summary: QI Residential - FY24-25 - 2 findings

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Everglades Youth Academy – Maximum/High Risk
Youth Opportunity Investments, LLC.
(Contract Provider )
5050 SE 168th Street
Okeechobee, Florida 34972
Review Date(s): October 22-25, 2024
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Yvrose Sylvain, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Nicos Antonakos, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Christine Calvert-Joyner, Office of Accountability and Program Support, Regional Supervisor
(Standard 3)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 1 and
Interviews)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Everglades Youth Academy – Maximum/High RiskMQI Program Code: 1482
Provider Name: Youth Opportunity Investments, LLC. Contract Number: 10289
Location: Okeechobee County / Circuit 19 Number of Beds: 80
Review Date(s): October 22-25, 2024 Lead Reviewer Code: 125
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
5.08 Contraband Procedure
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 73 (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 * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 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 73 (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 73 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Satisfactory
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 73 (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 73 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Limited
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Satisfactory
5.24 Controlled Observation Satisfactory
5.25 Controlled Observation Safety Checks and Release Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 73 (Revised September 2022)
Program Overview
Everglades Youth Academy - Maximum/High-Risk program is an eighty-bed program, for
thirteen to twenty-one-year-old males located in Okeechobee, Florida. The program is operated
by Youth Opportunity Investments, LLC, through a contract with the Department. The program
provides services including maximum-risk and high-risk Mental Health Overlay Services
(MHOS). The program is co-located with Everglades Youth Academy - Sex Offender Program
under the same contract on the same campus. The program fosters each youth by providing
Skillstreaming the Adolescent, Moral Reconation Therapy, Impact of Crime, Thinking for a
Change, and Living in Balance curricula. Additional treatment services include individual, family,
recreational, and group therapy. The program’s administration is comprised of one facility
administrator (FA), three assistant facility administrators (AFAs), one human resources
manager, and one administrative assistant. Case management services are to be provided by
one director of case management, five case managers, and two transition services managers.
Medical services are accessible twenty-four hours a day, seven days a week and are provided
by a registered nurse (RN) serving as the health services administrator, one additional RN, two
licensed practical nurses (LPNs), a contracted physician, a contracted optometrist, a contracted
dentist, and a contracted psychiatrist. Mental health staff at the program include one designated
mental health clinician authority (DMHCA), one licensed therapist, four non-licensed therapists,
and one part-time therapist. Educational services are overseen by Florida Scholars Academy
and provided by Florida Virtual School. The building is designed with two wings, each containing
three separate living units. The Everglades Youth - Academy Maximum/High-Risk program
occupies four living units. Each living unit has sixteen individual sleeping rooms, a case
management office, an open-concept day room, and an adjoining classroom. The program has
one main master control and two sub-control stations, seven therapist offices, education offices,
program administration offices, a maintenance office and storage areas, one large recreation
field, six small recreation courts, a kitchen, a medical clinic, two medication pass rooms, and an
automotive sally port. The program has 113 video security cameras monitored by master control
staff and six cameras were inoperable at the time of the annual compliance review. The video
surveillance system is capable of recording over thirty days of video footage. At the time of the
annual compliance review, the program had ten vacancies consisting of three therapists, three
master control technicians, two shift supervisors, one staff development position, and one AFA
position.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 73 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program maintains a written policy and procedures to ensure all newly hired staff and
volunteers receive an initial background screening. The program had fifty newly hired staff since
the last annual compliance review. A review of the staff records found forty-nine received a
background screening prior to contact with youth and confidential records and one staff record
showed an initial background screening was in progress and the staff had not had contact with
youth at the time of the annual compliance review. Documentation reflected a criminal history
report was reviewed and the Department’s Staff Verification System (SVS) module was updated
for each of the forty-nine staff. None of the reviewed records were applicable for obtaining an
exemption prior to working with youth. Two of the reviewed staff had a break in service as
indicated in SVS, and documentation supported the staff had a new background screening
completed prior to working with youth. The program utilizes a pre-employment assessment tool
for all direct care staff. Reviewed documentation reflected each of the applicable newly hired
staff received a passing score on the pre-employment assessment tool prior to hire. There were
no volunteers, contracted staff, and/or interns applicable for an initial background screening
since the last annual compliance review. The Annual Affidavit of Compliance with Level 2
Screening Standards was submitted to the Department’s Background Screening Unit (BSU) on
January 22, 2024, meeting the annual requirement.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program maintains a written policy and procedures to ensure all staff and volunteers
receive a background rescreening every five years from their initial date of hire. The program’s
administrator tracks each staff’s hire date and volunteer start dates to determine when the five-
year rescreening should be submitted. The program had two staff applicable for a five-year
rescreening since the last annual compliance review. Each staff’s rescreening was completed
and submitted to the Department’s Background Screening Unit prior to their anniversary date.
Each rescreening was completed at least ten business days prior to each staff’s five-year
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Office of Accountability and Program Support Page 10 of 73 (Revised September 2022)
anniversary. There were no volunteers or interns applicable for a five-year rescreening since the
last annual compliance review.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program maintains a written policy and procedures ensuring an environment free of abuse
and neglect and in which youth and staff feel safe and secure. The policy reflects youth and
staff have unhindered access to reporting alleged abuse to the Florida Abuse Hotline. The
policy outlines the reporting procedures for staff to follow when a youth would like to make an
abuse call. Additionally, the program maintains a staff handbook which outlines the program’s
code of conduct. All staff are required to sign and acknowledge receipt of the handbook and
code of conduct which outline the grievance policies and their understanding of the program’s
code of conduct. A review of seven staff records found each record contained documentation of
acknowledgement, receipt, and review of the program’s code of conduct. Observations
conducted during the annual compliance review week found postings of the Florida Abuse
Hotline and the Department’s Central Communications Center (CCC) throughout the program.
The program’s practice for when a youth requests to call the Florida Abuse Hotline is to have
the youth care worker contact the shift supervisor on the radio, and then the shift supervisor
takes the youth to place the call. The program completed the Trauma Responsive and Caring
Environment (TRACE) self-assessment from June 21 to July 1, 2024, for the Mental Health
Overlay Services program; however, the review of the results of the self-assessment were
cancelled on October 8, 2024, due to inclement weather. A review of all incidents since the last
annual compliance review found there were five incidents which involved complaints related to
physical, psychological, or emotional abuse, and three of the five incidents were found as
substantiated. One incident was unsubstantiated. One incident’s investigation was ongoing at
the time of the annual review. The program had seventy-two reportable incidents since the last
annual compliance review, of which five were related to allegations of abuse. The Florida Abuse
Hotline and/or the CCC were notified as required for each reviewed incident. There were no
applicable cases for any potential human trafficking victims, children of sexual exploitation, or
labor trafficking reported at the time of the annual compliance review. Five youth were
interviewed, and three reported never being stopped from reporting abuse to the Florida Abuse
Hotline or the CCC. Two youth reported they have never had the need and they have never
witnessed a staff stop a youth from calling. Each of the five youth knew where the telephone
numbers were posted. All five interviewed youth reported feeling safe in the program. All five
youth reported staff are respectful when talking with them. Each youth reported never hearing
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 73 (Revised September 2022)
staff use curse words when speaking to youth. All five youth reported they never exchanged
emails, telephone numbers, or social-media contact information with staff. All five interviewed
staff explained the process for allowing staff and youth to call the Florida Abuse Hotline or the
CCC to report suspected abuse. All interviewed staff reported they never observed another staff
telling a youth they could not call the Florida Abuse Hotline. Each staff reported they never
heard another staff use profanity while speaking with youth. An interview with the facility
administrator (FA) explained staff with allegations of abuse are removed from youth contact
pending an investigation and depending on the severity of the incident, staff can be terminated.
The FA reported the program’s policy indicates an internal investigation would immediately be
conducted to ensure the safety of each youth in the program.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program maintains a written policy and procedures regarding abuse reporting, which is
following the Department’s criteria for reporting abuse. The program’s practice is to initiate an
internal investigation regarding the complaint and remove the staff involved from contact with
youth, when necessary. The program had five allegations related to physical, psychological, or
emotional abuse involving a staff since the last annual compliance review, of which all five were
reviewed. Reviewed documentation found management took immediate action regarding the
staff involved incidents by initiating an internal investigation in all incidents. In two incidents, the
staff failed to properly supervise youth and violated policy and a written/oral reprimand was
issued for each staff involved. Documentation indicated one staff was terminated due to the
outcome of the internal investigation and the nature of the incident. In one incident,
documentation supported the staff received a coaching session. In one incident documentation
supported there was no evidence to support the allegations against the staff and no action was
necessary. At the time of the annual compliance review, there was an open abuse allegation
which was pending an internal investigation and the Department’s review. An interview with the
facility administrator (FA) reported all allegations of child abuse or suspected child abuse were
immediately reported to the Florida Abuse Hotline. The informal interview with the FA explained
all allegations of abuse are reported to the Department’s Central Communications Center (CCC)
within two hours of the incident or becoming aware of the incident.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program maintains a written policy and procedures regarding the response to incidents in
accordance with Florida Administrative Code. The program had seventy-two reportable
incidents since the last annual compliance review. A review of seven incidents found each was
reported to the Department’s Central Communications Center (CCC) within two hours of the
incident or staff becoming aware of the incident. Six of the seven incidents were documented in
the program’s logbook and one incident was reported by a youth’s juvenile probation officer
(JPO). A review of the program’s internal incident reports found there were no additional
incidents which should have been reported to the CCC and were not. The program has
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Office of Accountability and Program Support Page 12 of 73 (Revised September 2022)
experienced an increase in the number of reportable incidents to the CCC compared to the last
annual compliance review period. An informal interview with the program’s facility administrator
(FA) confirmed the program has a policy in reference to the CCC and ensures all matters which
require reporting are verbally reported within two hours of when the program became aware of
the incident. In addition, documentation indicated several of the program CCC incidents were
medical incidents and outside agency investigations.
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 maintains a written policy and procedures regarding the utilization of physical
intervention techniques in accordance with Florida Administrative Code. The program had
twenty Right Interactions (RI) incidents since the last annual compliance review. There was
documentation to support a summary of RI Reports was submitted to the Department each
month since the last annual compliance review. The program’s RI Plan was last updated on
November 16, 2023. The program’s RI Plan was approved by the Department’s Office of Talent,
Leadership, and Culture on December 22, 2023. Four of the five interviewed staff reported they
used RI and were able to explain the program's RI process and procedures. One staff reported
they never used RI. A review of five RI Reports found all involved staff completed appropriate
statements prior to the end of their shift. The RI Reports were reviewed and processed within
seventy-two hours by all required parties. None of the reviewed incidents were applicable for the
use of mechanical restraints or an incident resulting in injury. None of the reviewed incidents
were applicable for a youth alleging abuse.
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 maintains a written policy and procedures regarding a pre-service training plan for
all new staff. The pre-service training is provided through a combination of instructor-led and
web-based courses. The program considers case managers, operations managers, therapists,
and assistant facility administrators (AFAs) as direct care staff and includes them in the staff-to-
youth ratio. A review of instructor credentials verified all were qualified to deliver the provided
trainings. The program has an annual pre-service training plan/calendar, which was approved
by all required officials and is updated as changes occur. Seven staff training records were
reviewed for pre-service certification training. All seven reviewed training records documented
each staff completed the certification process within 180 days of hire. All seven records showed
documentation to support each staff exceeded the required 120 hours of pre-service training.
Completed trainings included Right Interactions (RI), first-aid, cardiopulmonary resuscitation
(CPR), automated external defibrillator (AED), professionalism and ethics, suicide prevention,
emergency procedures, child abuse reporting, Prison Rape Elimination Act (PREA), and
program operating procedures prior to having any contact with youth. The program’s contract
outlined program specialist training and hours of job specific training for safety and security
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Office of Accountability and Program Support Page 13 of 73 (Revised September 2022)
specialists such as adolescent development, balanced approach to restorative justice, the
Department’s Central Communications Center (CCC), civil rights, communication,
confidentiality/Health Insurance Portability and Accountability Act (HIPAA), diversity,
Department history, equal employment opportunity, human trafficking, infection
control/bloodborne pathogens, information security awareness, the Department’s Juvenile
Justice Information System, mental health and substance abuse, quality report writing, youth
supervision, standards of conduct, trauma responsive practices, electronic vapor products, the
grievance process, Exposure Control Plan, the behavior management system, Mental Health
Overlay Services, Substance Abuse Treatment Overlay Services, and the intended and safe
use of tools. One newly hired shift supervisor had completed an additional thirty-three hours of
training in coaching, leadership, and personal accountability. All completed trainings were
documented in the Department’s Learning Management System (SkillPro) and were delivered
by qualified trainers.
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 maintains a written policy and procedures regarding in-service training for all staff.
Seven staff training records were reviewed for in-service training. All seven training records
documented each staff exceeded the twenty-four hours of annual in-service training
requirements. All seven staff had current certifications in Right Interactions (RI). Each staff had
certification in first-aid, automatic external defibrillator (AED), and cardiopulmonary resuscitation
(CPR). Completed trainings included human trafficking intervention, information security
awareness, mental health and substance abuse, Prison Rape Elimination Act (PREA),
professionalism, interpersonal communication, and ethics, sexual harassment, suicide
awareness and prevention, trauma responsive practices, emergency response and emergency
drills, infection control, blood-borne pathogens, the Exposure Control Plan, Mental Health
Overlay Services, Substance Abuse Treatment Overlay Services, and juvenile sex offenders.
Each of the three applicable staff exceeded the eight hours of management/supervisory training
in the areas of coaching, leadership, and personal accountability. The program has a training
calendar which is updated as changes occur. All trainings were delivered by qualified trainers
and were documented in the Department’s Learning Management System (SkillPro). The
program maintains a written in-service training plan which was submitted and approved prior to
implementation.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program maintains a written policy and procedures regarding the grievance process
confirming each youth’s right to grieve and ensure all youth are treated fairly, respectfully,
without discrimination, and their rights are protected. The program’s grievance procedures
include informal, formal, and appeal phases. The youth are provided with the opportunity to file
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Office of Accountability and Program Support Page 14 of 73 (Revised September 2022)
an alternative informal request by utilizing a Request to Speak form as a first opportunity to
voice an objection and informally resolve a complaint. Grievance and Request to Speak forms
were available to youth as observed during the program tour. Reviewed documentation found
there were two grievances and several Request to Speak forms submitted by youth since the
last annual compliance review. A review of both formal grievances revealed the youth’s
grievances were resolved at the formal phase. Each grievance was addressed within the two-
day time frame. During the annual compliance review week, five youth and five staff were
interviewed. All five youth were able to explain the grievance process to include submission of a
completed grievance form into the secured grievance box. Four of the five interviewed youth
reported being able to request assistance in completing a grievance form, if needed, and one
youth reported never completing a grievance form. All five interviewed staff were able to explain
the grievance process. An interview with the facility administrator (FA) reported the grievance
process has three phases which consist of informal, formal, and appeal phases. The FA stated
grievances will be reviewed and investigated by the assigned staff member within two days of
the assignment and the person investigating the grievance will never be the subject of the
youth’s grievance.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program maintains a written policy and procedures for facilitator staff training for the
delinquency interventions models and evidence-based practices. The program’s policy requires
staff to be trained on the specific delinquency interventions models, strategy, and evidence-
based practices curriculum. The program’s non-clinical and non-primary delinquency
intervention model offered at the program is Thinking for a Change (T4C). The program had
one case manager trained to facilitate T4C for the annual compliance review period, who
resigned in October 2024. The trained case manager’s education and work experience were
considered by the program when determining staff delivery for the delinquency intervention
model. The supplemental group T4C was not provided during the annual compliance review
period. The program’s activity schedule was reviewed and determined at least sixty percent of
youths’ awake hours include structured, planned programming or activities. The facility
administrator’s interview reported Living in Balance (LIB) and Skillstreaming the Adolescent
were the curricula used to address the specialized needs of the population.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a written policy and procedures to address life and social skills training
for youth. Life and social skills training is provided utilizing the Skillstreaming the Adolescent
and Living in Balance (LIB) curricula. The life and social skills groups specifically address
communication, interpersonal relationships and interactions, non-violent conflict resolution,
anger management, and critical thinking. A review of the program’s activity schedule confirmed
each group is provided to the youth once to twice a week by the therapists. All staff conducting
groups received formal and on-the-job training by a certified trainer to deliver the curriculum.
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Skillstreaming the Adolescent groups incorporate health and hygiene skills. A review of seven
youth case management records and group sign-in sheets indicated services were delivered, as
required. Five interviewed youth reported they participated in life and social skills groups at the
program. An interview with the facility administrator (FA) indicated all youth are to participate in
daily mental health groups and life and social skills groups such as Thinking for a Change
(T4C), LIB, and Skillstreaming the Adolescent. The designated mental health clinician authority
(DMHCA) stated youth are provided and encouraged daily to use and practice learned skills
from groups. Additionally, youth are presented daily with opportunities during group activities to
practice the skills they have learned.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s restorative justice programming includes Impact of Crime (IOC) groups, which is
a primary service. In addition, youth participate in reparation activities at the program. The
facility administrator (FA) explained youth regularly participated in community service projects,
mailed holiday cards to the local senior assisted living home, youth planted vegetables which
were harvested and donated to a local domestic abuse shelter, and listened to guest speakers
as part of their restorative justice activities. In addition, youth participated in activities which
included raising chickens and donating the eggs to the local domestic abuse shelter.
Furthermore, the program offers restorative justice and community service opportunities for all
youth, which allow youth to complete community service through canteen points, assisting in the
kitchen, assisting maintenance staff, assisting with the animal husbandry program, making
posters and cards, food collection and can drives, and participation with the greenhouse. The
groups and activities are designed to assist youth in accepting responsibility for harm they have
caused by their past criminal actions, challenging them to recognize and modify their
irresponsible thinking such as denying, minimizing, rationalizing, and blaming victims, and
expose youth to victims’ perspectives through victim speakers. The program did not have youth
participating in restorative justice activities during the week of the annual compliance review;
therefore, an observation was not made. All five interviewed youth reported they participated in
restorative justice groups/activities while at the program.
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 written policy and procedures addressing youth alerts. The program enters
alerts into the Department’s Juvenile Justice Information System (JJIS) for youth requiring an
alert which may not have been entered prior to the youth’s admission. The program has an alert
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board in the main conference room which identifies each youth’s special alerts, escape risk,
and/or gang affiliation. The alert board identifies youth placed on any type of mental health alert.
Reviewed documentation indicated the program’s internal alert report is reviewed daily during
shift briefings by the program's supervisory staff. Observations verified kitchen staff have access
to each youth’s diet and allergy alerts in the kitchen. Seven youth records were reviewed for
case management, medical, mental health, and substance abuse alerts. All applicable alerts
were accurately entered into JJIS. All internal and JJIS alerts were downgraded or discontinued
by a medical staff, the director of case management, and/or licensed mental health staff. An
interview with the facility administrator (FA) reported all internal alerts are entered into JJIS by
their specific departments and medical alerts are updated. The nursing interview reported all
nurses are responsible for updating the medical alert system. Five staff were interviewed, and
each reported they are informed of youth alerts during shift meetings, a review of the program’s
alert board, and a medical alert log which indicates all the youth medical and mental health
alerts.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program has a written policy and procedures to ensure the management of all records are
consistent across operations and programs, the company philosophy, goals, objectives, and the
legal and contractual requirements. A review of seven youth healthcare, mental health and
substance abuse, and case management records showed each was marked “Confidential” and
each record documented the youth’s name, Department identification number (DJJID), the
youth’s date of birth, county of youth’s residence, and committing offense. The case
management records contain sections labeled as legal information, demographics and
chronological information, correspondence, case management and treatment team activities,
and miscellaneous. Observations during the annual compliance review week showed all
Individual Healthcare Records, mental health and substance abuse records, and case
management records were secured in a locked room, which was not accessible 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 a written policy and procedures in place to ensure the program has a
community support group or advisory board meeting at least every ninety to 120 days. The
program has a community advisory board which meets quarterly. Reviewed meeting minutes,
sign-in sheets, and agendas documented meetings took place in person on March 26, May 28,
and September 30, 2024. The ninety to 120 days were not met between the May 28 and
September 30, 2024 dates. The meeting was held five days late. Although the board is located
in a rural community, the advisory board member roster consists of a law enforcement
representative, four different interested community partners, a community business member, a
school district representative, a member of the judiciary, a victim advocate agency, a
representative of the LGBTQIA+ community, and a faith-based community member. The
advisory board includes two different members who were a parent/guardian of a child with
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previous involvement in the juvenile justice system. The program maintained documentation of
their email and mailed recruitment efforts. A review of community advisory board agendas and
meeting minutes confirmed the program provides the board members with information regarding
program updates, community updates, and restorative justice community service activities. An
interview with the facility administrator (FA) reported the community advisory board meeting is
held quarterly. The FA stated agendas, meeting minutes, and sign-in sheets are maintained. A
telephone call was made during the annual compliance review week to a local community
partner who serves as a board member. A message was left with the board member’s secretary
and there was no return call; therefore, no interview could be conducted.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program maintains a written policy and procedures to ensure staff personnel records
contain accurate and updated information. The program’s practice is to conduct evaluations
ninety days after hire and annually, thereafter, for all staff. The administrative staff reported they
provide coaching sessions as needed. The program maintains a detailed position description for
all staff and a written agreement outlining duties for all contracted staff. Seven staff personnel
records were reviewed, of which three contained an annual performance evaluation, and four
contained a ninety-day performance evaluation. Each staff had an evaluation which was based
upon a set of established performance standards which aligned with the duties outlined on the
staff’s position description. All seven reviewed performance evaluations found each staff’s
evaluation was based on the performance standards for their position. The evaluations rated the
staff’s quality of work, modeling of appropriate behavior, a positive reinforcement in a four-to-
one ratio, and each evaluation included ratings on the staff’s job-specific responsibilities. Five
staff were interviewed, and each staff had knowledge of how often they received an evaluation.
Staff reported yearly, every six-months, and during their job probation period. An interview with
the facility administrator (FA) reported staff are evaluated after their first ninety days and
annually, thereafter, on their job performance.
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 is required to implement all items and 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 simply listed in contract. These items typically exceed
the minimum requirements outlined in Florida Statute and Florida Administrative Code. The
program tracks measurable contract conditions through outcome measures entered into the
Department’s Juvenile Justice Information System (JJIS), which are administratively monitored
by the assigned contract manager annually. The program’s contract contains site-specific
requirements to include diverse media, faith-based opportunities, restorative justice and
community service offerings, parenting education, motivation, achievements, and reward
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activities. A review of documentation, on-site observations, and an interview with the facility
administrator (FA) validated the program was providing special contract conditions, as required.
The program has a partnership with a community prison ministry representative who leads
religious activities for youth desiring to participate. The program offers restorative justice and
community service opportunities for all youth, which allows youth to complete community
service through canteen points, assisting in the kitchen, assisting maintenance, assisting with
the animal husbandry program, making posters and cards, food collection and can drives, and
participation with the greenhouse. The program has an animal husbandry program with
chickens on-site. Youth have built, maintained, and provide regular care for the chickens. The
program’s greenhouse has been updated and repaired and has been functional since the last
annual compliance review. Approximately seven youth have been participating in the animal
husbandry program. The program provides education and support for youth expecting a child
during the youth’s transition phase. There were approximately four youth who were fathers and
received parent education and/or resources while in the program since the last annual
compliance review. The program’s registered nurse provides instruction on developmental
milestones, shaken baby syndrome, car seats, and water safety to confirmed fathers. Youth
coordinate with their therapists regarding specific family therapy. Expectant fathers are provided
additional materials such as books, brochures, and mentoring opportunities during their stay.
Special visitations are coordinated, when appropriate. An informal interview with the compliance
manager confirmed the program had a total of four applicable youth who received parental
resources and education. Observations in the youth’s living units showed books and other
publications were provided and the program has a youth library. The library has educational and
fictional reading materials for youth to sign-out. Specific requests are accommodated as
appropriate. Materials are screened and vetted through the lead teacher for appropriateness.
Media donations are encouraged by parent/guardians and community stakeholders. On-site
observations and informal interviews confirmed the youth have access to a variety of reading
materials in addition to tablet access. Youth tablets have pre-loaded educational games, access
to religious materials, and books. The program participates with drives for the donation of
clothing, shoes, hygiene items, food and engage in holiday celebrations with the program youth.
The next community activity scheduled is for a food and can drive which will be held for
Thanksgiving and is scheduled for November 5, 2024. All eligible youth completed all of their
community service hours while at the program. Youth with community service requirements
coordinate with the assigned case manager to ensure performance planning reflects the need
and community service. Hours are tracked on logs and provided to the assigned juvenile
probation officer. The program utilizes trained volunteers, mentors, and other members from the
community to provide positive modeling and experiences with the youth. The program has a
partnership with the community and local church volunteers, nonprofit agencies, to include a
domestic violence shelter, professional athletes, the local sheriff’s office, and staff mentors to
speak and model experiences with youth. On-site observations reflected the youth were wearing
their assigned uniform and were observed to be appropriately dressed. The program has a
barber chair, and it is utilized as part of the incentivized barbershop program. The program
participates in additional activities with community partnered programs. The program’s activities
include sport competitions, training camps, and other achievement celebrations. Incentives and
celebrations for positive behavior and youth success include honor roll, graduations, student of
the month, classroom of the week, daily, weekly, and monthly incentives, a football team, inter-
program sports tournaments, movie nights, music studio access, canteen, gym access,
quarterly dinners with administration, academic competitions, cook-off competitions, student
council, carnival/field days, family days, holiday celebrations, and pizza parties. Informally
interviewed youth and the interviewed assistant FA confirmed the program held incentive
celebrations in addition to the daily and weekly incentives for academic and behavioral
achievements.
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1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program maintains a written policy and procedures which address data trend analysis
components. The program’s administration and management policy addresses research efforts
to enhance operations and contribute to the base knowledge of juvenile justice. The program’s
quality assurance and program planning policy detailed a formal process for monitoring and
evaluating quality, compliance, fidelity, appropriateness, safety, and effectiveness of all program
services utilizing a framework for measurement and evaluation of outcomes and process
measures. The program conducts weekly security audits. The report identifies any deficiencies
and potential issues within the program and anticipated resolution dates. A review of the weekly
security audits confirmed the audits were conducted and completed on a weekly basis as
required. An interview with the program’s compliance manager explained the program’s efforts
to collect and analyze data. Additionally, the program participates in monthly compliance
reviews to discuss accomplishments, the facility administrator’s (FA’s) plan of action, any
corrective actions put in place, monthly staff and youth survey responses relating to perceptions
of program safety, living environment, treatment environment, whether youth community
meetings are occurring, and monthly incidents. The program conducts interviews with families
and youth on a quarterly basis, tracks outcome measures, monitors incident reports, conducts
internal fidelity monitoring, tracks evidence-based services, incidents, and quality improvement
audits. The program discusses scores, results, and findings in the morning management
meetings, monthly management meetings, community advisory board meetings, and during the
program’s all-staff meetings.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a written policy and procedures regarding initial contacts to the
parent/guardian and court notification. A review of seven youth case management records
showed the program notified each parent/guardian by telephone within twenty-four hours of
admission. Each reviewed record included documentation revealing the program notified each
parent/guardian in writing within forty-eight hours of the youth’s admission. Each record had
documentation indicating the juvenile probation officer (JPO), court, and applicable post
residential services counselor were notified in writing within five working days of the youth’s
admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a written policy and procedures regarding youth orientation. A review of seven
youth case management record’s documentation showed the program provided each youth an
orientation on the day of admission. Each reviewed case management record documented a
signed receipt acknowledging the youth received an orientation packet including a copy of the
youth handbook. The program’s orientation included services available, daily schedule,
expectations and responsibilities of the youth, written information on the program’s behavior
management system including rules governing conduct and positive and negative
consequences for behavior, information on how to access medical and mental health services,
access to the Florida Abuse Hotline or the Department’s Central Communications Center (CCC)
if the youth is over eighteen years of age, the program’s zero-tolerance policy regarding sexual
misconduct including how to report incidents or suspicions of sexual misconduct, special
accommodations, the right to be free from sexual misconduct, the right to be free from
retaliation for reporting such misconduct, the agency’s sexual misconduct response policies and
procedures, items considered to be contraband including illegal prohibited items, and
possession which may result in the youth being prosecuted. Additionally, the youth orientation
included information on the performance plan process, dress code and hygiene requirements,
procedures regarding visitation, mail, and use of the telephone, expectations for release from
the program, including the youth’s successful completion of individual performance plan goals,
recommendation to the court for release based on the youth’s performance in the program, the
court’s decision to release, community access, grievance procedures, emergency procedures,
procedures for fire drills and building evacuation, a program tour and a general layout of the
program which focuses upon those areas not accessible to youth, and assignment to a living
unit and room, treatment team, and a staff advisor or youth group. Information is conveyed
verbally to youth with limited reading skills or who are visually impaired, deaf, or otherwise
disabled. Observations of a youth orientation were not conducted due to the program not having
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an admission during the annual compliance review week. An interview with five youth was
conducted, and each youth stated they received an orientation within twenty-four hours of their
admission. Each youth confirmed orientation to the program included program rules,
procedures, schedules, and other pertinent information. Each youth reported orientation was
conducted within twenty-four hours.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a written policy and procedures which address obtaining written consent of
youth who are eighteen years of age or older. A review of seven youth case management
records showed three youth records were applicable for youth who were eighteen years of age
or older. A review of each youth’s record found a consent form signed by each youth prior to
any release of information related to the youth’s physical or mental health screenings,
assessments, or treatments.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a written policy and procedures regarding the classification process for youth
upon admission to the program and completion of reassessments as warranted. A review of
seven youth case management record’s documentation confirmed each record contained an
admission classification form including all required elements outlined by Florida Administrative
Code. The program’s classification form included physical characteristics of the youth, age and
maturity level, identified special needs, history of violence, gang affiliation, criminal behavior,
sexual aggression or vulnerability to victimization, youth’s perception of vulnerability, youth’s
history of potential or verified human trafficking, suicide risk, medical risk, escape risk, and
security risk. Seven youth case management records documented the date of the youth’s
classification, included all elements on the classification form, and confirmed they were
completed on the day of admission. A review of the Department’s Juvenile Justice Information
System (JJIS) alerts, and the programs internal alerts confirmed there were no issues affecting
each youth’s classification. Each of the seven reviewed youth were applicable for risk factors.
These risk factors included the date of the initial classification, suicide risk, medical risk, escape
risk, and security risk. Each of the seven youth were classified for purposes of assignment to a
living area, sleeping room, and youth group or staff advisor. Youth with medical, mental health,
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substance abuse, security risk factors, and/or special needs identified during or subsequent to
the classification process are immediately entered into the program’s internal alert system and
JJIS. Reclassifications were conducted for each of the seven youth reviewed and revealed there
was an increase in each youth’s privileges or freedom of movement. Reviewed documentation
confirmed the program’s policy and procedures clearly outlined the classification process and
included a classification system promoting safety and security, as well as effective delivery of
treatment services, based on the determination of each youth’s individual needs and risk
factors, which addresses, at a minimum, items outlined in Florida Administrative Code. The
program’s policy regarding reassessment ensures all program youth are pre-screened prior to
admission by the treatment team conducting a thorough review of the electronic commitment
packet and a review of JJIS alerts. Upon admission the program’s youth participate in an initial
intake screening process, including the completion of the Facility Entry Physical Health
Screening, Massachusetts Youth Screening Instrument, Second Version (MAYSI-2),
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) screening, and
Assessment of Suicide Risk, if applicable. An interview with the facility administrator (FA)
confirmed an initial intake screening process takes place within twenty-four hours. An admission
classification meeting is conducted to formally review the youth's history, special needs, and risk
factors to determine the appropriate levels of supervision. Additionally, the alert status needs
are identified for potential safety and security risks impacting the living unit and room
assignment. An admission classification meeting will be held to include the youth, therapist,
case manager, nurse, and living unit representative at a minimum. Each parent/guardian shall
be invited to participate in the classification meeting, if available.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a written policy and procedures regarding gang identification including
notification to law enforcement. A review of seven youth case management records showed one
youth was applicable for notification to law enforcement of suspected gang association. Two
additional case management records were provided by the program. Each of the three
applicable records documented local law enforcement was notified of suspected gang activity
prior to the Monitoring and Quality Improvement (MQI) seven-day notice. Reviewed
documentation confirmed each youth’s home county law enforcement program was notified of
the youth’s gang affiliation. Reviewed documentation reflected all gang alerts were maintained
in the Department’s Juvenile Justice Information System (JJIS) and updated as required, upon
identification. Each of the three applicable records documented gang information was shared
with the educational staff at the program and the youth’s juvenile probation officer (JPO). None
of the three applicable youth had a post-residential services counselor.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a written policy and procedures regarding a youth’s participation in gang
prevention and/or intervention activities. The program’s policy addresses providing youth an
opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang. The
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program utilizes the Project Renew curriculum and Impact of Crime (IOC) intervention groups as
part of the gang prevention and intervention curricula. A review of seven youth case
management records was conducted. One youth was applicable for being identified as a gang
member, or affiliated. The program was able to provide two additional applicable youth records.
Documentation supported all three youth participated in gang prevention and intervention
strategies. Each youth’s performance plan included goals and objectives related to gang
intervention strategies to be completed prior to release from the program. An additional gang
intervention strategy included ARISE Foundation’s Life Skills Gangs: 50+ Stories of Fractured
Lives. A review of the program’s sign-in sheets reflected the youths’ participation. An interview
with the facility administrator (FA) confirmed the program’s gang intervention and prevention
strategies.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a written policy and procedures to ensure a Residential Assessment for Youth
(RAY) is completed for each youth within thirty days of admission. A review of seven youth case
management record’s documentation showed each record contained a RAY which was
completed within thirty days of admission. Each initial RAY was maintained in the Department’s
Juvenile Justice Information System (JJIS). Seven youth case management records revealed
each youth was applicable for reassessments. Each youth record indicated RAY
Reassessments were completed at least every ninety-days. Each initial RAY and
reassessments were maintained in the youth’s official case record. Each youth case record
documented the dates of the youth’s reassessment, and any other updates or reassessments
were completed when deemed necessary by the intervention and treatment team to effectively
manage the youth’s case.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a written policy and procedures regarding the completion of the Youth Needs
Assessment Summary (YNAS). A review of seven youth case management record’s
documentation supported each youth’s YNAS was completed within thirty days of the youth’s
admission. Each youth’s YNAS was documented in the Department’s Juvenile Justice
Information System (JJIS).
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2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a written policy and procedures outlining performance plan development,
goals, and transmittal. A review of seven youth case management record’s documentation
confirmed each youth’s Individualized Performance Plan (IPP) was developed within thirty days
of the youth’s admission and developed after the completion of the initial Residential
Assessment for Youth (RAY) and the Youth Needs Assessment Summary (YNAS). Each of the
seven reviewed IPPs were developed and signed by the treatment team leader, youth,
administrative representatives, living unit representatives, treatment staff, education staff, the
Department of Children and Families (DCF) counselor, when applicable, and all parties who had
significant responsibility in goal completion. A review of documentation showed each of the
seven completed IPPs were mailed to each youth’s parent/guardian requesting a signature;
however, none were returned to the program at the time of the annual compliance review. Each
of the seven IPPs had the signature sheet of parties who had significant responsibility in goal
completion filed in the youth’s official case record. Each reviewed IPP included the youth’s
individualized goals based upon the prioritized needs identified during the initial assessment,
addressed the youth’s three top criminogenic needs, specific delinquency interventions based
on RAY results, court-ordered sanctions, and transition activities targeted for the last sixty-days
of the youth’s anticipated stay. Each IPP outlined program staff responsibilities and target dates
for goal completion. Each of the seven IPPs were sent to each youth’s committing court judge,
juvenile probation officer (JPO), and parent/guardian. Two youth were involved with DCF;
therefore, the IPP was sent to the youth’s counselor within ten days of completion. Five
interviewed youth confirmed they participated in the development of their performance plan,
treatment goals, and received a copy of their performance plans.
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 written policy and procedures in place ensuring revisions to a youth’s
performance plan. A review of seven youth case management records revealed four youth were
applicable for Individualized Performance Plan (IPP) revisions. Each of the four record’s
revisions were based on the Residential Assessment for Youth (RAY) Reassessment results,
when acquired information warranted updates, and based on the youth demonstrating progress
toward completing a goal. None of the four records were applicable for youth demonstrating lack
of progress toward completing a goal and facilitating transition activities during the last sixty
days of the youth’s stay. Each of the seven reviewed youth had additional plans, to include
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academic or treatment plans, included in their performance plans. Two youth were applicable
for a case plan through the Department of Children and Families (DCF) and the performance
plans coordinated with the DCF plans.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety-day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a written policy and procedures ensuring the completion of performance
summaries and transmittals. A review of seven youth case management records revealed each
was applicable for initial Performance Summaries. Five youth were still within their ninety
calendar days. All seven youth’s records included Performance Summaries which were
completed within ninety days following the signing of the performance plan, or at shorter
intervals. None of the seven youth were applicable for a Performance Summary prepared prior
to the youth’s release, discharge, or transfer from the program. All seven Performance
Summaries included all required elements to include the youth’s status on each performance
goal, overall treatment progress, academic status, credits earned in the program, performance
and behavior in school, youth’s behavior, level of motivation and readiness to change,
interaction with peers, interaction with staff, overall behavior adjustment to the program, and
significant positive and negative events. Each youth’s Performance Summary included
documentation which was signed confirming the youth read and was allowed to add comments
to the Performance Summary. Each youth was provided a copy of the signed summary, and the
original summary was filed in the youth’s case management record. Each Performance
Summary was signed and dated by the treatment team leader, staff preparing the summary,
facility administrator (FA) or designee, and the youth. Documentation showed each
Performance Summary was sent to the youth’s committing court, juvenile probation officer
(JPO), youth, parent/guardian, and the Department of Children and Families (DCF), when
applicable. Two of the seven youth were involved with DCF, and a copy of each youth’s
Performance Summary was sent within ten working days. Three closed case management
records were reviewed for release summaries. Each record included a copy of the youth’s
original summary, along with justification for release, sent with the Pre-Release Notification
(PRN) to the JPO. Reviewed documentation showed the release summary and PRN was sent
within seventy-two hours prior to release. Signed copies were retained in each of the three
records. Once the PRN was approved, the program provided a written notification to the youth’s
parent/guardian regarding the planned release and the program completed a Residential
Assessment for Youth (RAY) exit assessment. None of the three records were applicable for the
court objecting to the youth’s release. Reviewed documentation and an interview with the
compliance manager verified victim notification was not needed for the three closed case
management records.
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2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a written policy and procedures regarding parental/guardian involvement in
case management services. Documentation supported the program makes efforts to include the
parent/guardian in the assessment process, development of the youth’s performance plan,
progress reviews, formal treatment team meetings, and transition planning. If the
parent/guardian is unable to attend the meetings in person, they are afforded the opportunity to
participate by telephone or conference call or are able to provide verbal or written input prior to
the meeting. At the time of the annual compliance review the program did not have any
scheduled treatment team meetings; therefore, an observation was not conducted. A review of
the youth’s progress notes revealed the program reaches out to the parent/guardian to facilitate
involvement by telephone, by email, and/or a letter will be sent to the residence. An interview
was conducted with the facility administrator (FA), and it was indicated all parents/guardians are
provided a handbook upon admission. The youth’s parent/guardian is encouraged to participate
in monthly treatment team meetings and family sessions. Five youth were interviewed, and four
youth stated their parent/guardian participated by telephone or in person. The other youth was
eighteen years of age and stated they do not include their parent/guardian.
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 written policy and procedures regarding treatment team meetings. A review
of seven youth case management records determined formal treatment team meetings were
held every thirty days for each youth, and informal meetings were held bi-weekly, as required.
Documentation for each of the formal and informal treatment team review meetings included the
youth’s name, date of review, required attendees, comments from treatment team members or
others, a brief synopsis of the youth’s progress, performance plan revisions, performance plan
goals, positive and negative behaviors, behaviors resulting in physical interventions, the youth’s
documented opportunity to demonstrate skills acquired in the program, treatment progress, and
Residential Assessment for Youth (RAY) Reassessment results. All seven records contained
formal treatment team documentation in the youth case management record. All required
parties were present either in person or by telephone during the formal and informal treatment
team meetings. At the time of the annual compliance review the program did not have any
scheduled treatment team meetings; therefore, an observation was not conducted. An interview
with five youth indicated one youth was eighteen years of age and did not include their
parent/guardian in treatment team meetings. The other four youth stated their parent/guardian
appear by telephone or in person and actively participate in the planning.
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2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a written policy and procedures addressing transition planning, conferences,
and Community Re-Entry Team (CRT) meetings. A review of three closed youth case
management records was conducted and the transition conference was held at least sixty days
prior to the youth’s targeted release date. Each record documented the youth, treatment team
leader, facility administrator (FA) or designee, and other team members attended the transition
conference. There was documentation provided to support the program invited and encouraged
the youth’s juvenile probation officer (JPO), parent/guardian, education staff, and any other
additional pertinent parties to participate in the youth’s transition conference. One of the three
youth was determined to have a human trafficking history; therefore, the service provider was
involved. Documents supported each transition conference included a review of transition
activities on the youth’s performance plan, necessary performance plan revisions, additional
transition activities as needed, target completion dates, and persons responsible for transition
activities. The treatment team leader obtained attendees’ dated signatures, representing their
acknowledgement of the transition goals and accountability for completion. A copy of the plan
was sent with a request for return with signature to anyone not in attendance who had a
responsibility for completion of transition goals; however, none were returned. None of the forms
were transmitted electronically. Reviewed documentation found a CRT meeting was conducted
prior to each youth’s release and the youth and case manager participated. Documentation
revealed there was evidence of an invitation to participate in the CRT meeting for each of the
three closed case management records.
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 written policy and procedures outlining the requirements of the exit portfolio.
A review of three closed youth case management record’s documentation showed each youth’s
exit portfolio was discussed during the transition conference. One of the three reviewed exit
portfolios contained a state-issued identification card and the other two did not. Documented
telephone contacts and notes demonstrated the program was actively working with the youth
and the family to obtain an identification card. One record contained a Social Security card and
none of the youth portfolios contained a birth certificate. An interview with the program’s
compliance manager and reviewed documentation showed telephone contacts and notes where
the program was actively working with the youth and the family to obtain the required
documents. Each exit portfolio contained a copy of the youth’s transition plan, a calendar of
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upcoming appointments, vocational certificates earned at the program, school transcripts,
résumé, and a sample employment application. Documentation supported each youth’s exit
portfolio was verified during the exit conference, and documentation indicated the exit portfolio
was given to the youth upon release and forwarded to the youth’s juvenile probation officer
(JPO). The program’s contract did not include any additional requirements for the exit portfolio.
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 written policy and procedures to ensure the completion of each youth’s exit
conference. Three closed youth case management records were reviewed and determined
there was documentation each youth’s exit conference was conducted after the program notified
the youth’s juvenile probation officer (JPO) of the youth’s pending release, and at least fourteen
days prior to the youth’s release date. Reviewed documentation indicated the date of the
conference, signatures, and a summary pending transition goals were included. The youth’s
date of admission and date of termination were documented in the case record and correlated
with the Department’s Juvenile Justice Information System (JJIS). Each record had
documentation reflecting the status of transition activities established at the transition
conference and the plans were finalized for the youth’s release. Documentation revealed
provisions for continuation of education and employment. The youth’s parent/guardian and JPO
were aware of the vocational plan for the youth and there was documented evidence the youth’s
case manager and parent/guardian were aware of the plan, documents, and post-release
discharge plans. Each of the three exit conferences had documentation to confirm the treatment
team leader, parent/guardian, education representative, JPO, youth, and other pertinent parties
participated, and there was documentation in each youth record indicating the exit conference
was held separately from the transition conference and Community Re-Entry Team (CRT)
meetings.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a written policy and procedures regarding written provisions for youth input.
The program has a formal process to promote constructive input by youth through giving them a
Request to Speak form, which will be filled out and submitted. This form is located on each
youth living unit. Additionally, the program attends town hall meetings and student advisory
board meetings, which are held monthly for each living unit. There was a review of the
program’s sign-in sheets, agendas, and meeting minutes to confirm the meetings were being
held as required. Advisory meetings were conducted once each month and the town hall
meetings were conducted twice each month. An interview with five youth indicated youth may
submit a grievance form about a concern or can request to speak to a supervisor or the facility
administrator (FA), if needed. Additionally, a youth may request to speak with a therapist to
convey concerns or issues at the program. An interview with the FA indicated monthly surveys
are completed by youth, bi-weekly town hall meetings are conducted, and monthly student
advisory council meetings are conducted to allow youth input and for them to communicate their
concerns, as well as address any systemic issues they may have.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program maintains a written policy and procedures regarding the designated mental health
clinician authority (DMHCA). The program employs a clinical director who serves as the
program’s DMHCA. The program’s DMHCA is a full-time staff who is on-site at least forty hours
each week and is responsible for the coordination and implementation of mental health services
in the program. As a part of the assigned responsibilities, the DMHCA shall ensure consistent
and appropriate mental health services and shall be available on-call twenty-four hours a day,
seven days each week to provide consultation in the event of emergencies. The program’s
assistant clinical director shall coordinate licensed clinician coverage as needed and assist in
DMHCA responsibilities in their absence. The program’s DMHCA is a licensed clinical social
worker. A review of the license determined it was free and clear in the State of Florida with an
expiration date of March 31, 2025. The interviewed DMHCA confirmed their on-site schedule of
at least forty hours each week and being on-call for emergencies. The program’s licensed
clinical director provides back-up DMHCA coverage. A review of the assistant clinical director’s
license reflected it was free and clear in the State of Florida with an expiration date of March 31,
2025. The interviewed DMHCA indicated their role in the coordination and implementation of
mental health services at the program includes the provision of clinical supervision, fidelity
monitoring, oversight of service tracking, and the facilitation of group, family, and individual
counseling.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and procedures regarding licensed mental health and
substance abuse staff to establish requirements for qualified professionals in the delivery of
mental health and substance abuse services. All licensed and non-licensed mental health and
substance abuse staff are hired in accordance with contract, Florida Administrative Code, and
mandated guidelines. Treatment shall be provided by individuals meeting qualifications. The
program’s designated mental health clinician authority (DMHCA) is responsible for ensuring
staff working under their supervision are qualified to provide services based on education,
training, and experience. The program is shared with the Everglades Youth Academy - Sex
Offender Program under the same contract number on the same campus. The shared mental
health staff include a licensed DMHCA, a licensed assistant clinical director, one licensed
therapist, and a licensed psychologist. Each reviewed license was free and clear in the State of
Florida and available on-site as required.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and procedures regarding non-licensed clinical staff.
The program shall ensure all mental health and substance abuse services are provided by
licensed or non-licensed clinical staff members who are qualified to provide such services based
upon education, training, experience and who are working under the direct supervision of a
licensed mental health professional. The program’s designated mental health clinician authority
(DMHCA) holds an active and clear license and serves as the program’s supervisor for all on-
site clinical staff. The program is shared with the Everglades Youth Academy - Sex Offender
Program under the same contract number on the same campus. The mental health staff are
shared amongst the programs. The program’s contract requires one licensed DMHCA, one
licensed assistant clinical director, and eight therapists. At the time of the annual compliance
review the program’s non licensed staff included five full-time therapists and one part time
therapist. The program reported having one vacancy. The non-licensed position has been
vacant since August 2024. A review of direct supervision logs for non-licensed staff since the
last annual compliance review reflected each staff received face-to-face clinical supervision for
the weeks in which services were provided without exception. Supervision was documented on
the program’s form and included all elements of the Department’s Licensed Mental Health
Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision Log
form. The program is licensed under Florida Chapter 397 with the Department of Children and
Families to provide adolescent substance abuse services. The license was displayed in the
lobby and expires April 1, 2025. A review of the non-licensed staff’s experience and education
indicated two staff held a master’s-level degree and three held a bachelor’s-level degree. All
three staff with bachelor’s-level degrees had fifty-two hours of specialized pre-service training to
include sixteen hours of training on duties and responsibilities prior to working with youth. Each
of the five non-licensed staff had twenty hours of training in the administration of the
Department’s Assessment of Suicide Risk, Crisis Assessments, and emergency health services
as required.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program maintains a written policy and procedures to establish a system to gather
important treatment and emergent needs information prior to the youth’s entry into the general
population. A review of seven mental health and substance abuse records indicated the
program completed a Massachusetts Youth Screening Instrument, Second Version (MAYSI-2)
on the day of admission. The program documented the review of information to include the
commitment packet and existing documentation of mental health and substance abuse
problems or history of human trafficking. Each reviewed MAYSI-2 was completed in full in the
Departments Juvenile Justice Information System and documented the date of completion and
name of staff completing the screening. Six of the seven MAYSI-2s indicated the need for
further assessment; however, it is the program’s practice to complete an Assessment of Suicide
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Risk and a comprehensive evaluation for all youth regardless of screening results. Each youth
was referred for further assessment in accordance with the program’s policy. None of the
reviewed records were applicable for emergency procedures or the youth being in crisis. Two
youth were applicable for suicide ideation indications and were placed on suicide precautions as
required. The reviewed screening policy indicated the facility administrator (FA) is responsible
for the implementation of a standardized mental health and substance abuse screening
process. The procedures require the review of available information, the completion of a
MAYSI-2, staff training in screening administration, and a process for youth in crisis requiring
immediate attention. The interviewed FA reported the case manager or designee will facilitate
an admission classification meeting for all admitted youth immediately following an initial intake
screening process. Meeting outcomes will be documented and a justification for room
placement will be identified on the admission classification form. Staff will be notified of referrals
and recommendations made within the meeting through verbal communication, alert
communication board updates, entries in the program’s logbook, and email correspondence.
Additionally, the admission classification meeting documentation will be signed and placed into
the youth's record.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a written policy and procedures to provide an evaluation and
assessment process to determine the mental health and substance abuse treatment needs of
the youth and to guide the development of the youth’s individualized treatment plan. Youth
identified by screening or staff observation as in need of further evaluation must be referred for
a comprehensive mental health and/or substance abuse evaluation. The program’s assessment
and evaluation process is completed during the first three weeks of residential placement with
the youth, parent/guardian, applicable Department of Children and Families case counselor, as
well as others involved in the youth’s care as indicated. The evaluation and assessment process
is completed by licensed mental health professionals or mental health clinical staff working
under the direct supervision of the licensed mental health professional. The program’s practice
is to refer and assess all youth regardless of intake screening outcomes. A review of seven
youth records indicated a new combined mental health and substance abuse comprehensive
evaluation was completed for each youth. Each evaluation was completed within thirty days of
admission and each youth consented to substance abuse services prior to the evaluation. Each
combined evaluation included the date of referral/admission, date of the evaluation, identifying
information, the reason for the evaluation, relevant background information, behavioral
observations, a Mental Status Examination, procedures administered, discussion of findings,
diagnostic impressions, patterns of drug and/or alcohol use, impact of use on major life areas,
risk factors for continued use, and recommendations. Each reviewed assessment was
completed by a non-licensed staff and signed by a licensed staff within ten days. The program is
licensed under Chapter 397 to provide substance abuse treatment to adolescents.
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3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a written policy and procedures to establish individualized treatment
planning processes which guide service delivery. A review of seven youth records indicated
each contained an initial mental health and substance abuse treatment plan completed within
seven days of admission. Each initial plan was documented on the program’s form and
contained all elements of the Department’s Initial Mental Health/Substance Abuse Treatment
Plan form. Each initial plan indicated the youth would see the psychiatrist for an evaluation
regardless of medication status. Two of the youth were applicable for psychotropic medications
and the plan included the medication details. Each of the seven initial plans were completed by
a non-licensed staff working under the direct supervision of the designated mental health
clinician authority (DMHCA) and signed by the DMHCA the same day. Each plan was signed by
the youth, parent/guardian, when available, treatment team leader, program administration, and
a living unit representative. Three plans documented the participation of each parent/guardian
by telephone. Each of the seven reviewed records were applicable for an individualized
treatment plan to be completed within thirty days and treatment plan reviews to be completed at
thirty-day intervals. Two of the individualized treatment plans were for youth prescribed
psychotropic medications and the plans included the medication details and the medication
monitoring schedule. The seven reviewed records were applicable for fifty treatment plan
reviews. Forty-nine reviews were completed at least every thirty days as required and one was
not completed due to the youth being in the local jail. A review of the individualized treatment
plans and reviews confirmed they documented participation of the youth, parent/guardian,
juvenile probation officer, treatment team leader, living unit representative, and education staff.
Each plan was signed by the non-licensed staff and the DMHCA on the same day. Observed
goals and objectives were individualized for each youth and included individual counseling,
group counseling, family counseling, and applicable psychotherapy. A review of video compared
to sign-in sheets for three separate mental health groups indicated the groups were occurring as
scheduled and as documented.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program maintains a written policy and procedures requiring individualized, trauma
informed, developmentally appropriate mental health and substance abuse treatment services
to be provided to all program youth in need of such services. All treatment services are guided
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by an individualized treatment plan which addresses the youth’s needs in accordance with
Florida Administrative Code. Treatment planning shall focus on the provision of mental health
and substance abuse interventions and treatment as appropriate to reduce or alleviate the
youth’s symptoms of mental disorder and/or substance abuse impairment. All treatment
services are provided by qualified mental health professionals with education, experience, and
training to perform the services being administered. The assigned intervention and treatment
team shall assist in developing, reviewing, and updating the youth’s initial and individualized
mental health/substance abuse treatment plans. All youth who receive mental health and/or
substance abuse treatment shall have a discharge summary completed which documents the
focus and course of treatment as well as the recommendations for follow-up mental health and
substance abuse services upon release from the program. A review of seven youth records
indicated each youth was assigned to a treatment team upon arrival to the program. Reviewed
treatment planning meetings documented participation from the youth, program administration,
living unit representative, education staff, applicable vocational staff, medical staff, mental
health and substance abuse staff, and applicable parents/guardians for all youth. The program
is licensed under Chapter 397 to provide substance abuse services to adolescents. Each youth
with substance abuse treatment goals received treatment by a qualified professional. Each
youth record contained a substance abuse consent and the Department’s Authority for
Evaluation and Treatment. Progress notes were documented on the program’s form and
contained all elements of the Department’s Counseling/Therapy Progress Notes form.
Reviewed progress notes verified treatment included individual psychotherapy and psychosocial
skills. Each reviewed record verified services were provided as stipulated in the youth’s
treatment plan. Three closed records were reviewed for discharge summaries. Each summary
was documented on the Department’s Mental Health/Substance Abuse Treatment Discharge
Summary form. None of the youth were applicable for being released on suicide precautions.
Each discharge summary documented future services needed. Reviewed documentation
supported the plans were discussed during the exit conference with the youth, parent/guardian,
and assigned juvenile probation officer (JPO). Each record documented the youth and
parent/guardian signed the plan and the plan was sent to the assigned JPO.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program maintains a written policy and procedures regarding mental health and substance
abuse treatment services to be provided to youth with co-occurring disorders. Mental health and
substance abuse services shall be provided in accordance with Florida Administrative Code.
The program provides Mental Health Overlay Services (MHOS). Required clinical treatment
groups include Moral Reconation Therapy (MRT), Skillstreaming the Adolescent, and Living in
Balance (LIB). Five interviewed youth indicated they participated in individual and family therapy
at the program. Five interviewed staff indicated only mental health staff facilitate mental health
groups. An interview with the designated mental health clinician authority (DMHCA) indicated
the program provides individualized treatment through individual, group, and family therapy. The
interviewed facility administrator confirmed the required clinical groups at the program. A review
of the contract requirements and the program’s practices was completed during the annual
compliance review week. Documentation confirmed the DMHCA was on-site for forty-hours
each week and licensed staff were on-site at least five days each week. The program is shared
under the same contract number with the Everglades Youth Academy - Sex Offender Program
and the program’s clinical staff are shared between the two programs. The required counselor
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to youth ratio is not to exceed one counselor to sixteen youth. A review of caseload
assignments indicated they were between ten and fifteen youth. The program was providing
individual therapy once every two weeks, family therapy at least monthly, applicable psychiatric
services every two weeks, and mental health/substance abuse groups four times each week as
required. The program has an independent contract with a licensed psychologist who provides
services as needed.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program maintains a written policy and procedures to ensure the provision of psychiatric
services for the treatment of serious mental disorders through the use of a contracted
psychiatrist. The contracted psychiatrist shall be responsible for the provision of psychiatric
services which include psychiatric evaluation, psychiatric consultation, medication management,
and medical supportive counseling provided to youth with a diagnosed 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 Florida Administrative Code. A review of
the psychiatrist’s license indicated they held a medical doctor license which was free and clear
in the State of Florida with an expiration date of January 31, 2026. The interviewed psychiatrist
and a review of their agreement verified they were on call and available for emergency
consultation twenty-four hours a day, seven days a week. The psychiatrist serves as a brief
representative of treatment team and psychiatric recommendations for youth are incorporated
into evaluations and planning at the program. The program did not utilize a back-up psychiatrist
during the annual compliance review period. An informal interview with the regional compliance
staff verified the program would utilize a psychiatrist from another program if coverage was
needed. The program does not use a psychiatric advanced practice registered nurse. A review
of the psychiatric sign-in logs verified the psychiatrist was on-site bi-weekly since the last annual
compliance review. Documentation supported the psychiatrist actively participates in, manages,
and supervises psychotropic medication services at the program. The program does not utilize
tele-psychiatry services. The designated mental health clinician authority (DMHCA) reported the
psychiatrist is on-site for four hours bi-weekly. The interviewed psychiatrist reported they are on
call twenty-four hours each day as needed. The psychiatrist reported they review the psychiatric
logs and treatment team trackers when they are on-site to deliver face-to-face psychiatric
services. The psychiatrist reported they have no concerns with services provided at the
program. A review of seven records indicated two were applicable for psychiatric services;
therefore, and additional record was requested and reviewed. Two of the three youth entered
the program with prescribed psychotropic medications and one youth was prescribed
medication after admission. The two reviewed initial diagnostic psychiatric interviews for youth
on medications included history, a Mental Status Examination, a DSM-5 diagnosis, treatment
recommendations, prescribed medications, explanation for the need of medications, target
symptoms, initial treatment goals, potential side effects, and frequency of medication
management. Each youth was referred for a psychiatric interview upon admission, as it is the
program’s practice to refer all youth. Each interview was documented on the Department’s
Clinical Psychotropic Progress Note (CPPN) form and included page three when medication
was prescribed and/or continued. The three youth were applicable for twenty-five psychiatric
medication reviews to be completed at least every thirty days. Twenty-four were completed
without exception and one could not be completed due to the youth being in the local jail. None
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of the reviewed records were applicable for a psychiatric evaluation update. Each instance
where page three of the CPPN was used the psychiatrist documented the identifying data,
diagnosis, target symptoms of each medication, effects of the medication, medication dosage,
dosage range, frequency, route of administration, side effects, adherence to the medication
regime, and whether there was telephone contact with the youth’s parent/guardian. Each was
signed and dated by the psychiatrist. None of the reviewed records were applicable for the
monitoring of Tardive Dyskinesia or the use of tele-psychiatry.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program maintains a written policy and procedures regarding the Suicide Prevention Plan
which describes the essential components and provides guidelines for the identification,
management, and assessment of a potential suicide or at-risk youth. Potential suicide risk or at-
risk youth refer to youth who have a history of or demonstrate behaviors which indicate they are
thinking about or contemplating suicide; however, are not acutely suicidal. The acutely suicidal
youth who attempt suicide or present an imminent threat of suicide must be treated as an
emergency and the program’s Emergency Response Plan shall be implemented. A review of
the program’s Suicide Prevention Plan indicated it was last signed by the designated mental
health clinician authority (DMHCA) and facility administrator on October 21, 2024. The reviewed
plan included all required elements.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
The program maintains a written Suicide Prevention Plan which serves as the program’s suicide
prevention procedures. The Suicide Prevention Plan addresses the program’s suicide
prevention services, suicide precautions and observation logs, as well as suicide prevention
training. A review of seven youth records indicated each was applicable for an Assessment of
Suicide Risk (ASR) to be completed upon admission as part of the program’s standardized
practice. The program reported they only had two youth who were identified as being actively
suicidal and requiring interventions since the last annual compliance review. A review of the
seven ASRs completed as part of the admission process indicated each was completed in full
and each youth was transitioned to standard supervision after a conference was documented
with the designated mental health clinician authority (DMHCA) and the facility administrator
(FA). Six were completed by licensed staff and one was completed by a non-licensed staff and
signed by the licensed DMHCA within twenty-four hours. Two youth requiring suicide
interventions were referred for an ASR after staff observations. Each ASR was completed within
twenty-four hours by a non-licensed staff and signed by the licensed DMHCA the next day. Both
youth were maintained on suicide precautions and the proper alerts and notifications were
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made. Each ASR documented a conference between the assessor, DMHCA, and the FA
regarding the decision to place the youth on suicide precautions. Both youth were subsequently
transferred to a Baker Act receiving facility. The program logbooks clearly documented
supervision status and alerts for the two reviewed youth. A video review of one youth on suicide
precautions verified the center’s practice of maintaining constant sight and sound supervision of
at-risk youth.
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 did not utilize secure observation since the last annual compliance review;
therefore, this indicator is rated non-applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a written policy and procedures requiring staff to always maintain at
least constant supervision of the youth on precautionary observation and document their
observations of the youth on the Suicide Precautions Observation Log in intervals which do not
exceed thirty minutes. A review of seven youth records indicated none were applicable for being
placed on precautionary observation. The program had two youth applicable for placement on
suicide precautions since the last annual compliance review; however, one youth was
applicable for multiple placements. A review of three precautionary observation events indicated
supervision was documented on the Department’s Suicide Precautions Observation Log. Each
log indicated youth behavior was documented in real time and did not exceed thirty-minute
intervals. Two events were applicable for the youth displaying warning signs and the
notifications to the applicable parties was documented. Mental health staff clearly documented
warning signs and consultation on the logs. Each log documented the signature of the
supervisor and the mental health staff, in addition to clearly documenting safe housing
requirements.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a written policy and procedures requiring all staff who work with youth to
receive six hours of annual training on suicide prevention and implementation of suicide
precautions. Suicide prevention trainings completed on the Department’s Learning Management
System (SkillPro) are included in the six hours of annual suicide prevention training. All staff
who work with youth must be trained in suicide precautions and emergency response
procedures and participate in mock suicide drills quarterly, on each of the three shifts. The drills
are designed to practice responses to a suicide attempt or incident of serious self-injury and
include methods for contacting other programs for back-up support, medical personnel, and
emergency medical services. Drills include the provision of life saving measures such as
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cardiopulmonary resuscitation (CPR) and use of a suicide response kit. A review of seven staff
training records verified each received the required six hours of training. The program has three
suicide response kits which are co-located with first-aid kits in master control, east sub-control,
and west sub-control. A review of mock suicide drills indicated the program completed at least
one drill on each shift quarterly. Drills included the provision of life-saving measures for acutely
suicidal youth or youth in crisis. A review of a mock suicide drill video confirmed drills were
simulated and staff acted out and then debriefed scenarios. The program does not use program
youth in drill simulations and staff who are not present for a drill receive a verbal review during
the program’s mandatory monthly all-staff meeting. The interviewed facility administrator
reported drills occur monthly. Five interviewed staff reported when a youth is suicidal, they are
responsible for notifying mental health staff, searching youth for sharp objects, maintaining
constant sight and sound supervision, documenting supervision, and notifying the supervisor.
The interviewed staff reported the suicide kits are located in medical, master control, and sub-
controls. Each of the five interviewed staff reported drills are conducted at least monthly.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written policy and procedures regarding crisis intervention. Crisis
intervention shall be provided to youth in crisis in the least restrictive means possible to protect
the safety of the youth, safety of staff and others while maintaining control and safety of the
facility. The program has developed a Crisis Intervention Plan to ensure the protection of youth,
to the extent possible, and 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 self or others which would require suicide
precautions or emergency treatment. A review of the program’s Crisis Intervention Plan
indicated it contained all required elements.
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 maintains a written Crisis Intervention Plan addressing mental health crisis
intervention services and Crisis Assessments. A review of seven youth records found none
were applicable for a Crisis Assessment. An informal interview with the regional compliance
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manager verified there were no youth applicable for a Crisis Assessment during the annual
compliance review period.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written Emergency Response Plan for mental health and substance
abuse emergencies to ensure the highest quality of care, safety, and management of the youth.
The plan is maintained and annually reviewed by the facility administrator (FA) and designated
mental health clinician authority (DMHCA). A review of the plan verified it contained all required
elements and was last signed on October 21, 2024, by the DMHCA and the FA.
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 maintains a written Emergency Response Plan for mental health and substance
abuse emergencies to serve as the program’s emergency response procedures. The plan
outlines procedures for emergency mental health and substance abuse services and Baker and
Marchman Acts. The program had a total of three Baker Acts since the last annual compliance
review. Each reviewed event indicated the staff immediately referred the youth for an
assessment and placed the youth on precautionary observation once warning signs presented.
The program’s clinical staff assessed each youth within two hours and referred the youth for an
evaluation at a Baker Act facility. Each youth was transported by law enforcement and returned
to the program on precautionary observation until assessed by mental health staff. Each youth
was maintained on precautionary observation until an Assessment of Suicide Risk (ASR) and a
Mental Status Examination were completed. Each ASR was completed by a non-licensed staff
and reviewed by the conferring licensed designated mental health clinician authority.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a written policy and procedures for an ongoing safety planning process
for each admitted youth. Safety planning is designed to identify stimuli which have both positive
and negative effects on the youth. Within fourteen days of admission, the intervention and
treatment team shall meet with each youth to develop the Safety Plan. The Safety Plan shall be
updated in an ongoing collaboration with the youth to identify specific behaviors or triggers
which may decrease the youth’s sense of safety and increase the likelihood the youth may
experience a traumatic stress related response. The Safety Plan shall include input from the
parent(s)/guardian(s) as well as information gathered from the youth’s history and evaluations, if
applicable. The plan shall be updated every thirty days or following any significant behavioral or
mental health event identified by the treatment team. A review of seven youth records indicated
each had a Safety Plan created within fourteen days of admission and reviewed every thirty
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days. Each plan documented warning signs, youth baseline behavior, crisis recognition, jointly
developed coping strategies, preferred intervention strategies, and a debriefing process. Each
plan was jointly prepared with the youth, parent/guardian, and mental health staff. Each plan
incorporated information from previous assessments and interviews. Two of the plans required
an update due to a significant event and updates were documented within the plan reviews. The
seven reviewed records contained fifty-eight Safety Plan reviews. The plans are accessible to
staff and located in west sub-control and east sub-control. Five interviewed youth reported they
contributed to the development of their Safety Plans. The interviewed facility administrator
reported Safety Plans are reviewed, at a minimum, every thirty days.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a written policy and procedures which require a contracted health authority to
provide on-site medical services to youth being provided services in the program. The program
currently maintains an independent contractor agreement with a State of Florida physician to
serve as the designated health authority (DHA). The DHA is a licensed physician who holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
Florida. The DHA has a clear and active license in the State of Florida, expiring January 31,
2026, with specialty training in pediatrics and experience in adolescent health. A review of the
Florida Department of Health documentation showed the DHA didn’t have any disciplinary
cases or public complaints on record at the time of the annual compliance review. The program
does not utilize an advance practice registered nurse (APRN) or physician’s assistant (PA). The
DHA is required to be on-site up to eight hours weekly with a week defined as the seven-day
period beginning on Sunday and ending on Saturday. A review of documentation since the last
annual compliance review indicated the DHA was on-site as required except for two weeks in
which the program’s back-up DHA provided coverage. The program has a back-up DHA who
has a clear and active license in the State of Florida expiring on January 31, 2025. The back-up
DHA was utilized during the weeks of July 13, 2024, and July 20, 2024, due to the primary DHA
being on scheduled vacation. A review of the medical policy and procedures indicated there was
no inclusion or approval from the Department’s Office of Health Services for
telemedicine/telehealth services. The interviewed DHA stated their role is to complete
Comprehensive Physical Assessments (CPAs) within seven days of intake, to complete follow-
up appointments as needed, to complete Health-Related History reviews, and periodic
evaluations every ninety days. The DHA stated medical policies and procedures are reviewed
annually.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a written policy and procedures in place for licensed medical staff. The
licensed medical staff policy was reviewed and revealed the designated health authority (DHA)
is clinically responsible for all healthcare services provided to the youth. The program’s
operating procedures and nursing protocols are approved by the DHA. The daily clinical
services, such as intake evaluations, assessments, health education, and medication
management, are performed by licensed medical staff. The licensed medical staff at the
program are registered nurses (RNs) and licensed practical nurses (LPN). The program has a
total of two RNs. One RN’s license is clear and active with an expiration date of April 30, 2024.
Another RN, who is the program’s health service administrator (HSA), had a license which was
clear and active with an expiration date of July 31, 2026. The program has two LPNs and both
of their licenses were clear and active with an expiration date of July 31, 2025. The program
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nursing staff was in compliance with the contract requirements. The required on-site hours for
the nursing staff according to contract included one RN who works three twelve hour shifts each
week with alternating weekends, and two LPNs who work three twelve hours shifts each week
with alternating weekends. The HSA shall work forty hours each week and covers weekends
when needed. Each of the nurses had current cardiopulmonary resuscitation (CPR)
certifications with expiration dates of March 21, 2026, March 27, 2026, and September 23,
2026.
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 a written policy and procedures in place for a medical facility operating
procedure (FOP) for all health-related procedures and protocols utilized. The program’s
designated health authority (DHA) and facility administrator (FA) sign and date all respective
FOPs, and conduct an annual review of all healthcare protocols, policies, and procedures.
Reviewed documentation indicated the DHA reviewed, signed, and dated FOPs on February 14,
2024, the psychiatrist signed on February 8, 2024, and the FA signed on January 11, 2024. The
nursing staff reviewed, signed, and dated the cover page acknowledging review of all FOPs,
healthcare protocols, and other procedures on January 11, 2024, September 19, 2024, and
October 7, 2024. All new policies or changes in policies made during the annual compliance
review period were reviewed and a signature page was added with the specific policy listed,
date of revision, and signatures. Reviewed documentation confirmed all newly hired healthcare
personnel received a comprehensive clinical orientation to the Department’s healthcare policies
and procedures by a registered nurse. The approval of treatment protocols or standing
procedures was written and authorized by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a written policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) for all youth admitted into the program. A review of seven
Individual Healthcare Records (IHCRs) revealed an AET was filed in four of the seven IHCRs
and “copy” was stamped on each AET. Four of the seven AET forms were signed by the youth’s
parent/guardian. Each of the four applicable AETs were signed by a Department representative,
and all were valid. Three of the seven reviewed IHCRs contained an eighteen-year-old consent
form documenting the release of information. The program had no applicable youth under the
supervision of the Department of Children and Families where the parent/guardian’s rights had
been terminated. An interview with the health services administrator (HSA) indicated medical
staff document consent for youth over eighteen years of age by having youth sign an eighteen-
year-old consent form.
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4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a written policy and procedures to ensure the parent/guardian is notified of
significant changes in any youth’s condition and obtain consent when new medications and
treatments are prescribed. A review of seven youth Individual Healthcare Records (IHCRs)
indicated each of the seven included notifications of documented parental/guardian notifications
for over-the-counter (OTC) medications beyond those covered by the Authority for Evaluation
and Treatment (AET). Consent was provided by the parent/guardian for each of the seven
reviewed records. Two of the seven youth were applicable for newly ordered medication, and
there was documentation of the attempted contact to the parent/guardian in the progress notes.
Each youth had written notifications sent utilizing the Department’s Parental Notification of
Health-Related Care form. Two of the seven youth were taking psychotropic medications at
admission and reviewed documentation indicated staff witnessed all telephone call attempts and
conversations for psychotropic medications. The parent/guardian consent for psychotropic
medications was documented on page three of the Clinical Psychotropic Progress Note (CPPN)
in each applicable record. Both records confirmed parental/guardian verbal consent was
received for psychotropic medication whenever a new psychotropic medication was prescribed,
discontinued, or the dosage was significantly changed. No youth were applicable for being in
the care of the Department of Children and Families (DCF) where there had been a termination
of parental rights. Each of the seven reviewed IHCRs documented the program verified
vaccinations within thirty days of the youth’s admission. None of the seven reviewed youth were
applicable for requiring new vaccinations or a religious exemption. Immunization records are
obtained from the Florida Shots website, school records, and the Department’s record. They are
reviewed by the medical staff upon admission into the program. An interview with the health
services administrator (HSA) revealed parental/guardian notifications are required when youth
are under eighteen for medication and when treatment is ordered, and a parental/guardian
consent form is sent by mail. The HSA stated the process for ensuring timely parental/guardian
notifications are done in real time, is for a follow-up call to be made and documented as an
attempt to obtain consent. When a youth's illness or injury requires emergency medical services
or is life threatening a code is called, an emergency transport is done if necessary, and the DHA
is notified. The HSA stated the procedures regarding informing the parent/guardian when
obtaining consent for new psychotropic medications, discontinuances, or psychotropic
medication adjustments, is for a call to be placed by the psychiatrist for any new orders or
changes and discontinuations, which are witnessed by medical staff, and the acknowledgment
form is sent to the parent/guardian, along with page three of the CPPN. The HSA stated flu
vaccines are provided on-site.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a written policy and procedures ensuring each youth receives a screening for
health concerns upon admission, or at a minimum, each time the physical custody of the youth
changes and they are returned or re-admitted to the program. Seven youth Individual
Healthcare Records (IHCRs) were reviewed. Each record indicated a Facility Entry Physical
Health Screening form (FEPHS) was completed on the date of admission. Each of the
screenings were completed by a registered nurse (RN) or a licensed practical nurse (LPN).
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None of the screenings were completed by direct care staff. None of the reviewed IHCRs were
applicable for changes in physical custody greater than twenty-four hours; therefore, no new
FEPHS re-screenings were required. An interview with the health services administrator (HSA)
indicated the medical office is the first stop for all youth intakes, so no time passes before
medical sees a newly admitted youth. Medical staff are notified of newly admitted youth to the
program by email and morning meetings. The HSA stated the medical staff complete the
admission screening and if the admission screening is completed by direct care staff, the nurse
documents their review on the FEPHS form. When there is a change in physical custody since
the youth's admission, the process for re-screening the youth upon return to the program would
be to complete another FEPHS form along with a drug screen.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy in place for youth orientation to healthcare services and health
education. All youth admitted into the program shall be oriented to the general process of
healthcare services. The youth orientation to healthcare services and health education was
reviewed. A review of seven Individual Healthcare Records (IHCRs) showed each youth
received a general care orientation which included access to medical care, sick call, what
constitutes an emergency and when to notify staff, the medication process to include side effect
monitoring, the right to refuse care and how it is documented, what to do in case of a sexual
assault or attempted sexual assault, the non-disciplinary role of the healthcare providers, and
standard universal precautions. The program has an education and orientation binder to ensure
all required orientation topics are reviewed with the youth. The program’s contract states health
education will be conducted monthly. Health education, at a minimum, covered seatbelt usage,
alcohol and drug related problems, sexually transmitted disease/infections, tobacco products,
including smoking cessation, dental hygiene, dental care, a review on basic personal hygiene,
immunizations, infection control, prevention of sexual and other physical violence, nutrition,
physical fitness, breast and testicular self-examinations, and parenting skills.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a written policy and procedures to ensure the designated health authority
(DHA) is notified when youth are admitted to the program. Four Individual Healthcare Records
(IHCRs) were applicable for youth with known or suspected chronic conditions. There was
evidence of a referral to the physician for each. None of the reviewed IHCRs were identified as
in need of emergency care upon admission. The four applicable IHCRs documented notification
to the DHA in the youth’s chronological progress notes, and the DHA was notified within twelve
hours of admission, and no later than noon the day following admission. Two of the seven
reviewed youth were taking psychotropic medication upon admission and the psychiatrist was
notified for both youth. An interview with the health services administrator indicated when youth
are admitted with serious or chronic conditions, the DHA is notified in real time upon admission.
The medical staff are responsible for the notification, and the notifications to the DHA are
documented in the youth’s progress notes.
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4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a written policy and procedures ensuring nursing staff shall complete the
Department’s Health-Related History (HRH) form prior to the Comprehensive Physical
Assessment (CPA). A review of seven youth Individual Healthcare Records (IHCRs) indicated
each had a completed/updated HRH form, within seven calendar days of admission. Reviewed
documentation indicated the program completed the HRH form on the day of admission for each
youth. Each of the seven reviewed HRHs were completed prior to the Comprehensive Physical
Assessment (CPA). Each HRH was reviewed by the designated health authority, which was
indicated by a checkbox on the CPA. An interview with the health services administrator
indicated medical staff are responsible for completing the HRH upon admission which must be
completed within seven calendar days.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a written policy and procedures ensuring each youth admitted shall receive
and/or shall have on record a current Comprehensive Physical Assessment (CPA) and Health-
Related History (HRH) form no later than seven calendar days of admission into the program. A
review of seven youth Individual Healthcare Records (IHCRs) showed each youth’s physical
assessment was completed on the Department’s CPA form. Each CPA was completed within
seven calendar days of admission, which was documented as complete by the designated
health authority (DHA). Each youth’s Medical Grade was documented on their CPA. There was
no indication of any missing or incomplete elements on any of the reviewed CPAs. Each
reviewed CPA had all sections complete in full utilizing “O” and/or “X” markings. Four of the
seven reviewed youth refused a portion of the exam, and a refusal form was completed by the
youth and documented by the clinician. The Department’s Problem List was updated as
required for each of the seven youth records reviewed. Each of the seven youth had at least
one verified Tuberculosis Skin Test (TST) documented in the IHCR within the last year. Each
youth’s result was documented on their CPA and their Infectious and Communicable Disease
(ICD) form correlated. An interview with the nurse indicated the DHA completes a new CPA
within seven days of admission and on a yearly basis. Additionally, they reported tuberculosis
(TB) screenings occur upon admission within seventy-two hours, if needed, and annually.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a written policy and procedures ensuring all youth entering the program are
clinically screened, evaluated, and treated, if necessary, for sexually transmitted infections
(STIs) and human immunodeficiency virus (HIV). A review of seven youth Individual Healthcare
Records (IHCRs) reflected six youth were identified as sexually active and were clinically
screened and evaluated for STIs utilizing the Sexually Transmitted Infections Screening form.
Further evaluation was required for six youth, and each was referred to the designated health
authority (DHA). The referral was documented on the STI screening tool for the six applicable
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youth, and testing was ordered. Each IHCR included documentation of testing, screening
results, clinical evaluations, and diagnosis documented on the Department’s Infectious and
Communicable Diseases (ICD) form. The IHCR for six of the seven youth documented testing
had been performed. There were no applicable youth who were out of the Department’s custody
for over thirty days and/or required a rescreening. Six youth were offered counseling and
testing. Consent forms in six applicable reviewed IHCRs reflected each youth was provided
treatment and/or a referral for a HIV test. Four of the six applicable youth received HIV testing
with consent documented. The other two youth refused testing. Each of the four applicable
youth’s results were in their IHCR in a sealed envelope marked “confidential,” consistent with
Florida Administrative Code. The envelope was signed by the DHA, indicating their review.
Documentation of pre-test and post-test counseling was contained in each of the four youth’s
IHCRs. The youth’s confidentiality was protected, as their HIV statuses were not included on the
program’s internal alert system. Additionally, the program had a policy and procedures reflecting
HIV test results are only disclosed to the youth, with the youth’s legally authorized
representative, healthcare providers during the course of consultation, diagnosis, or treatment of
the individual, the Department of Health for the purposes of reporting and control of spread of
disease, health facility staff committees conducting program monitoring, evaluation, and service
reviews, medical personnel who have been subject to a significant exposure, and healthcare
facility personnel or agents for the healthcare provider who have a need to know in the course
of patient care activities or administrative operations. All HIV pre and post-testing and
counseling services are provided by the nursing staff on-site. Five interviewed youth stated they
can ask for a HIV test. The health services administrator (HSA) was interviewed and stated
youth are screened for STIs upon intake and upon request by youth. If a screening indicates a
need for further evaluation, the DHA is notified immediately, and orders are received from the
DHA. STI screenings, evaluations, referrals, and testing are documented in the infectious and
communicable diseases section of the IHCR.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a written policy and procedures ensuring all youth shall be able to make sick
call requests and have their complaints treated appropriately through the sick call system. Sick
call care, including dental complaints, shall be available to all youth. 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. Each of the three youth completed a Sick Call Request form, and each Sick
Call Request form was completed by a registered nurse (RN). Each youth’s Sick Call Request
form was filed in their IHCR. None of the reviewed youth were in restricted housing. Each of the
three reviewed Sick Call Request forms were documented in accordance with Florida
Administrative Code. The reviewed sick calls were found to be recorded appropriately on the
Sick Call Index. In addition, each sick call was documented on the program’s Sick Call Referral
Log. The dates listed on each of the Sick Call Index logs corresponded to the completed Sick
Call Request forms located in each of the youth’s IHCRs. The program offers youth the
opportunity to make a sick call request seven days a week. Only a licensed healthcare staff may
conduct sick call and all sick calls are conducted in the medical clinic to ensure youth privacy.
Sick Call Request forms are available to youth and located in the day room areas of the living
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units. Sick call hours are posted on the medical door and in each of the living units. A review of
the daily schedule, posted sick call schedule, and nurse interview found sick call is held daily at
9:30 a.m. and 2:30 p.m. When there is not a licensed nurse on-site, the program has
procedures where the shift supervisor reviews all sick call requests as soon as possible. Five
youth were interviewed, and three youth stated they are seen immediately after placing a sick
call and two youth stated they are seen within one day. An interview with the health service
administrator (HSA) indicated sick call occurs twice a day within four hours of the request and
after hours there is non-healthcare staff trained to review sick calls. According to the HSA, the
RNs, and licensed practical nurses (LPNs) routinely conduct sick calls; however they are
reviewed daily by the RNs. An interview with the HSA indicated the designated health authority
(DHA) conducts sick calls when they are on-site inside of the medical office. The HSA validated
the program’s practice, indicating youth with three or more repeated sick call complaints are
referred to the DHA. A sick call was observed during the annual compliance review week. Youth
consent was obtained by regional monitor prior to observing sick call. The assistant facility
administrator escorted the youth to the medical clinic, the medical provider identified
themselves, and stated why the youth was there. The youth was seen in a private area with no
other youth present to hear or see the examination, and the youth was examined by licensed
staff. There was staff present during the exam; however, the medical staff was able to maintain
privacy due to staff being outside of the exam room.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a written policy and procedures ensuring there is a written plan to provide
twenty-four-hour emergency medical, mental health, and dental care to youth, as needed, in
response to unexpected illnesses, accidents, or conditions requiring immediate attention or an
immediate professional assessment to determine the severity. Seven youth Individual
Healthcare Records (IHCRs) were reviewed and six were applicable for episodic care. On-site
care was provided by a licensed healthcare staff for each event. Each event was documented in
the required subjective, objective, assessment, and plan (SOAP) format. All events were
documented on the Episodic Care Log, which corresponded with the on-site events observed in
the IHCRs. None of the six youth applicable for episodic or first-aid care needed follow-up care.
The program has a written medical facility operating procedure (FOP) which addresses episodic
and emergency care practices and documentation indicates the program’s episodic and
emergency care procedures. The program has a total of eight first-aid kits located in master
control, one in the two transport vans, one in dietary, one in the Home Builder’s Institute (HBI)
workshop, one in the medical clinic, one in the east wing, and one on the west wing. The first-
aid kits for the vans are stored in master control until the vans are used for transport. The
program has a process for ensuring contents are maintained and stored in accordance with
guidelines to prevent expiration or deterioration and are replenished as needed. First-aid kit
checks are conducted by medical staff weekly and an inventory of contents are kept, expiration
dates are documented, and contents are replenished as needed. The process for monitoring
the first-aid kits is handled by the nursing staff by ensuring inventory and logs match weekly. An
observation of three first-aid kits revealed each kit was fully stocked with the designated health
authority (DHA) approved contents. At the time of the annual compliance review the health
services administrator (HSA) conducted a self-test of the automated external defibrillator (AED)
and there were no discrepancies. The expiration date of the AED batteries is October 31, 2027,
for the AED in the medical clinic and August 2, 2027, for the AED in master control. The two
AED’s batteries were changed last on April 1, 2024, for the AED in the medical clinic, and
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August 2, 2023, for the AED in master control. The expiration date for the AED pads is June 27,
2025, for the AED in the medical clinic and November 17, 2025, for the AED in master control.
The AED pads were last changed on June 30, 2023. A list of emergency numbers was posted
and accessible for non-licensed and licensed staff and these numbers were inaccessible to all
youth in the program. Authorized direct care staff were appropriately trained in the
administration of the epinephrine auto-injector. A review of seven staff training records revealed
staff training requirements were met regarding episodic, first-aid, and emergency care. The
program has two operational shifts. Shift A is from 7:00 a.m. to 7:00 p.m., and shift B is from
7:00 p.m. to 7:00 a.m. A review of the program’s emergency medical drills reflected a drill was
conducted on each shift monthly for the last ten months. Emergency medical drills which include
the demonstration of cardiopulmonary resuscitation (CPR), first-aid, and an AED are conducted
at a minimum of quarterly. The emergency medical drills consisted of both announced and
unannounced drills and were conducted at least monthly on each shift. A review of the
program’s logbooks showed direct care staff participate in at least one drill which included the
use of CPR annually. Video observation review of drills confirmed drills simulated an episodic
care event which called for immediate first-aid and/or administration of CPR techniques and the
initiation of the emergency procedures to follow when a life-threatening emergency occurs. An
episodic care event observation was not conducted at time of annual compliance review as one
did not occur. The program has a policy in place for the use of NARCAN® and the program’s
policy on the use, access, and inventory of NARCAN® is for the possible overdose of
medication. The instruction for the use of NARCAN® is located on the box. The program stores
the NARCAN® in a locked box behind a locked door. Nursing staff and trained supervisors have
access to NARCAN®. Each staff with access to NARCAN® has been trained on when and how
to use NARCAN® by the HSA. The program’s inventory of NARCAN® is conducted through
weekly counts by medical staff. Seven staff were interviewed, and each stated they were
personally allowed to call 9-1-1 if a youth had a medical emergency. Five youth were
interviewed, and each youth stated they can see a dentist and doctor if needed. In an
interviewed with the HSA, it was confirmed the program has a total of eight first-aid kits. The
HSA indicated on-site episodic care is documented in the progress notes and on the Episodic
Log, and if non-healthcare staff provides emergency care the non-healthcare staff form is
reviewed by the nurse.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a written policy and procedures for the provision of off-site emergency and
non-emergency referrals for medical care and treatment. Evaluations conducted off-site shall be
recorded on the Department’s Summary of Off-Site Care Consultation Report form. The
designated health authority (DHA) reviews, signs, and dates the off-site care instructions. Seven
youth Individual Healthcare Records (IHCRs) were reviewed; however, only two were applicable
for off-site first-aid or emergency care. An additional IHCR was reviewed. For each of the three
reviewed youth IHCRs there was an indication the youth required off-site care. The Summary of
Off-Site Care Consultation Report form was utilized and filed within each of the youth’s IHCRs.
Reviewed documentation supported the parent/guardian was notified, as required for two of the
three reviewed youth. One youth was eighteen years old. Applicable discharge documents were
found to be filed within one youth’s IHCR. The remaining two youth did not require discharge
documents. The DHA reviewed, signed, and initialed all off-site care findings and information.
None of the reviewed youth required follow-up testing, referral, and/or an appointment. An
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interview with the program’s health services administrator (HSA) indicated medical staff track all
off-site care on the program’s Off-Site Care Log, transport log, and IHCR. Additionally, medical
staff notified and provided the DHA with the applicable youth’s discharge instructions upon the
youth’s return, for follow-up. To ensure the DHA is reviewing and initialing all off-site care
findings, instructions, and information is flagged for DHA review in the medical clinic and placed
on the DHA logs. According to an interview with the HSA, nursing staff tracks follow-up testing,
referrals, and appointments by using an appointment board and calendar in master control.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a written policy and procedures ensuring youth who have been identified with
a chronic illness receive regularly scheduled evaluations and necessary follow-up treatment. A
review of seven youth Individual Healthcare Records (IHCRs) indicated two of the seven youth
were identified with a chronic condition as documented on the Facility Entry Physical Health
Screening (FEPHS) form. An additional IHCR was reviewed. None of the youth were identified
as having a communicable disease. Each of the three applicable youth were taking prescribed
medication on an ongoing basis. None of the youth were undergoing treatment for a physical
health condition. Three youth were classified with a Medical Grade two through four, or a
Medical Grade five for youth who were additionally taking psychotropic medications. Each of the
three youth were placed on the program’s Chronic Illness List. A review of progress notes found
two of the three youth received periodic evaluations at least every ninety-days. One youth
wasn’t due for a periodic evaluation at the time of the annual compliance review. None of the
youth were applicable for taking anti-tuberculosis medications. Two of the three identified youth
were applicable and had an evaluation completed prior to a prescription renewal, change, or
expiration. None of the three reviewed youth were applicable for an off-site evaluation. There
were no indications of lapses in care or missed periodic evaluations in any of the reviewed
records. The Department’s Problem List for each youth was updated in accordance with Florida
Administrative Code. The program’s facility administrator (FA) was interviewed and stated a
review with healthcare staff occurs daily during morning management meeting and weekly for
designated health authority (DHA) updates/review. The DHA stated they ensure the periodic
evaluations are completed every ninety days and they are tracked by the chronic condition’s
tracker and medical alerts. The health services administrator was interviewed and stated youth
with chronic conditions are placed on the chronic condition’s tracker.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a written policy and procedures which outline the process for how medications
are to be received, stored, inventoried, and administered in a safe and effective manner. A
review of seven youth Individual Healthcare Records (IHCRs) indicated two of the seven youth
were admitted on prescribed medications. Documentation revealed the two youth’s medications
were verified prior to the youth being admitted into the program utilizing the Department’s
Prescription Medication Verification Checklist form. The prescription verification was included in
the chronological progress note, in the IHCR for the two youth admitted with prescribed
medication. The remaining five youth were not admitted with prescribed medications. For both
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applicable youth the DHA and the psychiatrist were contacted to obtain the order to resume the
specified medications prescribed prior to admission. All medications for each youth had a
current, valid order and were administered pursuant to a current prescription. Both youth were
applicable for current medications being continued, discontinued, changed, or new ones being
ordered, and the DHA placed an order on the Practitioner Order form. None of the youth were
applicable for restricted housing. Six of the seven youth were applicable for over-the counter
(OTC) medications not listed on the Authority for Evaluation and Treatment (AET) form. The
program utilizes a pre-printed Medication Administration Record (MAR) to document all
medication and treatment. Each of the six reviewed MARs met all requirements outlined within
Florida Administrative Code. There were no instances where trained non-healthcare staff
assisted in the delivery of medications. Documentation indicated medical staff initialed each
administered medication entry. There were no undocumented explanations for a lapse or errors
in medication administration for any of the reviewed youth. For the six applicable youth the
nursing staff documented side effect monitoring at a minimum of weekly on each MAR. Four of
the seven reviewed youth signed the Refusal of Treatment form indicating refusal, and refusals
were clearly documented on the MAR. The MAR contained all the required elements to include
youth name, Department identification number, date of birth, youth allergies, precautions,
Medical Grade, medical alerts, and a current picture of the youth. There were no youth in need
of parenteral medication during the annual compliance review period. Two of the seven
reviewed youth were prescribed psychotropic medication upon admission, and the DHA and
psychiatrist were notified the day of admission. The psychiatrist conducted an Initial Diagnostic
Psychiatric Interview with the youth within fourteen days of admission. Each youth received a
medication monitoring/review every thirty days, as required. There were no standing orders,
emergency treatment, or pro re nata (PRN) orders for psychotropic medications. An observation
of medication administration was conducted during the annual compliance review week.
Medication delivery was the sole responsibility of the nurse during the time of medication
administration. Consent was obtained by the regional monitor before observing the medication
administration. The youth was escorted to medication administration by the assistant facility
administrator, and the youth approached the nurse administering medication individually.
Nursing staff asked the youth their name and allergies. The nurse identified themself, reviewed
the MAR, and provided a brief overview as to why the youth was there. The youth provided their
name, date of birth, what medications they were prescribed, and if they had any allergies. The
registered nurse (RN) verified the Six Rights of Medication Administration which included the
right youth, right medication, right dosage, right time, right route, and right documentation for the
youth. No medications were observed to be pre-poured. Upon administering the youth’s
medication, the RN swiped the youth’s mouth and searched under the youth’s tongue. Seven
youth were interviewed, and six stated a nurse dispenses their medication, and one youth
reported the staff does. An interview with the health services administrator (HSA) indicated the
process for nursing staff to verify a youth’s medication regimen when a youth is admitted with
medications is by completing the prescription verification form and verifying with the pharmacist
and prescribing doctor. The nursing staff review medications upon admission and document the
verification in the IHCR. According to the HSA the program uses the standard Department MAR.
During an interview with the HSA, it was stated there is a training curriculum to train non-
healthcare staff on administering medication. The HSA trains non-healthcare staff at least yearly
in medication administration and the list is located in the medical clinic and master control.
According to the HSA, medications/prescriptions are procured through a local pharmacy. The
program utilizes a psychiatrist who is on-site bi-weekly for medication management and
treatment team meetings.
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4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a written policy and procedures ensuring medical equipment classified as
medications/sharps are secured and inventoried by using a routine perpetual inventory. The
medical equipment classified as sharps included syringes, needles, scissors, and suture
removal kits, and each was secured and inventoried utilizing a routine perpetual inventory
descending count as each sharp was being utilized and disposed. All medications were
identified and secured in the locked area designated for storage of medications and different
medications such as injectable, topicals, drops, and liquids were separated. The medication cart
was clean and organized with stock items separate from youth-specific medications. All
controlled substances had a perpetual inventory and were stored separately from other
medications. All medications were stored in a separate, secured/locked area, inaccessible to
youth. Narcotics and other controlled medications were stored behind two locks. Medications
which required refrigeration were stored in a secured refrigerator, which is used for medication
only. The program’s process for the destruction and disposal or return of expired or
discontinued medications consists of controlled substances being given to the pharmacy
consultant for disposal, and discontinued medications are given to the pharmacy consultant for
credit. Destruction Logs and Return Logs are kept updated for medications being destroyed and
returned to the pharmacy. Perpetual and weekly inventories of all sharps and stock over-the-
counter (OTC) medications were completed as required. There was a shift-to-shift inventory
count of all controlled substances documented on the youth’s Individualized Controlled
Medication Inventory Record. Supervisory-level, non-healthcare staff were trained in the
delivery and oversight of medication self-administration, and the training was delivered by a
registered nurse (RN). During the annual compliance review week an observation of the nurse
completing a count for three controlled medications, three OTC medications, and three sharps
showed the actual counts were listed on each log as well as the final count and shift to shift
count after each administration of medication. There were no discrepancies during these
observations. All counts matched the ending inventory numbers. The program’s reporting
criteria and procedures regarding inventory discrepancies starts with the nursing staff reviewing
all inventory logs ensuring it matches the actual count. An interview with the health service
administrator (HSA) indicated the process for disposal of medication consists of a Destruction
Log and a Return Log for medications sent back to the pharmacy for credit. Additionally,
controlled medications are destroyed with the pharmacy consultant which is witnessed by
nursing staff. The practice in securing controlled substances such as narcotics consists of them
being stored in double locks in the medication cart. An interview with the HSA indicated the
program has a current agreement with a consultant pharmacist who comes on-site monthly to
review medication, Medication Administration Records (MARs), and for the destruction of
medication. The program maintains a copy of a pharmacy consultant license on-site.
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.
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The program has a written policy and procedures ensuring there is an approved plan for
exposure control and infection control ensuring staff, youth, volunteers, and visitors are not
exposed to infectious and communicable diseases. The infection control procedures in place
include prevention, containment, treatment, and reporting requirements related to infectious
diseases, according to Occupational Safety and Health Administration (OSHA) federal
regulations and the Centers for Disease Control and Prevention (CDC) guidelines. The
designated health authority (DHA) and facility administrator reviewed the plan on January 11,
2024, while nursing staff reviewed and signed the Infection Control and Exposure Control Plan
on February 14, 2024. The infection control procedures included common infectious diseases of
childhood, self-limiting, episodic contagious illnesses, viral or bacterial infectious diseases,
Tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus (HIV), infectious diseases
caused by bloodborne pathogens, other outbreaks or epidemics caused by any other infectious
agent, outbreaks of lice or scabies, Methicillin-Resistant Staphylococcus Aureus (MRSA) and
other antibiotic resistant micro-organisms, foodborne illnesses, bio-terrorist agents, and
chemical exposures. The program maintains procedures for staff to adhere to universal
precautions and the program provides staff with the opportunity for Hepatitis B immunizations
and access to protective equipment. There weren’t any instances in which the local county
health department, CDC, and/or the Department’s Central Communications Center (CCC)
should have been notified of an infectious disease. The Exposure Control Plan was written in
accordance with OSHA standards and is available to all staff. The plan was reviewed and
signed annually by the administration of the program on February 14, 2024. The program’s
process for needle stick post-exposure evaluation consists of counseling, evaluation of reported
illness, and providing information to the individual who was exposed. The facility administrator
was interviewed and stated the Exposure Control Plan is in medical and master control and it is
reviewed annually with staff. An interview with the health services administrator (HSA) indicated
the nursing staff conduct infection control training for staff upon hire and annually.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a written policy and procedures requiring all program staff to promote
safety and security by maintaining active supervision of youth to include interacting positively
with youth, engaging youth in a full schedule of constructive activities, closely observing
behavior of youth, and consistently applying the program’s behavior management system
(BMS). The program’s contract requires staff-to-youth ratios to be one-to-ten during awake
hours and one-to-twelve during sleep hours. The ratio for off-site activities, transportation, and
visitation is one staff to five youth. The program staff are required to account for the
whereabouts of youth under their supervision and ensure staff-to-youth ratios are in compliance
with contract requirements. A program tour verified the daily youth activity schedule was posted
throughout the program and is designed to keep youth engaged in a full schedule of activities.
Observations of staff supervision for four days during the annual compliance review week
included classroom activities, line movement, school breaks, youth head counts, mental health
groups, vocational activities, youth searches, and outdoor/indoor recreation activities. In
addition, youth were observed working in the kitchen and using tools while participating in Home
Builder’s Institute (HBI) projects. The observations ensured staff-to youth ratios were
maintained, as required. A tour of the program verified the program and living units were clean,
well maintained, and graffiti free. A perimeter check was conducted, and fencing appeared to be
in good repair. Staff and youth were appropriately attired. During outdoor activities and/or
movement, observations verified staff were strategically positioned to ensure proper supervision
of youth and to ensure there were no physical obstructions in their view of the youth.
Observations of interactions between program staff and youth reflected the interactions were
positive and consistent with the program’s BMS. Three informally interviewed staff knew how
many youth they were supervising. The program’s policy states active supervision ensures
appropriate supervision of the youth is maintained at all times. Staff are to provide effective
positioning for optimal sight and sound supervision of youth. Staff shall communicate with youth
and co-workers effectively to ensure expectations are clearly defined. Video observations of
youth were conducted during sleep hours. The observations verified youth to staff ratio was in
compliance and staff were awake and alert.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program maintains a written policy and procedures addressing the implementation and
training of the program’s behavior management system (BMS) which has not changed since the
last annual compliance review. The program utilizes the iChoose BMS, which is a coordinated
system of promoting, monitoring, recognizing, and rewarding a youth’s progress. It is a program
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of incentives and consequences which promotes individualized skill building, appropriate
behavior, and accountability. Staff use point cards to monitor how well the youth are progressing
in the program. Youth earn points daily for complying with the program rules. At the end of the
week, the points are totaled, and the youth can obtain rewards based on the number of points
earned. Each youth enters the program on an orientation level prior to starting the BMS and
progresses their way up the four levels. The four levels of the BMS include beginner,
intermediate, veteran, and expert levels. Youth learn about the BMS during the orientation
process. Each youth is provided a program handbook which describes the BMS. A review of the
youth handbook indicated the BMS is designed to promote safety, respect, and fairness. The
BMS promotes and protects youth rights and has opportunities for positive reinforcement. The
BMS includes positive and negative consequences and uses constructive disciplinary actions.
The BMS promotes socially acceptable means for youth to meet their needs, includes a process
for explaining to youth the reasons sanctions are being imposed, youth have the opportunity to
explain their behavior, there are opportunities for staff and youth to discuss the impact of
behavior to others, includes reasonable reparations for harm caused by others, there are
discussions of alternative behaviors, promotes positive dialogue, and minimizes separation of
the youth from the population. A review of the BMS confirmed it is not used solely to increase a
youth’s length of stay, deny basic rights or services, promote the use of group punishment,
allow youth to punish other youth, or include disciplinary confinement. In addition, the
parent/guardian handbook includes a description of the BMS. A review of seven staff training
records indicated staff were trained on the BMS by the staff development coordinator. A review
of seven position descriptions confirmed the job functions include implementation of the BMS. A
review of seven youth case management records indicated each youth participated in an
orientation upon arrival to the program and received a copy of the youth handbook.
Observations found the BMS was posted throughout the program. Observations of staff and
youth interactions verified staff were adhering to the BMS by utilizing a ratio of four-to-one
positive rewards to negative consequences when redirecting the youth as indicated in the
program’s policy. The incentives for youth include using points to purchase items from canteen,
participating in Mega Monday and Phat Friday activities, playing board games and receiving
extra snacks. Five staff were interviewed, and each reported the BMS consists of a point system
and consists of incentives and consequences. Each of the interviewed staff verified youth
receive incentives which include the purchase of canteen items, receiving extra snacks, earning
extra phone calls, and participation in Mega Mondays and Phat Fridays. Five interviewed staff
stated nothing can be taken away from a youth as a consequence. Each interviewed staff stated
youth are informed of the consequences and they are able to explain their behavior during the
review of the Behavior Reports (BRs). Five youth were interviewed, and each stated the
consequences for negative behaviors included not earning daily points and receiving a BR.
Each youth stated they receive incentives such as special meals, snacks, and participation in
Mega Mondays and Phat Friday. Five interviewed youth stated staff use rewards the same for
all youth. All five youth were able to explain the difference between each level and how they
move from level to level. All five-youth verified youth are never allowed to punish other youth.
An interview with the facility administrator (FA) confirmed the program utilizes the iChoose BMS.
The BMS is responsive to the unique characteristics of the program’s population. The system is
designed to maintain order and security fostering compliance with the program rules teaching
youth alternative pro-social methods of dealing with problems using both rewards and a system
of progressive discipline. It promotes safety, respect, fairness and protection of rights within the
community, provides for constructive discipline and a system of positive and negative logical
consequences to encourage youth in meeting expectations for behavior, provides for positive
reinforcement and recognition for accomplishments and positive behaviors at a minimum ratio of
four-to-one positive to negative consequences, promotes socially acceptable means for youth to
meet their needs, which includes processes addressing the needs, and cognitive capacity of
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youth. The BMS promotes dialogue and peaceful conflict resolution, minimizes the separation of
youth from the general population, and assures consistent implementation and equitable
treatment through oversight and training. The FA stated rewards include incentive calendars, a
nightly incentive, Phat Friday, Mega Monday, random reinforcers to include additional telephone
calls, food incentives, music, and free time. The program ensures consistency by reviewing the
BMS during behavior review team meetings, annual performance evaluations, all-staff training,
and monthly coaching
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.
This program does not use room restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program maintains a written policy and procedures to conduct and document ten-minute
checks during sleep hours or at other times, such as during an illness or room restriction. The
program has a total of 113 video cameras capable of recording thirty-days of video footage.
During the annual compliance review week, the program reported two cameras were not
operational; however, a call was made to the Department’s Central Communications Center
(CCC) on October 29, 2024, stating there were several inoperable cameras which were not
reported. Prior to conducting checks, staff are situated where they are able to see any
movement within the living unit. Staff are required to conduct room checks every ten-minutes
and document the time of the check on the Ten-Minute Check Log when youth are sleeping. In
an informal interview the facility administrator (FA) stated there were two shifts from 7:00 a.m. to
7:00 p.m., and 7:00 p.m. to 7:00 a.m. during the annual compliance review period. A video
review of five ten-minute checks from the overnight shift and from each living unit verified staff
were conducting checks every ten-minutes and documented the times accurately on the ten-
minute check logbook with an exception. On October 4, 2024, at 4:27 a.m., video footage
showed the staff walked down the hallway of the living unit; however, did not look into the youth
rooms. In addition, the Ten-Minute Check Logs since the last annual compliance review were
reviewed. A sample of various days, times, and shifts indicated the ten-minute checks were
completed within the required frequencies. Five interviewed staff verified room checks were
conducted every nine-minutes when a youth is placed in their room for sleeping or non-
punishment reasons. In a formal interview, the FA stated the program has 113 cameras with two
cameras out of service and the program has video recording capabilities for thirty-days.
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5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program maintains a written policy and procedures to ensure youth are always accounted
for through a system of physically counting youth at various times throughout each day. The
program’s policy requires staff to conduct formal head counts each hour and after outdoor
activities. In addition, the policy indicates counts are conducted during power outages, escapes,
program disturbances, or any other disruptions which may occur. A review of the Continuity of
Operations Plan (COOP) verified program staff must always account for the whereabouts of the
youth in the care and custody of the program. This includes the need for continual head counts
to be conducted minimally, at the beginning of each shift, during any emergency situation, and
at regular intervals. Eleven randomly selected dates and times in the program’s logbook were
reviewed for census counts during the annual compliance review period. Documentation
validated head counts and movements were conducted at the beginning of each shift, after
outdoor activities, during emergency situations such as program disturbances, and during actual
and/or simulated drills. In addition, the program logbooks included documentation of new
admissions, releases, daily census counts, youth movements, transfers, and youth temporarily
away from the program. Observations made during the annual compliance review week
indicated it is the program’s practice to conduct hourly youth counts. Five interviewed staff
verified formal counts are conducted every hour. Each staff stated if a count cannot be
reconciled, the program is locked down, all movement is stopped, and an emergency count is
conducted until the count is reconciled. Each staff stated emergency counts are conducted
anytime a code is called, during power outages, if there is a discrepancy in the count, if a youth
is missing, and during drills.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a written policy and procedures to ensure the maintenance of a
chronological record of events, incidents, and activities in a central logbook. The program
maintains a bound logbook with numbered pages for each month. Observations and a review of
logbooks since the last annual compliance review found logbook entries were documented in
ink with no erasures or white-out areas. Errors were typically struck through with a single line,
and dated and initialed by the staff correcting the error. Reviewed documentation of randomly
selected days within the logbooks reflected each entry included the date and time of the event,
the name of the staff and youth involved, a brief description, and the name and signature of the
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staff making the entry. A review of logbook entries indicated recreation was conducted as
scheduled. The program ensures direct care staff, including each supervisor, are briefed when
coming on duty. Each staff signs the shift briefing sign-in sheet to acknowledge receiving the
information. A review of shift reports since the last annual compliance review verified each
report was completed on a daily basis. Staff have access to the shift report for at least forty-
eight hours after the briefing. Logbooks included entries for emergency situations, incidents,
special instructions for monitoring youth, population counts, law enforcement access to youth,
perimeter checks, and youth movement. In addition, admissions and releases were documented
as well as transports away from the program. Reviewed documentation and a review of the
Department’s Central Communications Center (CCC) reports indicated there were no instances
of escapes or attempted escapes during the annual compliance review period. Reviewed
logbooks reflected the program documented internal incidents reported to the Florida Abuse
Hotline and/or the CCC.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a written policy and procedures for assignment, inventory, tracking, and
storage of program keys. Keys are bound on a tamper resistant ring which includes a brass-
colored tag with the number of keys and a tracking number. Program keys are maintained in
master control on a board with the corresponding tracking number. The program has a daily key
log to track keys. The log indicates the name of staff and what type of key they are to be
assigned according to their position. The program maintains a master inventory list of program
keys. A random check of five different sets of program keys compared to the inventory list
indicated the keys were accounted for and the master control staff knew which area each key
was assigned to. Active keys are assigned to direct care staff while restricted keys are
designated for medical staff, kitchen staff, case managers, and therapists. An informal interview
with master control staff indicated the program’s practice is when direct care staff arrive to the
program, personal keys are collected by master control, and placed on a board in master
control. Medical staff, kitchen staff, case managers, and therapists receive their respective
restricted keys from master control after their personal keys are collected. Both the master
control operator and the staff receiving a program key initial the key log before, and again at the
end of the shift when the keys are returned. A review of the key logs and logbooks since the last
annual compliance review verified this practice. In addition, the program has a list of staff who
are assigned permanent keys. Permanent keys are issued, and staff sign an acknowledgment
form indicating a key identification number and the number of keys issued. A review of the
signed acknowledgment forms indicated each staff signed for the use of permanent keys. A
random check of three staff verified the number of keys on the key ring matched the inventory
and each staff knew their function. A review of the Department’s Central Communications
Center (CCC) reports since the last annual compliance review indicated there were no incidents
related to key control. Five staff were interviewed and were able to explain the program’s key
control process.
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5.08 Contraband Procedures Limited Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a written policy and procedures to identify materials considered to be
contraband, to prevent contraband from entering the program, and consequences when found
in the possession of youth in the program. The program’s youth handbook and policy include a
list of contraband items and informs youth of the consequences if found with contraband. Each
youth is provided with a written copy of the youth handbook upon admission into the program
and are oriented to the program rules including the list of items considered to be contraband.
The program’s policy and youth handbook included all items considered contraband as outlined
in Florida Administrative Code. The list of contraband items include sharps, escape
paraphernalia, tobacco products, lighters or matches, electronic or vaporless cigarettes,
unauthorized food or clothing, any intoxicating beverages, any controlled substance, any
prescription or non-prescription drug, any firearm or weapon, any explosive substance, non-
program issued keys, unauthorized currency, non-program issued cellular telephones and/or
equipment, electronic devices capable of taking pictures or video recordings, as well as smart
watches. In addition, the program’s policy and youth handbook include consequences if found
with contraband, search procedures of the physical plant, searching the program grounds, youth
searches, and searches of incoming and outgoing mail. The program’s policy specifies the
manner in which any unauthorized or contraband item is to be disposed of, to include return to
the sender, mailed to the youth’s home, returned to the youth upon release, or, in the case of
illegal contraband, turned over to law enforcement. Unannounced room searches are conducted
at least weekly at irregular and unpredictable times and common area searches are conducted
daily. During the program tour, several randomly selected rooms were checked, and no
contraband was observed. A review of shift reports, the master control logbook, visitation forms,
and common area search forms validated the program’s practice of monitoring areas of the
program, grounds, and youth rooms for contraband. The program’s policy requires case
managers to inspect all outgoing and incoming correspondence in the presence of the youth for
unauthorized items, contraband, or information which may breach the security of the program.
The program’s policy and procedures, and orientation training provided to all new staff, stipulate
staff, including supervisors and administrators, found in possession of contraband will be
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subject to disciplinary action up to and including dismissal. A review of the visitor’s sign-in log
verified it included an attestation statement. There was a total of fifty-one new staff hired during
the annual compliance review period. A review of fifty-one staff records found each included a
signed contraband attestation form. The program documents the confiscation and disposal of
contraband. All instances involving confiscation of illegal contraband require the program to turn
the item over to local law enforcement authorities and file a criminal report. A review of the
Department’s Central Communications Center (CCC) reports since the last annual compliance
review indicated there were five instances of contraband found at the program which were
turned over to law enforcement. During the annual compliance review week, the program had
an open major deficiency for contraband. The interviewed facility administrator (FA) reported the
program adheres to the Florida Statute which addresses contraband in residential programs.
Search practices are initiated according to the Department’s Right Interactions (RI) training
curriculum to assist in prevention, detection and removal of all items considered contraband or
unauthorized within the program. Program staff including school staff, subcontracted staff,
visitors, and volunteers are prohibited from introducing any item into the secure area without
authorization from the FA or designee. Any item or situation which may compromise safety or
security, is to be reported immediately to the on-duty supervisor. The introduction, removal or
possession of certain unlawful articles and the associated penalties are outlined in Florida
Statutes. Five staff were interviewed, and each stated room checks are conducted daily during
youth shower time, and twice a week by the assistant facility administrator (AFA) and the shift
supervisor.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a written policy and procedures to ensure searches and full body visual
searches, are conducted according to Florida Administrative Code at the time of admission,
after off-campus activities, and visitation. Parent(s)/guardian(s) are notified of searches during
visitation by way of the parent/guardian intake letter, which is mailed at the time of each youth’s
admission. Youth are searched before entering and prior to leaving the classroom, after outdoor
recreation activities, after work detail, and upon all movement. Youth who are a new admission,
re-admission, returning from visitation, returning from off-campus activities and/or appointments,
suspected of contraband, or are a security risk are full body searched. Observations made
throughout the annual compliance review week validated youth are provided instructions
regarding the search, youth searches were conducted by staff of the same gender as the youth,
were conducted in a manner so as not to degrade the youth, and were based on the Right
Interactions (RI) training manuals. Searches observed during the annual compliance review
week verified youth were searched after every movement and after using tools while
participating in Home Builder’s Institute (HBI) projects. During the annual compliance review
week there were no scheduled transports, no new admissions, no visitation, and no youth
returning from off-campus activities; therefore, searches for those activities could not be
observed. In-person observations and a video footage review of five staff indicated searches
were conducted as required. Five staff were interviewed, and each stated youth are searched
after every movement. Five youth were interviewed, and all indicated searches occur during all
movement, four stated after meals, and when returning from off-site activities, three stated after
returning from off campus, two stated after visitation, and one stated they are searched after
work detail.
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5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a written policy and procedures for transportation, operation, and
maintenance of each vehicle used to transport youth. The program has a total of three vehicles
and two are used to transport youth and one is for program use. Each vehicle used to transport
youth had an annual safety inspection conducted by a certified automobile mechanic.
Observations of the two program vehicles verified each was locked when not in use. One
vehicle used to transport youth was being serviced at a mechanic shop and could not be
observed. An observation of one vehicle used to transport youth found it had the appropriate
number of seatbelts, a seatbelt cutter, a window punch, up-to-date fire extinguisher, and a first-
aid kit with approved items by the designated health authority (DHA). Documentation indicated
weekly visual vehicle inspection checks are conducted on all vehicles as required and
documented on the preventative maintenance check sheets. The one observed vehicle used to
transport youth had passenger doors which could not be opened from the inside and had a
safety screen separating the front seat from the rear passenger’s compartment. A random
check of five staff personal vehicles and one program vehicle during the annual compliance
review week found all of the vehicles were locked and secured when not in use.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a written policy and procedures to ensure the safety and security of
youth and the community when youth are transported outside of the program. The program’s
human resources staff obtain monthly driving record information from the Department of
Highway Safety and Motor Vehicles for all staff designated to transport youth. The program
assigns a ratio of one staff to five youth during transport, not including the driver. The program
provides transportation for secure maximum-risk youth determined to be at greater risk. There
were no transportations scheduled during the annual compliance review week; therefore, a
transportation could not be observed. The program’s policy states youth are not permitted to
drive program or staff vehicles. Five staff were interviewed, and each stated prior to transport
the youth and vehicles are searched for contraband and youth are secured in the vehicle with
hand and leg cuffs, and by wearing the seatbelt. Four of five interviewed staff stated they use
the program’s cellular telephone or their approved personal telephone during transports, and
one staff stated they have not conducted a transport. A follow-up with the staff who reported
they use their personal telephone indicated the staff were on an approved list to have their
telephone. All five staff confirmed they are not allowed to use personal vehicles to transport
youth. Four of five interviewed staff stated the safety equipment in the transport vehicles
included a first-aid kit, suicide kit, seat belt cutter, and fire extinguisher. One staff did not
conduct transports and did not know which safety equipment was in the vehicles. All five
interviewed staff stated the transport vehicles are searched for contraband prior to and after
each use. Four of five interviewed staff stated they would call 9-1-1 and/or contact the program
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if an emergency arises during vehicle transport. One staff did not conduct transports and did not
know the emergency response during a transport. Each interviewed staff knew the staff to youth
ratio during transport. Each staff verified there are safety screens in the vehicles used to
transport youth. Five interviewed youth stated they never witnessed anyone placing contraband
in a transport vehicle. Five youth were interviewed, and three stated they are secured with leg
and hand cuffs; however, they were not secured to any part of the vehicle during transportation.
Two youth stated they have not been transported by the program. An interview with the facility
administrator (FA) verified all vehicles transporting youth have a safety screen.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a written policy and procedures to ensure safety and security is
maintained. The policy addressed who is responsible for conducting the audits, procedures to
implement corrective actions for deficiencies, and an internal system to verify deficiencies are
corrected. Weekly safety and security audits are conducted by the facility administrator (FA) or
designee and documented on the Safety and Security Audit Inspection form. Any deficiencies
are addressed on the form and a work order is submitted to the appropriate staff for corrections.
In addition, deficiencies are discussed during the morning management meeting. A review of
the safety and security inspection forms since the last annual compliance review indicated
inspections were completed as required. Supervisors conduct perimeter checks on each shift
and checks are documented in the program logbook. A review of the program logbooks verified
this practice. A review of deficiencies entered in the Department’s Juvenile Justice Information
System (JJIS) verified there were no deficiencies assigned in regard to safety and security
audits during the annual compliance review period. An interview with the FA indicated Weekly
Safety and Security Audit forms are submitted to the Department each week and they identify
any security issues or 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 maintains a written policy and procedures to have a tool management system
which ensures youth do not use tools or equipment as weapons or for security breaches. The
policy addresses the issuance, inventory, and control of equipment and tools. The policy states
prohibited tools at the program include machetes, bowie knives, and other long bladed knives. A
review of inventory logs and observations verified tools are securely stored when not in use,
easily marked for identification, inventoried prior to, and following work activities. All sharp
edged and pointed tools are inventoried daily when in use. The maintenance staff are
responsible for conducting the inventories and securely maintaining all Class A tools and
equipment. The maintenance staff completes a tool inventory list which documents each tool in
inventory. All maintenance tools were inaccessible to youth and were observed to be secured in
the maintenance building. Observations of the tool storage area found it was organized and
secure. Class B tools including mops, brooms, and buckets are maintained in a locked closet in
the hallway between the east and west wings which are inaccessible to the youth. The items are
used by staff and youth when performing daily cleanup activities. Staff are required to complete
a sign-out and sign-in log when items are taken and are returned to the designated storage
room. Kitchen staff are responsible for securing, maintaining an inventory log and sign-out/sign-
in log for kitchen utensils and sharps. A random review of ten unique kitchen utensils and
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sharps and unique tools in the maintenance building verified the tool inventory in the logs were
accurate. Reviewed documentation and the Department’s Central Communications Center
(CCC) reports verified there were no instances of missing or lost tools since the last annual
compliance review. If a tool is broken or inoperable, the physical plant manager is responsible
for replacing the broken tool. If a tool is missing staff will notify administration, fill out an incident
report, document the incident in the logbook, call the CCC, and the program will be searched
until the tool is found. The program has a vocational woodshop program on-site which is
operated by the Home Builder’s Institute (HBI) in which Class A tools are utilized by the youth.
Observations of tools in the vocational building indicated tools are maintained under lock and
key with access only to HBI staff.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. The program’s policy and procedures include
supervision requirements when youth are using tools, the issuing of tools to youth and staff, a
youth assessment to determine the youth’s risk, and established ratios, which include one staff
to five youth during work detail or vocational training. A review of the program’s procedures
verified staff are required to complete a sign-out and sign-in log when Class B tools are taken
and are returned to the designated storage room. A Youth Risk Assessment is completed by the
case manager for youth to use Class A and Class B tools. In addition, the Home Builder’s
Institute (HBI) program completes a risk assessment prior to youth participating in the program.
Seven youth case management records were reviewed, and each youth had a Youth Risk
Assessment completed by the case manager prior to the youth using tools. Seven youth case
management records included documentation each youth was trained on the intended and safe
use of class B tools. An observation of two youth working kitchen detail and two youth mopping
the living unit was conducted. In addition, youth were observed using Class A tools while
participating in the HBI program. The youth were properly supervised and followed safety
protocols. Five youth were interviewed, and each stated they use mops and brooms. Five staff
were interviewed, and each indicated youth are allowed to use mops and brooms. Four staff
reported youth can use tools when enrolled in the HBI program with a risk assessment
conducted prior to the use of tools.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a written policy and procedures establishing guidelines for outside contractors
who come on-site to complete repairs. When a contractor or vendor enters the program, they
sign the Outside Contractor On-Site Work Project Log which lists unauthorized items. The
program’s policy states personal cellular telephones and electronic devices capable of taking
pictures and/or audio/video recording, including smart watches, are prohibited in the secure
area. The physical plant manager or designee inspects all tools upon the arrival of outside
contractors and is responsible for providing approval if such tools are required. The program’s
guidelines for external workers include checking of tools upon arrival and departure, searching
of all vendors prior to entering the program, tool restriction while in the program, missing tool
follow-up, and restriction of youth from the work area. The outside contractor completes the
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program’s Outside Contractor form upon entrance to the program, where they list what tools are
needed to complete the work order. Maintenance staff will review the form and sign once the
tools are inventoried and approved. Upon exiting the program, the Outside Contractor form is
reviewed, all tools are verified, then the form is signed. Any tools required to be used within the
program are inventoried and recorded on the contractor’s agreement form before and after the
repair is completed. Reviewed documentation for three project invoices showed the vendors
signed contractor agreements. Documentation for the Outside Contractor forms verified the
forms were completed and all requirements were met. A review of the work project logs since
the last annual compliance review verified the contractors signed the log confirming notification
of what items are considered unauthorized. If any unauthorized items are needed by the
contractor while in the program, approval is obtained by the facility administrator (FA) or
designee.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program’s Continuity of Operations Plan (COOP) addresses fire, safety, and evacuation
emergency processes and the frequency of conducting drills at random times, and under varied
conditions. Reviewed documentation validated fire and COOP drills were conducted for all shifts
each month, as required. COOP drills included fire, riot, severe weather, flooding, hostage
situations, chemical spills, medical situations, and bomb threats which were covered on a
rotating basis. Drill documentation included the type of drill, date and time, participants, a brief
scenario description, deficiencies identified during the drill, and applicable corrective actions.
Documentation verified COOP drills were held during the all-staff meetings monthly.
Observations and an informal interview with the facility administrator (FA) verified there were
twenty-six annually inspected fire extinguishers and egress plans posted throughout the
program. Five interviewed staff all reported they had participated in COOP drills, suicide, and
medical drills. Five youth were interviewed, and each indicated drills are conducted at least
monthly and they have been instructed on what to do in the case of an emergency. An interview
with the FA indicated the program facilitates emergency/COOP, medical, mental health, fire,
and Right Interactions drills. Drills are conducted according to program drill calendar.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program maintains the Department-approved Continuity of Operations Plan (COOP)
available for all staff to review. The COOP was reviewed and submitted to the Department on
April 11, 2024. The Department approved the COOP on April 15, 2024. The COOP provides for
basic care and custody of youth in the event of an emergency or disaster. The COOP
addresses phases of a disaster plan as well as emergency management including
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preparedness, response, and recovery. The COOP addresses emergencies including fire
prevention, severe weather, riots, bomb threats, hostage situations, chemical spills, flooding,
and terrorist threats. In addition, the COOP plan includes staff roles and responsibilities,
equipment and supplies needed, youth information, provisions for continuity of care and custody
of youth, and provisions for public protection. The COOP is readily available to all staff and is
located in the administration conference room, the facility administrator’s (FA’s) office, and in
the assistant facility administrator’s (AFA’s) office. A review of the plan indicated alternative
housing has been identified should the program require evacuation due to an emergency or
disaster. The program has provisions of equipment and supplies maintained in the kitchen and
master control to ensure a continuous operation of services during emergency or disaster
situations. In addition, the program has a generator to provide continuous power. The program
maintains identifying information on each youth in the program in the event the program has to
evacuate, the youth record accompanies the youth to the temporary location. A review of seven
youth case management records indicated each has the youth’s name, Department
identification number, admission date, gender, race, contact information, emergency contact,
assigned juvenile probation officer (JPO), committing judge, victim information, physical
description, health status, and a photograph. The interviewed FA reported staff have full access
to the COOP.
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 written policy and procedures for the storage and inventory of flammable,
poisonous and toxic materials. Toxic items are stored outside the program in locked cabinets
within a locked chain link fence. A list of staff which includes the facility administrator (FA),
assistant facility administrators (AFAs), unit managers, medical staff, shift supervisors, and food
service staff confirmed they are authorized to use chemicals is maintained in the storage
cabinet. All caustic materials are stored according to type and use. A Safety Data Sheet (SDS)
binder is located inside the storage area with a picture of each material and a number
corresponding to the SDS for each chemical. A perpetual chemical inventory list is maintained,
and the chemicals are checked daily. A review of the inventory list verified this practice. The
program has a Chemical Daily Usage Log used to track all toxic items when in use by
authorized staff. Observations of the storage area indicated it is clearly marked hazardous
chemicals and securely locked. Items were stored on metal shelving and numbered according
to the SDS. Flammable items are stored in a metal cabinet clearly marked as flammable items.
Chemicals used to clean the program are stored in a locked closet located in the main hallway
of the program and in a secured closet in the kitchen. An inventory sheet is maintained and
documents daily use. A review of the storage closet verified the number and type of chemicals
were maintained on the inventory list. A random sample of ten chemicals verified the actual
count matched the inventory logs, the chemicals were secured, and the SDSs were present for
the items reviewed. In addition, the program maintains a written policy and procedures to
ensure all flammable, toxic, caustic, and poisonous items are disposed appropriately. The FA or
designee and maintenance staff are responsible for the control and accountability of all caustic,
toxic, poisonous, flammable, hazardous fluids, substances, or chemicals used in the program.
All unused hazardous materials are kept in the secured storage area located outside the
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program and are disposed of according to the SDS. In an informal interview the physical plant
manager stated the program makes every effort to use up all chemicals. Any unused chemicals
are taken to the local waste facility. The physical plant manager stated there were no chemicals
disposed of during the annual compliance review period. Used kitchen grease and waste is
stored in a large container outside the kitchen area and is disposed of by a local vendor. All
liquid waste from work details is disposed down plumbing drains. The program’s policy states all
chemical spills are reported to master control and the shift supervisor immediately. An
evacuation of the affected area is conducted, and a determination is made by the FA whether to
contact outside assistance to contain the spill. Staff and youth are not allowed to return to the
affected area until it has been deemed safe by a qualified professional. The interviewed FA
stated the disposal of hazardous items and toxic substances, or chemicals are in accordance
with Occupational Safety and Health Administration standards.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a written policy and procedures prohibiting youth from handling any
flammable, poisonous, and/or toxic items or materials. Youth are not to clean, handle, or
dispose of any toxic, bio-hazardous bodily fluids, or human waste. Youth are strictly prohibited
from the maintenance area where toxic items and chemicals are stored. An observation of two
youth working kitchen detail, and two youth mopping the living unit was conducted. None of the
observed youth were handling chemicals or cleaning products. Observations of completed
projects at the Home Builder’s Institute (HBI) verified youth used paint after receiving a risk
assessment. Five youth were interviewed, and each youth stated they did not use any
chemicals or cleaning products.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
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• 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.
This 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 written policy and procedures to allow youth to have visitation and
communication with family members while in the program. The program assists youth and
families in maintaining connections in a visitation environment which provides monitoring,
control of movement, and security practices to ensure visitor, youth, staff, and program safety.
The program’s policy provides each youth opportunities to promote communication and
engagement which fosters family reunification and community connections. The program
maintains a list of approved visitors; however, attorneys, representatives of the court, juvenile
probation officers (JPO), other agency representatives, and clergy are authorized to visit at any
time. Searches of visitors will be conducted upon entry and all youth are to be searched
following visitation sessions. The program’s visitation policy indicated considerations for
requests of alternative visitation arrangements with parents/guardians, if needed. Youth are
informed about visitation upon their admission to the program during the orientation process.
The visitation and communication procedures are covered in the youth handbook,
parent/guardian handbook, and addressed on the orientation checklist. Visitation is held two
days a week on Saturdays and Sundays from 9:00 a.m. to 11:30 a.m. Youth are given
opportunities to communicate with their family in person, by telephone, and by mail. Each youth
is provided an opportunity to correspond with identified individuals specified on their Approved
Correspondence List and legal representatives. Youth are permitted weekly telephone calls.
The youth’s use of telephone calls is documented in each youth’s case management
chronological documentation. A review of the telephone chronological notes verified youth have
consistent telephone communication with family members. Youth can write to their
parent/guardians at least once each week and are encouraged to correspond with the JPO and
committing judge. All outgoing and incoming mail is searched by the case manager. A review of
the logbooks, visitation sign-in logs, and outgoing and incoming mail logs verified the program
allows visitation and mail only for approved immediate family members to include
parents/guardians, stepparents, siblings, grandparents, and spouses. The JPO must approve
the immediate family members. It is the program’s practice for the assigned case manager to
follow-up with the JPO regarding human trafficking victims to determine whether the
parent/guardian should be permitted to communicate with the youth; however, there were no
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youth applicable for a history of human trafficking during the annual compliance review period.
Five youth were interviewed, and each confirmed they can call and/or send letters to their
parent(s)/guardian(s). The interviewed facility administrator (FA) stated for youth whom English
is not their primary language the program uses interpreter services and a language assistance
program.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a written policy and procedures to ensure each youth has a variety of
recreation and leisure activities. A review of the staff roster confirmed the program has a
recreation therapist, who met all requirements for the position. An informal interview with the
recreation therapist and reviewed documentation of seven youth records verified recreational
therapy is part of each youth’s initial wellness plan. The recreation therapist stated there is a
discussion with the youth on goals they can work on, then progress of goals is measured during
treatment team meetings. The program’s recreation calendar designates an activity for the
youth to participate in during outdoor recreation each day, as well as a calendar of alternative
activities if recreation is indoors. The program’s activity schedule is posted throughout the living
units and common areas of the program. All activities promote social and cognitive skill
development, creativity, teamwork, healthy competition, mental stimulation, and physical fitness.
Youth are provided with at least one hour of large muscle activity daily. Reviewed
documentation of the logbook and daily activity schedule confirmed the program has a range of
supervised and structured indoor and outdoor recreation and leisure activities for the youth, for
at least one hour daily. Observations made throughout the annual compliance review week
validated youth are provided with at least one hour of indoor or outdoor recreation and leisure
time. Five staff were interviewed regarding the type of recreation activities the program provided
and how long were the activities. Staff indicated the program provides youth with at least one
hour each day. Each staff indicated the outdoor activities consist of basketball, and football. The
indoor activities consist of board games, card games, watching television, playing video games,
and using the weight room. Five youth were interviewed, and each youth stated they are
provided at least one hour of physical activity which includes playing basketball, football, dodge
ball, and access to the gym.
5.23 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program maintains a written policy and procedures to ensure staff searched and inspected
controlled observation rooms prior to placing a youth in controlled observation. The program has
a designated area to house youth who have been placed on controlled observation.
Observations of the rooms indicated the program met the measurement and construction
required by Florida Administrative Code. The program had 139 controlled observation
placements since the last annual compliance review. Thirteen Controlled Observation Reports
were reviewed and all thirteen reviewed Controlled Observation Reports indicated same gender
staff searched the youth and staff inspected the room before the youth were placed in controlled
observation.
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5.24 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program maintains a written policy and procedures regarding controlled observation.
Program staff are authorized to temporarily place a youth in a controlled observation room if
there is an imminent risk to the youth harming themselves or others, or if the youth is causing
major damage to the program which may cause a security risk. If a youth is placed in controlled
observation for any of these reasons, a Controlled Observation Report is to be completed upon
the youth’s placement. The program had 139 controlled observation placements since the last
annual compliance review. A review of thirteen Controlled Observation Reports verified
supervisors or administration authorized the placement of youth in controlled observation. None
of the reviewed Controlled Observation Reports indicated the youth exhibited behaviors
indicative of a mental health crisis or had suicide ideation. Documentation indicated youth
placed in controlled observation were identified as an imminent risk to the youth harming
themselves or others, or the youth were causing major damage to the program which may have
caused a security risk, or the youth were physically out-of-control, and less restrictive methods
were ineffective, and staff needed to quickly gain control for program safety. All thirteen
Controlled Observation Reports indicated staff advised youth for the reason for controlled
observation and the expected behavior to be released. All thirteen Controlled Observation
Reports indicated medical staff completed a Health Status Checklist for the youth in controlled
observation. One of the reviewed Health Status Checklists indicated youth sustained injuries
and the youth was observed and treated by healthcare staff. A review of thirteen Controlled
Observation Reports indicated eight youth remained over two hours in controlled observation
and the facility administrator (FA) or designee granted the extension for remaining in controlled
observation over two hours for seven youth. One youth was in controlled observation for two
hours and forty-seven minutes; however, there was no approval by a supervisor for continuing
observation over two hours.
5.25 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program maintains a written policy and procedures to ensure safety checks for youth on
controlled observation are conducted. A safety check is to be conducted every fifteen minutes to
ensure the youth is safe and observe the youth’s behavior. Once the youth is determined to be
appropriate for release from controlled observation, the facility administrator (FA) or designated
supervisor gives approval for the youth’s release. The release is documented on the Controlled
Observation Report. The program had 139 controlled observation placements since the last
annual compliance review. Thirteen Controlled Observation Reports were reviewed, and each
report indicated staff completed the first page of the report and the report was submitted to a
supervisor. Staff conducted safety checks at least every fifteen minutes and documented the
Controlled Observation Safety Check forms. All thirteen controlled observation forms indicated a
FA or designee approved the release of the youth from controlled observation based on the
youth’s behavior and no longer being a threat to self and others. A review of thirteen Controlled
Observation Reports verified the FA or designee approved the report within fourteen days of the
youth’s release from controlled observation. Documentation verified staff made a determination
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if an alert was warranted after the youth was released from controlled observation.
Documentation showed the Controlled Observation Report, Health Status Checklist, and
Controlled Observation Safety Check forms were maintained in an administrative file and in the
youth’s individual management record. Reviewed documentation verified staff designations for
controlled observations were included in the program’s operating procedures.
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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 career and technical education (CTE) services being provided as contracted include Florida
Ready to Work Soft Skills, Occupational Safety and Health Administration-10 (OSHA-10), and
first-aid/cardiopulmonary resuscitation (CPR). The program’s contracted CTE services include
industry certifications, Florida Ready to Work credentials, OSHA-10, first-aid, CPR, and
automated external defibrillator (AED). Qualified instructors provide all CTE services. Florida
Ready to Work certifications include Soft Skills, Digital Skills, and academic employability skills.
Youth can receive certifications in OSHA-10, culinary, and construction. In addition, youth can
participate in Home Builder’s Institute (HBI) programming and learn Pre-Apprenticeship
Certificate Training (PACT) and carpentry skills. All youth in the program are enrolled in
coursework towards earning industry certifications during school hours from 8:00 a.m. through
3:00 p.m. Monday through Friday. Five youth records were reviewed, and three youth had
completed Florida Ready to Work Soft Skills and one youth had completed OSHA-10 within the
contracted time frame. Five interviewed youth stated there are no interruptions during the school
day. Five youth were interviewed and one youth responded the program is preparing them well
for their high school equivalency diploma, high school, vocational school, employment, and/or
college, and four youth responded very well. The interviewed facility administrator (FA) stated
contract specific vocational services include Florida Ready To Work, Home Builder’s Institute,
food handler certification, and other CTE certifications.
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 maintains a written policy and procedures to provide for educational access. The
program integrates education into the daily schedule. A sample of three videos and three
logbook reviews showed youth were going to and returning from class on time. In addition,
randomly selected logbook entries over the past year were reviewed and youth were moved
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accordingly. In a review of the youth interviews, all five interviewed youth stated there are no
interruptions during the school day.
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) which
ensures the integrity of the required minimum instruction time distributed over a twelve-month
period. This indicator was reviewed; however, will not be rated until the 25/26 review cycle. The
district-approved calendar and daily school schedule were reviewed, which incorporated the
required 250 days of instruction, with twenty days used for teacher planning, and a minimum of
twenty-five hours of instruction weekly. The daily school schedule was approved by the school
board on April 29, 2024. Youth are enrolled in academic courses through Florida Scholars
Academy and receive credit, as appropriate, when courses are completed. A sample of three
videos and three logbook reviews showed classes were facilitated appropriately. An informal
interview with the instructional leader reported the educational schedule is adhered to.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle. 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
programming through Life Management Skills, Personal Finance, and Money Management
courses. The career education program does include Type 3 programming through course
offerings, to include Digital Information Technology and Life Management, which provide
content and competencies for specific careers. Each course offered by the education provider
includes soft skills for specific careers. The education contract provider is responsible for
providing Career and Professional Education (CAPE) courses leading to pre-apprentice
certifications and industry certifications. The interviewed instructional leader stated youth
complete a career strengths and interest questionnaire upon entry and are placed into Digital
Information Technology and Life Management courses. Progress reports are sent to case
management, by email within twenty-four hours of treatment team meetings. Teachers add
behavior notes to the academic progress reports.
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.
Education services are provided by Florida Scholars Academy/Florida Virtual School (FLVS).
This indicator was reviewed; however, will not be rated until the 25/26 review cycle. The
contracted education provider maintains a policy and procedures requiring an Education
Transition Plan to be developed upon each youth’s admission. Three closed case youth records
were reviewed, and none contained an Education Transition Plan. Many youth entered the
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program before July 1, 2024, when the new education provider began their contract, so they
would not have had an Education Transition Plan developed by the provider. Any youth who
was admitted between July 10, 2024, and December 1, 2024, may have had a paper Education
Transition Plan filled out; however, it was from an old form. Starting December 2, 2024, all
paraprofessionals were trained on how to complete the new Education Transition Plan and
those will be uploaded into the Department’s Juvenile Justice Information System, (JJIS) by the
school counselors/transition specialists.
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.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle. The contracted
educational provider has procedures in place to provide for qualified instructional personnel. A
review of seven instructional personnel and four flex instructional personnel found each had a
valid Florida educator’s certificate. All eleven teachers’ credentials were active on the
Department of Education (DOE) website. Seven instructional personnel taught out-of-field
courses at the program, however, none obtained approval by the school board for teaching out-
of-field. Each instructor taught one to seven out-of-field courses at the program. A review of the
three youth school schedules confirmed all teachers were accurately listed. A review of three
youth records for out-of-field parent/guardian notification letters showed no notifications were
sent out prior to October 7, 2024, and none of the letters accurately reflected the classes or
teaching assignments outside of their field of expertise.
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.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle. The education
contracted provider is responsible for referring all youth who receive their high school diploma or
equivalent to Florida Youth College (FYC). A review of three closed youth records found none
were applicable for a referral to FYC. Two additional youth applicable for a referral during the
annual compliance review period were provided and reviewed. Documentation supported both
youth were referred to FYC and one youth had received certifications from Tallahassee State
College. The other youth referral was pending.
6.08 Florida Youth College (Post-Secondary Contract Provider) Failed 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/
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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.
Each referral received by Florida Youth College (FYC) from the education contracted provider is
assigned a career navigator. The career navigator then connects with youth through the
residential contracted provider to schedule an orientation session. During orientation, the youth
and career navigator develop a career pathway plan to include postsecondary courses and/or
enrollment in a state or technical college. The career navigator continues to assist youth on their
career pathway plan and have incremental follow-up sessions scheduled through the residential
contracted provider. A review of three youth closed records found no youth met the eligibility
criteria for a referral to FYC. A review of one applicable youth record found there was no
documentation a FYC career navigator was assigned for the youth. There was no
documentation a thirty-day follow up was conducted after the youth’s release from the program.
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report_type: QI Residential

program_name_raw: Everglades Youth Academy - Max

rule: Indicator 5.08

excerpt: Contraband Procedures

rating: Limited Compliance

rule: Indicator 6.08

rating: Failed Compliance