of youth shall be conducted before and after
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each use of vehicles and before and after group movements. Formal counts were not observed
during the annual compliance review week; however, program staff were observed conducting
informal counts before and after all youth movements. During the annual compliance review
week, on the tour, staff were asked how many youth they were supervising in classrooms, and
all were able to respond with the correct number of youth being supervised. A review was
conducted of randomly selected dates each month from the time of the last annual compliance
review, with one full day being reviewed each month. Staff documented counts at the beginning
of each shift, after each outdoor activity, during emergency situations, the total daily census
counts, formal head counts, youth movement, new admissions, releases or discharges, and
transfers. In addition, the logbooks also have a section where hourly counts are documented.
Seven staff were interviewed, and all said counts are conducted every thirty minutes and these
counts are called in by master control.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures which require them to maintain a chronological record
of events, incidents, and activities in a central logbook. The program is also required to ensure
direct care staff are briefed when coming on-duty. A full day of logbooks each month from the
time of the last annual compliance review were reviewed. The program maintains logbooks
which are bound with numbered pages. None of the logbooks reviewed had any entries
removed or destroyed. Of the twelve logbooks reviewed, eight had errors which were corrected.
Six of the seven had errors which were struck through with a single line and initialed by the staff
correcting the error. One had an error which was scribbled out and not initialed. All logbook
entries included the dates and times of the events, with the names of the staff and youth
involved, a brief descriptions of the events, and the names and signatures of the staff making
the entries. All internal incidents reported to the Florida Abuse Hotline and/or the Department’s
Central Communications Center (CCC) were documented in the logbooks reviewed. The
program maintains a logbook in the control room of the housing module. This logbook is carried
by staff when youth are away from the housing module to be continuously updated.
Documentation in logbooks confirmed entries made during the previous two shifts were
reviewed by incoming staff. The logbooks document minimal interference of educational
instruction, to include arrival and departure from class, on all except one day reviewed, and this
deviation was due to an escape, which was clearly documented. All logbooks contained entries
which verified recreation was conducted as scheduled. In addition to the logbooks, the program
maintains shift reports which summarize the events, incidents, and activities. Incoming staff sign
and date the shift reports for the previous shift to indicate they have reviewed or were verbally
briefed about its contents. Logbooks included entries for emergency situations, incidents, the
use of mechanical restraints, special instructions for supervision and monitoring of youth,
population counts at the beginning and end of each shift, perimeter security checks, requests
from law enforcement access to youth, removal of youth from the mainstream population,
admission and releases, and information relating to escapes or attempted escapes. Transports
away from the facility, including the names of the staff, youth involved, and the destination were
documented in all except one instance. The exception was a youth who went out to court, which
was documented on the census summary; however, there was not a chronological entry on the
notes of the logbook.
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5.07 Key Control (CRITCAL) Limited 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 which outline the key control process. The process
governs the control and use of keys, to include key assignment and usage, restrictions on
usage, inventory and tracking of keys, and secure storage of keys not in use. The procedures
also address missing or lost keys and reporting and replacement of damaged keys. A
distribution of keys was not observed during the annual compliance review week due to the
times the program has shift change. A key inventory was conducted, which revealed a
discrepancy. The Key Control Log showed key ring two checked out to maintenance, however,
the key ring was in the key locker. The annual compliance review team was advised the lead
staff had not yet signed the key ring back in. Keys are stored in a locked cabinet, which is in the
master control room, and this is also secured and inaccessible to youth. Permanent issued keys
are kept to a minimum and must be authorized in writing by the program director (PD). The PD,
maintenance, human resources, and the clinical director are the only staff with permanent keys.
The program has a broken key report which is to be completed whenever a key is broken. This
report, along with the broken key, are forwarded to the maintenance staff, who is responsible for
replacing the broken key. During the review of the locked key box, two broken keys were
discovered in the bottom of the box, which had not been reported or sent to maintenance for
replacement. It is unknown how long the broken keys have been in the box. One of the broken
keys was a restraint key, and it is unknown what the other key was for. The broken keys were
removed by maintenance staff. Since the last annual compliance review, the program did not
have any incidents reported to the Department’s Central Communications Center (CCC)
regarding keys. An informal interview was conducted with the supervisor. The supervisor said
keys for areas such as medical, youth and staff records, and youth property lockers are
restricted to staff working those areas; however, staff were unable to provide a key inventory
log, which shows who is authorized to check out certain keys, the number of keys on the ring, or
the locks the keys access. The key inventory log had been removed from master control to
make copies; however, not returned. The maintenance staff returned a copy of the key inventory
log to master control when this was discovered. The program reconciles and track keys by
ensuring keys are checked out of the locked box in master control. When staff are checking out
keys, they turn in their personal keys and check out the key ring they are using for the day. This
is documented on the Key Control Log. Three staff were informally interviewed regarding keys.
All three were able to identify the number of keys on their key ring and the function of each key.
Seven staff were interviewed, and all said they turn in their personal keys upon entering the
facility, to check out keys, and their personal keys are stored in the locked key cabined in
master control. All staff said the Key Control Log is used to account for keys which are checked
out.
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5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures requiring them to address illegal contraband and
prohibited items. The program must list items and materials considered contraband when found
in the possession of youth. Contraband lists are given to youth, staff, and visitors through
handbooks and the orientation process. The procedures also advise staff who are found in
possession of contraband in a program will be subject to disciplinary action and, if applicable,
notification to law enforcement. The program ensures this is accomplished by searching the
physical plant, facility grounds, youth, visitors, staff, and incoming and outgoing mail. The facility
visitors sign-in log contains the required attestation statement. Nine new hire staff records were
reviewed, and all contained completed attestation forms. The program provided documentation
which confirmed the confiscation of contraband and its disposition. This documentation was
maintained in the youth case record, as applicable. There were no instances of illegal
contraband which was required to be turned over to law enforcement or reported to the
Department’s Central Communications Center (CCC) during the annual compliance review
period. The program provided logbooks, incident reports, and search reports which verified the
frequency of searches. The program director (PD) was interviewed and advised all contraband
items are delivered to the shift supervisor for proper locked storage or elimination. Visitors in
possession of contraband will be asked to lock items in their vehicle or leave the facility. The PD
confirmed illegal contraband will be confiscated and held until law enforcement arrives at the
scene, at which time it will be turned over to law enforcement. Seven staff were interviewed, and
five said searches are conducted weekly on a random basis, and two staff said searches were
not part of their job because they are not direct care staff.
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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 and procedures which require staff to conduct searches to ensure no
contraband is being introduced into the facility. During the annual compliance review week,
youth were observed being searched before and after movement. Searches were conducted in
accordance with policy, and youth were treated with dignity and respect to minimize stress and
embarrassment. These searches were conducted by the appropriate number of staff and
gender, and all searches were thorough, with appropriate instructions given to youth. There
were no transports, visitation, off-campus trips, or tool check-outs during the annual compliance
review week; therefore, observations of searches during these events were not made. A video
review of five separate days was conducted, which showed eight staff and two visitors being
searched when entering the facility. All observed searches were conducted as required. Seven
staff were interviewed, and all said youth are searched before and after every movement. Seven
youth were interviewed, and all advised they are searched after all movements and whenever
items are missing.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a policy and procedures which ensure all vehicles used to transport youth are
properly maintained and all maintenance is documented. The program maintains one vehicle
which is used to transport youth. During the annual compliance review week, an inspection
revealed the vehicle contained all required safety equipment, had all maintenance records
indicating the annual inspection on August 20, 2024, and any deficiencies, such as the
replacement of the brakes, was documented and completed. During the annual compliance
review week, five random staff vehicles were checked in the parking lot. All five vehicles were
found locked and secure.
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 ensure the appropriate minimum staff-to-youth
ratio is maintained, while youth are transported off facility grounds to ensure safety and security
is maintained for youth, staff, and the public. Although no youth were observed being
transported during the week of the annual compliance review, records and interviews indicated
all equipment, including cellular telephones and the proper ratio of staff-to-youth are provided.
The program’s human resource department reported reviewing monthly driving records of all
staff from the Department of Highway Safety and Motor vehicles to ensure all staff have a
current driving license and no violations have been reported. Seven staff were interviewed, and
all were able to describe how youth are restrained during transport. All staff were aware of the
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communication devices provided for transport as well as the safety equipment on transport
vehicles. All staff confirmed youth are not allowed to ride in staff vehicles. All staff confirmed
transport vehicles are searched prior to and after each use. All staff were aware of the
supervision ratio and what to do in the event of an emergency while on transport. Seven youth
were interviewed and asked if they had ever been handcuffed to any part of a transport vehicle.
Six said no, and one said they have never been on a transport. All seven said they have never
seen a staff place contraband inside of a vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures to secure and maintain a safe physical plant, its
grounds, and perimeter. The program director (PD) is responsible for ensuring the weekly audits
are completed, as required, and will develop and implement any corrective action. An internal
system has been developed to verify and correct all deficiencies, to which none have been
reported from the time of the last annual compliance review. The PD was interviewed and
advised the shift supervisor completes daily perimeter checks and walk-throughs to identify any
deficiencies to the physical plant and reports such to the physical plant manager and PD. Any
deficiencies identified result in a work order to be generated to address the deficiencies.
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 regarding tool management which ensure youth do
not use tools as weapons or to breach security. The program has an inventory system which
ensures all tools are inventoried and any tool issued for work are monitored and controlled for
safety and security. All sharp-edged tools are inventoried daily and all machetes, bowie knives,
and long bladed knives are prohibited. In the event of a missing tool, staff shall immediately
notify the program director and maintenance supervisor and an investigation will ensue to locate
any missing items. A tool tag is placed on the shadow board until the tool is recovered. Ten
tools were inventoried, and all were accurate in count, secure, and easily identified.
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 are
appropriately supervised. The procedures include the supervision requirements when youth use
tools, the issuance of tools to youth and staff, including an assessment to determine the risk of a
youth to self or others if they are issued tools, ratios, tool distribution and collection, and search
criteria during work projects. Three youth were observed during the week of the annual
compliance review with cleaning tools cleaning the day room of the unit. One staff was observed
supervising the youth and confirming the completion of chores, which is an appropriate youth-to-
staff ratio. Seven youth case management records were reviewed, and all contained
documentation which confirmed youth were trained on the intended and safe use of tools. All
seven youth also had a risk assessment in their records, which were completed prior to the use
of tools. Seven staff were interviewed, and all said youth can only use brooms, mops, and scrub
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brushes. Seven youth interviews were reviewed, and it was noted they were trained in the
proper use of the tools, and a risk assessment was completed prior to the youth using the tools.
Seven interviewed staff stated all youth were permitted to use tools, such as brooms, mops, and
scrub brushes. Five of the seven interviewed youth reported being able to use scrub brushes
and seven stated they could use mops and brooms.
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 include
information regarding tool control and restrictions. Maintenance staff assigned to an outside
contractor while at the program are responsible to account for all tools used before and after the
work is completed. While contractors are on-site, youth are not permitted to be present in the
work area. All sign-in sheets and instruction sheets for outside contractors were reviewed from
the time of the last annual compliance review, and all were properly completed. The guidelines
for repairment and external worker tools include checking the tools upon arrival and departure,
tool restrictions while in the facility, restricting youth from the work area, and follow-up
procedures for any missing tool. A complete inventory of all tools was checked upon arrival and
departure of the contractor. The program also provided policies to the vendor regarding
prohibited personal cellular telephones, and electronic equipment capable of taking pictures and
taking audio recordings, including smart watches.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a policy and procedures which require they conduct fire, safety, and
evacuation drills to ensure youth and staff are prepared for immediate implementation or
mobilization in the event of an emergency or disaster. The program’s Continuity of Operations
Plan (COOP) addresses fire, safety, and evacuation emergency processes and drills, as well as
the frequency of conducting drills. Fire drills are to be conducted monthly on each shift and
COOP drills are required to be conducted quarterly. A review of the program’s drill log confirmed
all fire drills and COOP drills were conducted, as required. Documentation for all drills contained
the type of drill, date and time, participants, brief scenario, and findings and recommendations.
During the tour the week of the annual compliance review, fire evacuation routes and egress
plans were observed throughout the facility. The program has seventeen fire extinguishers
which were last inspected in April 2024. Seven staff were interviewed and all said they
participate in monthly fire drills as well as COOP drills. Seven youth were interviewed, and all
said they were instructed on what to do in the event of a fire. Five youth said fire drills are
conducted monthly, one said they didn't pay attention as to how often they are conducted, and
one said they are conducted every two months. The program director (PD) was interviewed and
was able to describe the various drills conducted at the program as well as the frequency in
which they are conducted.
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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 policy and procedures requiring they maintain a coordinated disaster plan
and a Department approved Continuity of Operations Plan (COOP). The plan provides for the
basic care and custody of youth in the event of an emergency or disaster, while ensuring the
safety of staff, youth, and the public. Copies of the program’s COOP are maintained in the
master control room, the administration area, the case management area, and the program
director’s (PD) office. The plan is available for all staff to review, as needed. The COOP was
reviewed and updated on March 27, 2024, and submitted to the Department for approval on
April 15, 2024. The program’s coordinated disaster plan and COOP are a combined plan and
address alternate relocation sites which have been approved by the Department’s regional
director. The program maintains equipment and supplies for continuous operation and services
during an emergency in the kitchen, master control, storage closet, maintenance, and in the
modular living unit. Supplies include food, water, flashlights, bedding, batteries, tape, clothing,
and hygiene items. In the event of an evacuation, youth records are sent to the temporary
location with youth. The PD was interviewed and confirmed the COOP is available for staff in
master control, administration, PD’s office, and case management. The program maintains an
administrative hard-copy file containing youth information, in the event of an evacuation. These
records include youth name, Department identification number (DJJID), admission date, date of
birth, gender, race, contact information, emergency contact, juvenile probation officer (JPO),
committing judge, victim information, physical description, health status,
and a photograph.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures which require the program director (PD) or designee
to maintain strict control of flammable, poisonous, and toxic items and materials and a complete
inventory of all such items. The maintenance personnel, or other trained staff who have the
safety equipment for diluting, handling, and disposing of hazardous and/or solid waste, shall be
responsible for disposing of hazardous items and toxic materials. The program’s policy states all
flammable, poisonous, and toxic materials and any substances labeled "keep out of reach of
children" or "harmful if swallowed" shall be kept under strict control, stored in a secure area
inaccessible to youth, and an accurate inventory must be always maintained. During the annual
compliance review, all flammable, poisonous, and toxic items were found secured in the
maintenance shop, which is inaccessible to youth. Maintenance staff is the only authorized
position to handle these items. Maintenance staff are responsible for disposal of flammable,
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toxic, caustic, and poisonous items in accordance with local, state, and federal requirements. A
review of the program’s disposal log revealed there have been no items disposed of since the
time of the last annual compliance review. An informal interview was conducted with the
maintenance staff which confirmed maintenance staff are responsible for disposal of flammable,
toxic, caustic, and poisonous items, in accordance with the Occupational Safety and Health
Administration (OSHA) standards. Liquid waste, such as dirty mop water and unused
beverages, is disposed of in plumbing drains. The program does not have a fully functioning
kitchen; therefore, does not have a need to dispose of kitchen grease and waste. The program
has not had a chemical spill from the time of the last annual compliance review. An inventory
was conducted of the six different chemicals the program uses. All the inventories matched the
actual count of what was on hand. All of the items were secured, and all contained Safety Data
Sheets (SDS).
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 which prohibit youth from using, handling, or
accessing dangerous or hazardous chemicals or responding to chemical spills. The procedures
state all flammable, poisonous, and toxic materials, and any substances labeled "keep out of
reach of children" or "harmful if swallowed" shall be kept under strict control, stored in a secure
area inaccessible to youth. During the tour and throughout the annual compliance review week,
observations were made which confirmed all flammable, poisonous, and toxic items and
materials were kept secured and inaccessible to youth. Youth did not handle, use, or clean-up
dangerous or hazardous chemicals or bio-hazardous materials, or human waste. Youth were
observed cleaning, using a broom, dustpan, dust mop, and mop. Staff were supervising each
youth, and at no time were youth allowed to handle chemicals. Seven youth were interviewed,
and all said they do not handle any cleaning products or chemicals.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
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age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures which allow for youth to have visitation and
communication with family members while in the program. During orientation, youth are
informed of visitation and communication processes. The program encourages visitation from
parents/guardians, and they send a welcome letter upon admission of each youth, which
outlines the days and time of visitation, who is allowed to visit, and the rules of visitation. The
visitation schedule is posted at the main entrance of the facility and in the youth dormitory. The
program offers visitation on Sundays from 2:00 p.m. through 4:00 p.m. Family days are held
quarterly, on designated days, from 11:00 a.m. through 2:00 p.m. Holiday visitation is also
provided and scheduled depending on which day of the week a particular holiday occurs. A list
of authorized visitors and correspondence is maintained in each youth’s case management
record and updated as needed. Intake calls are made within twenty-four hours of arrival. Each
youth is permitted to successfully make one call each week. Calls are allowed for approximately
fifteen minutes and are scheduled by the shift supervisor or designee. Youth may correspond
with individuals on an approved correspondence list. They are also provided an opportunity to
correspond with attorneys, case managers, clergy, and other officials. Youth are encouraged to
correspond with parents/guardians at least once a week. Seven youth case management
records were reviewed, and each record contained an approved correspondence, visitation, and
telephone log. Seven youth were interviewed regarding corresponding with their family, and all
said they were able to call or send a letter to a parent/guardian. All outgoing mail is searched.
The program director was interviewed and advised the program has an agreement with a third-
party service for translations.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 70 (Revised September 2022)
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a policy and procedures requiring they provide a variety of recreation and
leisure activities. A review of the program’s activity schedule confirmed the program holds
supervised and structured indoor and outdoor recreation and leisure activities for youth for at
least one hour daily, which included large muscle activities. A review of the logbook confirmed
youth were receiving recreation and leisure activities, in accordance with the daily activity
schedule. Activities promoted social and cognitive skill development, creativity, teamwork,
healthy competition, mental stimulation, and physical fitness. During the week of the annual
compliance review, the review team observed youth engaged in physical activities, and the
program was taking precautionary measures to ensure youth did not overexert themselves and
did not suffer from heat stress or dehydration. The program has a recreation therapist, and a
review of the recreation therapist’s credentials revealed all position requirements were met.
Seven youth records were reviewed, and all contained recreational therapy in their
Individualized Treatment Plan. Seven youth were interviewed, and all said they have at least
one hour of recreation daily. Recreation activities include basketball, football, weightlifting, and a
running program. Seven staff were interviewed, and all were aware of the various recreational
activities available for youth and were aware of the minimum amount of time provided.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 70 (Revised September 2022)
Standard 6: Career and Technical Education (CTE), and Education
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program’s contract requires them to provide career and technical education (CTE) services
options for the youth of forklift operator/Occupational Safety and Health Administration (OSHA)
recognized training, Entrepreneurship certification through Junior Achievement, Microsoft Office
Suite (MOS) certification; National Retail certification through RISE UP, National Retail
Association, ServSafe certification, and Horticulture certification through 4-H. The program’s
services include certifications in OSHA-10 General Industry training and OSHA-30, First-
aid/cardio-pulmonary resuscitation (CPR)/automated external defibrillator (AED), MOS, Florida
Ready to Work - Soft Skills, National Retail and OSHA Forklift. As a result of the CTE services
offered at the program, thirty-four participated in OSHA-10, thirty-six youth have received First-
aid/CPR/AED services, twenty-two youth participated in OSHA-30, sixty youth participated in
MOS, sixty-eight youth participated in Florida Ready to Work – Soft Skills, three youth
participated National Retail, and one youth participated in OSHA Forklift. The number of youth
who have completed a certification or received a certificate of completion for CTE services are
twenty-two participated in OSHA-10, thirty youth have received First-aid/CPR/AED, fifteen youth
completed OSHA-30, thirty-seven youth completed MOS, ten youth completed Florida Ready to
Work – Soft Skills, one youth completed National Retail, and one youth completed OSHA
Forklift. The program indicated there were no youth who participated in ServSafe during the
annual compliance review period. Additionally, twenty youth have taken courses which are
offered through Florida Youth College and during the review period four youth have completed
one course, three youth have completed twenty-four credits, and three youth have completed
forty-eight credits. According to the program’s schedule, eligible youth can receive CTE
services every Monday to Friday between 8:30 a.m. to 3:15 p.m. and periodically on weekends
for all youth. A review of the schedule and video review during the annual compliance review
week confirmed CTE services are available. CTE instruction is provided online. The program’s
recreation therapist is listed as the administrator to assist youth to enroll in the online ServSafe
and OSHA-10 courses. These courses are not delivered at the program but rather virtually. An
independent company delivered the First-aid/CPR/AED course to the youth. OSHA-10 serves
as a base level certification which can lead to multiple industry certifications from the American
Welding Society (AWS) and the National Center for Construction Education and Research
(NCCER), both of which are identified on the master credentials list. Ten youth are currently
enrolled in OSHA-10 and six youth are currently enrolled in OSHA-30, which include
coursework towards earning an industry certification. Seven youth were interviewed, and six of
the youth indicated the program is preparing them very well for high school, high school
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 70 (Revised September 2022)
equivalency diploma (GED), vocational school, employment, and/or college and the remaining
youth stated he is being prepared well. The interview with the facility administrator confirmed
CTE services such as First-aid/CPR/AED and OSHA-10 are being provided to youth at the
program. A review of seven youth records confirmed all seven youth completed Florida Ready
to Work Soft Skills, three youth completed OSHA-10, and two youth completed First-
aid/CPR/AED.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program offers educational services through the Florida Virtual School (FLVS). A review of
the program’s activity schedule and the daily academic schedule revealed the program's activity
schedule aligns with the daily school schedule. Seven youth were interviewed. Three youth
reported no interruptions, while four reported interruptions occurred when they acted out or an
altercation took place. A review of randomly selected days in the logbook throughout the annual
review period indicated education classes started and ended on time according to the schedule,
except on February 25, 2025, when classes began five minutes late and ended four minutes
early, and on October 14, 2024, when classes started ten minutes late. Observations of
program video on June 11, 2025, June 12, 2025, and June 16, 2025, took place. The footage
showed the youth were in school during scheduled times or within a few minutes of the
scheduled time. All required education times were met for those days.
6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Education services are provided through a contract with Florida Virtual School (FLVS). The 250-
day calendar is distributed over twelve months and includes twenty days for teacher training and
planning. A review of the daily school schedule revealed education provides six fifty-minute
classes from 8:30 am to 2:45 pm, with a sixty-minute lunch break from 12:05 pm to 1:05 pm,
fulfilling the weekly requirement of twenty-five hours of instructional time. The interview with the
lead teacher indicated all youth receive credit for completing a course. She also reported the
school schedule is adhered to. Observations of the program video on June 11, 2025, June 12,
2025, and June 16, 2025, took place. The video observation showed teachers were present
during scheduled classroom time. This indicator is rated NA; If this indicator had been rated, the
preliminary rating would be satisfactory.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The education contract provider is responsible for developing a career education program
appropriate for the educational abilities and goals of youth in the program and appropriate for
the length of stay and classification of youth in the program. The career education program does
include Type 1 through Life Management Skills and Personal Finance and Money Management
courses. The career education program also includes Type 2 through Career and Technical
Education (CTE) course offerings which provide exploration and knowledge of occupations
within those specific careers. A career strengths and interest questionnaire is completed by
each youth upon entry. Each CTE course offered by the education provider includes soft skills
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 70 (Revised September 2022)
for those specific careers, such as communication, interpersonal and decision-making skills.
The interview with the facility administrator confirmed CTE services such as First-aid/cardio-
pulmonary resuscitation (CPR)/automated external defibrillator (AED), and Occupational Safety
and Health Administration OSHA-10 courses are being provided to youth at the program. The
interview with the lead educator indicated career education services are offered to the youth
such as Digital Technology, Foundations of Programming, & Personal Finance. Assessments
include FAST PM testing, Reading Retakes, high school equivalency diploma (GED), Algebra,
Geometry, History, & Biology. This indicator is rated NA; If this indicator had been rated, the
preliminary rating would be satisfactory.
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The contract requires, the contracted educational provider must develop an Education
Transition Plan (ETP) for each youth. Upon entering a residential commitment program, an ETP
must be developed for each youth. Three closed case records were reviewed; none contained
an ETP. Many youth entered the program before December 1, 2024, when the new education
provider, Florida Virtual School (FLVS), began completing ETPs, so they would not have had an
ETP developed. FLVS has recently developed an education plan template and trained its staff
to implement an ETP for each youth as they move forward. Some transition information was
obtained from the Electronic Education Exit Plan (EEEP). The interview with the instructional
leader indicated transition forms are now completed for every youth upon entry. She also
reported Exceptional Student Education (ESE) services are provided for students with
disabilities, services for students who are identified as English Language Learners (ELL), 504
Plans for students with disabilities, or in need of accommodations not covered in an Individual
Education Plan (IEP). This indicator is rated NA; If this indicator had been rated, the preliminary
rating would be failed.
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The contracted educational provider has procedures in place to provide qualified instructional
personnel. Upon reviewing the educational instructional staff for the facility, including flex
teachers who provide virtual education at the program, it was noted all teachers have active
certifications, according to the Florida Department of Education website. Flex teacher
certifications suggest all are currently certified in their teaching subjects. One teacher was
teaching in -field and out-of-field subject areas. One teacher was teaching two areas out-of-field.
Florida Virtual School (FLVS) provided parent notification for teachers who were also teaching
outside their field. However, the letter didn’t indicate which subjects were taught out of field.
Three teachers provide Exceptional Student Education (ESE) services in the program, and
FLVS provided certifications for the ESE instructors. This indicator is rated NA; If this indicator
had been rated, the preliminary rating would be satisfactory.”
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 70 (Revised September 2022)
6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
A review of three closed case management records for youth identified with employability as a
goal at the time of release found all contained a referral to the Florida Youth College (FYC). The
lead teacher was interviewed and indicated postsecondary pathways are available to youth
including Certified Technical Education (CTE) electives and the transition services manager
refers the youth to the FYC. CTE electives include Occupational Safety and Health
Administration (OSHA) 10, First-aid/cardio-pulmonary resuscitation (CPR)/automated external
defibrillator (AED), OSHA-30, Business, Ready to Work, Project Anchor, Serv Safe, Retail
Certificate Rise Up, and OSHA Forklift. This indicator is rated NA; If this indicator had been
rated, the preliminary rating would be satisfactory.
6.08 Florida Youth College (Post-Secondary Contract
Provider) Satisfactory Compliance
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or Registered Pre-apprenticeship/
Registered Apprenticeship programming that leads to a Registered Pre-apprenticeship
Certificate of Completion from FLDOE. For youth transitioning from the Department, follow-up
shall be completed in thirty, sixty, ninety, and 180 days after their release.
A review of three closed case management records for youth identified with employability as a
goal at the time of release found they all included documentation to support an orientation was
conducted with Florida Youth College (FYC), including the date and time. All three records
documented the thirty-day, sixty-day, and ninety-day follow-up in the appropriate time frame.
Two of the three noted the 180-day follow-up forty-seven days late. The remaining one was
conducted on time. All three youth records included a career plan and had a copy of each
youth’s admission and registration to a postsecondary program.
The lead teacher was interviewed and stated the postsecondary pathways for youth are
identified when they have finished their high school diploma or high school equivalency diploma
(GED). The youth are provided Certified Technical Education (CTE) electives, and the transition
services manager makes the referrals to Florida Youth College (FYC). When youth get admitted
to the program a school credit check is conducted and depended on the credits received youth
are offered curriculums based on middle school, high school, or GED. If a youth is between
sixteen and eighteen years of age the parent/guardian has to consent, and a notarized GED
form needs to be completed, so the youth can be enrolled in the GED path. Youth who are
eighteen years or older can enroll in GED without parental consent. The teacher stated the
Florida Scholar Academy (FSA) instructors/teachers in the classroom facilitate access for the
youth to the on-line courses. All teachers are either certified in English/Social Science or
Math/Science and assist the youth in navigating the on-line system, as well as assisting the
youth in scheduling live lessons with the lex teachers (on-line teachers), help if the youth need
extra assistance understanding the on-line lessons, and provide extra videos to understand the
curriculum. The FSA instructors in the classroom do provide certain electives through on-line
materials and short in-person sessions individually with each youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 70 (Revised September 2022)

report_type: QI Residential

rule: Indicator 3.08

rating: Limited Compliance

rule: Indicator 5.01

excerpt: Youth Supervision (CRITICAL)

rule: Indicator 5.07

excerpt: Key Control (CRITCAL)