summary: QI Residential - FY24-25 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
South Florida Youth Academy
TrueCore Behavioral Solutions, LLC
(Contract Provider)
3300 Northwest 27th Avenue, Northwest 35th Street Entrance
Miami, Florida 33142
Review Date(s): August 13-16, 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:
Troy McGee, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Nicos Antonakos, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Interviews)
Acasha Pressley, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Yvrose Sylvain, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Sharon Wong, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Program Name: South Florida Youth Academy MQI Program Code:
Provider Name: TrueCore Behavioral Solutions, LLC Contract Number: 10762
Location: Miami-Dade County / Circuit 11 Number of Beds: 30
Review Date(s): August 13-16, 2024 Lead Reviewer Code: 198
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 75 (Revised September 2022)
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Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 75 (Revised September 2022)
In d ic a t o r R a t in g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t * 1 .0 3
M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 4
In c id e n t R e p o rtin g (C C C ) * 1 .0 5
P ro te c tiv e A c tio n R e s p o n s e (P A R ) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 6
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 7
In -S e rv ic e T ra in in g 1 .0 8
G rie v a n c e P ro c e s s 1 .0 9
In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .1 0
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 1
R e s to ra tiv e J u s tic e A w a re n e s s fo r Y o u th 1 .1 2
In te rn a l A le rts S y s te m a n d A le rts (J J IS )* 1 .1 3
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 4
A d v is o ry B o a rd 1 .1 5
S ta ff P e rfo rm a n c e 1 .1 6
S p e c ia l C o n tra c t C o n d itio n s 1 .1 7
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s 1 .1 8
D a ta T re n d A n a ly s is 1 .1 9
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 75 (Revised September 2022)
In d ic a t o r R a t in g s
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n 2 .0 1
Y o u th O rie n ta tio n 2 .0 2
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r 2 .0 3
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s 2 .0 4
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t 2 .0 5
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s 2 .0 6
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y ) 2 .0 7
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S ) 2 .0 8
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls a n d T ra n s m itta l * 2 .0 9
P e rfo rm a n c e P la n R e v is io n s 2 .1 0
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls 2 .1 1
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s 2 .1 2
In c o rp o ra tio n o f O th e r P la n s In to P e rfo rm a n c e P la n 2 .1 3
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s ) 2 .1 4
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T ) 2 .1 5
E x it P o rtfo lio 2 .1 6
E x it C o n fe re n c e 2 .1 7
Y o u th In p u t 2 .1 8
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Limited
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 75 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 75 (Revised September 2022)
In d ic a t o r R a t in g s
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e * 4 .0 1
L ic e n s e d M e d ic a l S ta ff* 4 .0 2
F a c ility O p e ra tin g P ro c e d u re s 4 .0 3
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t 4 .0 4
P a re n ta l N o tific a tio n /C o n s e n t 4 .0 5
H e a lth c a re A d m is s io n & R e s c re e n in g F o rm 4 .0 6
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n 4 .0 7
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e A d m is s io n N o tific a tio n 4 .0 8
H e a lth -R e la te d H is to ry 4 .0 9
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g 4 .1 0
S e x u a lly T ra n s m itte d In fe c tio n & H IV S c re e n in g 4 .1 1
S ic k C a ll P ro c e s s 4 .1 2
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re 4 .1 3
O ff-S ite C a re /R e fe rra ls 4 .1 4
C h ro n ic Illn e s s /P e rio d ic E v a lu a tio n s 4 .1 5
M e d ic a tio n M a n a g e m e n t 4 .1 6
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s 4 .1 7
In fe c tio n C o n tro l/E x p o s u re C o n tro l 4 .1 8
P re n a ta l C a re /E d u c a tio n 4 .1 9
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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Standard 5: Safety and Security
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 75 (Revised September 2022)
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In d ic a t o r R a t in g s
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
Y o u th S u p e rv is io n *
o m p re h e n s iv e a n d C o n s is te n t Im p le m e n ta tio n o f th e B e h a v io r M g t S y s te m a n d S ta ff T ra in in g
U s e o f R o o m R e s tric tio n
T e n M in u te C h e c k s *
C e n s u s , C o u n ts , a n d T ra c k in g
L o g b o o k E n trie s a n d S h ift R e p o rt R e v ie w
K e y C o n tro l*
C o n tra b a n d P ro c e d u re
S e a rc h e s a n d F u ll B o d y V is u a l S e a rc h e s
V e h ic le s a n d M a in te n a n c e
T ra n s p o rta tio n o f Y o u th
W e e k ly S a fe ty a n d S e c u rity A u d it
T o o l In v e n to ry a n d M a n a g e m e n t
Y o u th T o o l H a n d lin g a n d S u p e rv is io n
O u ts id e C o n tra c to rs
F ire , S a fe ty , a n d E v a c u a tio n D rills
D is a s te r a n d C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P )
S to ra g e , In v e n to ry , a n d D is p o s a l o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
Y o u th H a n d lin g a n d S u p e rv is io n o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
E le m e n ts o f th e W a te r S a fe ty P la n , S ta ff T ra in in g , a n d S w im T e s t *
V is ita tio n a n d C o m m u n ic a tio n
R e c re a tio n a n d L e is u re
S e a rc h a n d In s p e c tio n o f C o n tro lle d O b s e rv a tio n R o o m
C o n tro lle d O b s e rv a tio n
C o n tro lle d O b s e rv a tio n S a fe ty C h e c k s a n d R e le a s e P ro c e d u re s
p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
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re s id e n tia l, p ro b a tio n ).
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Standard 6: Educational Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 75 (Revised September 2022)
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6 .0 4
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I n d i c a t o r R a t i n g s
S t a n d a r d 6 - E d u c a t io n a l S e r v ic e s
C o n tr a c t S p e c ific C T E S e r v ic e s ( R e s id e n tia l C o n tr a c t)
E d u c a tio n a l A c c e s s ( R e s id e n tia l C o n tr a c t) *
E d u c a tio n a l A c c e s s ( E d u c a tio n C o n tr a c t) *
C a r e e r E d u c a tio n ( E d u c a tio n C o n tr a c t)
E d u c a tio n T r a n s itio n P la n ( E d u c a tio n C o n tr a c t)
Q u a lifie d In tr u c tio n a l P e r s o n n e l ( E d u c a tio n C o n tr a c t)
F lo r id a Y o u th C o lle g e ( E d u c a tio n C o n tr a c t)
F lo r id a Y o u th C o lle g e ( P o s t- S e c o n d a r y C o n tr a c t)
id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re
w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c
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Program Overview
The South Florida Youth Academy is a thirty-bed program, for fourteen- to eighteen-year-old
males, located in Miami-Dade, Florida. The program is operated by TrueCore Behavioral
Solutions LLC, through a contract with the Department. The program provides Substance Abuse
Treatment Overlay Services (SAOS), Comprehensive Treatment Services for Co-Occurring
Disorders, and Mental Health Overlay Services (MHOS). In addition, the program fosters each
youth by providing care and custody services, case management and coordination services,
health and nursing services, mental health and substance abuse services, delinquency
programming, gender specific services, academic services, career and technical education, and
restorative justice evidence-based interventions. Additional treatment services provided include
Impact of Crime (IOC), Cannabis Youth Treatment (CYT), Skillstreaming the Adolescent, New
Direction, process group, Group Treatment for Substance Abuse, and the Mental and Emotional
Health Series. Program administration is comprised of a facility administrator (FA), a director of
clinical services, and a health services administrator (HSA). Case management services are
provided by two case management staff and two transition services managers. Mental health
staff at the program include the director of clinical services who acts as the designated mental
health clinician authority , one full time licensed therapist, one licensed pro-re-nata (PRN)
therapist, two non-licensed therapists, and one recreation therapist. Medical services are
offered seven days a week and are provided by three registered nurses (RNs). One RN serves
as the HSA. The program contracts with a licensed medical doctor (MD) to serve as the
designated health authority (DHA). The DHA is on-site once a week for two hours. Educational
services are provided by the Florida Scholars Academy. The layout of the program includes one
main building which consists of two living unit areas, two portable classrooms, and common
areas. The program has sixty operating security cameras providing coverage. At the time of the
annual compliance review, the program had eleven full-time and one part-time vacant positions
to include one registered behavioral technician, one case manager, one youth specialist III, one
youth specialist II, five youth specialist Is, two master control technicians, and a part-time dietary
associate.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 75 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a written policy and procedures to ensure all newly hired staff and volunteers
receive an initial background screening. The Annual Affidavit of Compliance with Level 2
Screening Standards was submitted to the Department’s Background Screening Unit on
December 12, 2023, meeting the annual requirement. The teachers received an annual
screening on December 13, 2023, meeting the annual requirement. The program had fifteen
newly staff hired since the start up review. A review of eleven applicable direct care staff records
confirmed pre-employment assessments were administered. A pre-employment assessment
passing score was documented in each of the eleven staff’s records. A review of each staff’s
record verified staff completed a background screening prior to contact with youth and
confidential youth records. Each staff’s criminal history report was reviewed. There were no staff
applicable for an exemption prior to working with youth. There were no staff applicable for a
break in service. The program added each staff to their Clearinghouse employee roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a written policy and procedures to ensure all staff and volunteers receive a
background rescreening every five years from their initial date of employment. The program’s
contract is less than five years old; therefore, no staff were applicable for a five-year
rescreening.
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1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a written policy and procedures ensuring an abuse-free environment. There
were two incidents alleging physical abuse reported to the Department’s Central
Communications Center (CCC) since the start up review. There were no applicable cases for
any potential human trafficking victims, children of sexual exploitation, or labor trafficking
reported. Five reviewed records documented staff reviewed and signed a code of conduct. A
program tour was conducted and confirmed the Florida Abuse Hotline and the CCC telephone
numbers were posted throughout the program. The program’s steps for reporting abuse include
if a youth exhibits or feels like they are being abused, the staff allow the youth to make the
telephone call to the hotline, and if physical abuse is suspected law enforcement is called. All
staff are allowed to call the CCC to report an incident. The program completed a Trauma
Responsive and Caring Environment (TRACE) self-assessment on June 14, 2024. There were
no applicable incidents related to physical abuse since the start up review for this program
which occurred on September 13, 2023. There were no substantiated incidents related to
physical, psychological, or emotional abuse since the start up review. Five youth were
interviewed and stated they feel safe at this program. Five youth stated they have never been
stopped from reporting abuse to the Florida Abuse Hotline or CCC since they have been at this
program. Each of the five interviewed youth stated they know the telephone number for the
Florida Abuse Hotline and if not, they know where it's posted. Each interviewed youth stated
staff are respectful when talking with them and other youth. Each interviewed youth stated they
never heard staff use profanity when speaking to them or other youth. Each interviewed youth
stated they have never exchanged emails, telephone numbers, or social media contact
information with staff. Five staff were interviewed and stated the process for allowing staff and
youth to call the Florida Abuse Hotline or CCC to report suspected abuse is to notify the
supervisor, notify the facility administrator (FA), and allow the youth to make the call, or the
supervisor or staff can make the call. Five interviewed staff stated they never observed another
staff telling a youth they could not call the Florida Abuse Hotline. Each interviewed staff stated
they never heard another staff using profanity while speaking with youth. An interview with the
FA stated staff must adhere to the code of conduct. The program's staff code of conduct
emphasizes the importance of maintaining a safe and respectful environment for all youth
participants. Staff members are expected to model positive behavior, uphold the dignity of every
individual, and foster a nurturing atmosphere. In the event of any physical abuse, threats, or use
of profanity towards youth, immediate action will be taken, which may include a thorough
investigation of the incident, disciplinary measures against the offending staff member, and
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potential reporting to relevant authorities. The program incorporates trauma-responsive
practices by creating a safe and supportive environment which acknowledges and addresses
the unique needs of individuals who have experienced trauma. Staff are trained to recognize the
signs of trauma and to respond with empathy and understanding, fostering strong, trusting
relationships with youth. The program emphasizes consistency and predictability in routines,
which helps to create a sense of stability. Additionally, the program offers opportunities for
emotional expression through various activities, such as art and group discussions, allowing
participants to process their experiences in a constructive manner. By prioritizing a holistic
approach which includes trauma-informed care, the program aims to promote resilience and
healing among youth.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program has a written policy and procedures to ensure immediate action is taken to
address incidents of physical, psychological, and emotional abuse. The program had two
incidents alleging abuse towards a youth since the start up review of the program. Reviewed
documentation found the program took immediate action to address allegations of physical
abuse in both instances. An interview with the facility administrator (FA) stated upon receiving a
report or allegation, management initiates an immediate investigation to gather facts while
ensuring the confidentiality and safety of the affected parties. This process includes interviewing
witnesses, reviewing documentation, and assessing the circumstances surrounding the
allegation. Management prioritizes the well-being of the youth and takes appropriate interim
measures, such as suspending the alleged offender if necessary. Throughout the investigation,
management maintains open communication with relevant stakeholders, including law
enforcement and child protective services, as required. Once the investigation is complete,
management takes decisive action based on the findings, which may include disciplinary
measures and additional training.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a written policy and procedures for reporting incidents to the Department’s
Central Communications Center (CCC) within the required two-hour time frame. The program
had a total of eighteen CCC incidents reported since the start up review of the program. A
review of five CCC reports confirmed all incidents documented the incident date and time, date
and time program became aware of incident, and were reported within the two-hour time frame.
Each of the reviewed CCC incidents documented type of incident and were documented in the
program logbook, as required. There were no additional incidents or grievances which should
have been reported to the CCC noted during the annual compliance review week. The program
did not experience an increase of incidents to the CCC. The program’s start up review occurred
on September 13, 2023.
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1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program has a written policy and procedures related to Right Interactions (RI) including the
use of verbal and physical intervention techniques and mechanical restraints. A review of the
program’s RI binder indicated there was a total of thirty-one RI incidents since the program’s
start up review. Documentation found there were monthly summaries maintained by the
program of all RI incidents, which were submitted to the Department’s regional office by the
fifteenth of each month. The program’s RI plan was updated on April 29, 2024. The program’s
RI plan was approved by the Department on May 3, 2024. There was no measurable increase
in previous RI incidents due to the program’s start up review occurring on September 13, 2023.
The program’s RI rate during the most recent quarter was 3.20, which was above the statewide
Residential RI rate of 1.81. An interview with the facility administrator (FA) stated upon the
occurrence of a RI incident, staff are required to complete a detailed report documenting the
circumstances, actions taken, and the individuals involved. This report is submitted to
management for review, where it is assessed alongside any video footage or witness accounts.
Management conducts a thorough analysis to determine whether the use of force was justified
and in alignment with the program’s policies. Regular reviews of RI incidents are scheduled to
identify patterns, inform staff training, and implement necessary adjustments to de-escalation
techniques. Five staff were interviewed and four staff stated they always use verbal de-
escalation techniques and follow the RI policy. Staff reported verbal techniques are always used
throughout the process and, if necessary, they will use authorized techniques to restrain youth
and continue with verbal techniques. One staff was not in a direct care position and did not need
to be RI trained. A review of five RI Reports indicated each was completed prior to the end of
the staff’s workday and included statements from all staff involved. A review of the five RI
Reports confirmed there were no injuries to the staff or youth requiring notification to the
Department’s Central Communications Center (CCC). There were no youth applicable for a RI
medical review. In each of the reviewed reports, the RI Report was reviewed by a supervisor or
designee and a RI instructor or RI-certified supervisor. For each of the reviewed reports the RI
incident report was reviewed by the administrator, or designee, within seventy-two hours of the
incident.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has a written policy and procedures outlining the pre-service training requirements
for newly hired staff. Youth specialist I, II, and IIIs, and staff mentors are considered to be direct-
care staff and are counted in the staff-to-youth ratio. Pre-service training is provided through a
combination of instructor-led, web-based courses, and on-the-job training. Documentation
confirmed all instructors were qualified to deliver the trainings provided. Five staff training
records were reviewed for pre-service trainings. Each training record confirmed staff completed
a minimum of 120 hours of training within 180 days of hire. Each staff completed the essential
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skills trainings as outlined in the program’s policy prior to any contact with youth to include child
abuse recognition, reporting, and prevention, cardiopulmonary resuscitation (CPR), first-aid,
automated external defibrillator (AED), emergency procedures, facility or program operating
procedures, Prison Rape Elimination Act (PREA), professionalism and ethics including
standards of conduct, Right Interactions (RI), and suicide awareness and prevention. Reviewed
documentation confirmed each staff completed additional pre-service trainings to include active
shooter preparedness, adolescent development and behavior, balanced and restorative justice,
the Department’s Central Communications Center (CCC) reporting, civil rights, communication,
Health Insurance Portability and Accountability Act (HIPPA), Department of Juvenile Justice
history, Equal Employment Opportunity (EEO), gang awareness, human trafficking, infection
control, information security awareness, the Department’s Juvenile Justice Information System
(JJIS), mental health and substance abuse, motivational interviewing (MI), quality report writing,
safety, security, and supervision of youth, sexual harassment, trauma responsive practices, and
each staff received effective and respectful treatment of youth training. All staff received
additional specialized treatment training as outlined in the contract. The training plan/calendar
was approved by the facility administrator as the highest-ranking official at the location, the
assistant secretary for Residential Services, and the director of Talent, Leadership, and Culture.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a written in-service training plan which was submitted to the Department’s
Office of Talent, Leadership, and Culture on August 12, 2024, and is still awaiting approval.
According to the program’s contractual requirements, specific training is required for different
position classifications such as management, case managers, mental health, and direct care
staff. Five staff training records, including two supervisors’ training records, were reviewed for
in-service training. Each staff completed training in active shooter preparedness and Prison
Rape Elimination Act (PREA). Each staff had current certifications in cardiopulmonary
resuscitation (CPR), first-aid, and Right Interactions (RI). Each reviewed staff completed training
in active shooter preparedness, human trafficking intervention, information security awareness,
mental health and substance abuse, professionalism and ethics including standards of conduct,
sexual harassment, suicide awareness and prevention, trauma responsive practices,
emergency response and emergency drills, infection control, blood-borne pathogens, and the
Exposure Control Plan. A review of two supervisor training records confirmed completion of
eight hours of management and supervisory training inclusive of leadership, organizational
skills, delivering constructive criticism, motivating employees supervisory training, and smart
performance management. Reviewed documentation confirmed the program has an annual in-
service training calendar which is updated as changes occur.
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1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has established written procedures specifying the process for youth to grieve
actions of program staff and conditions or circumstances in the program related to the violation
or denial of basic rights. The program has a three-phase grievance process which includes
informal, formal, and appeal phases. The informal phase process includes a Let’s Talk form
which is filled out by the youth. This consists of the youth attempting to resolve a complaint or
situation with the staff on duty at the time of the grievance. The formal and appeal phases
include the documented intervention of administrative staff. Youth are informed of the grievance
process at the time of admission. All youth have access to the grievance forms, as they are
available to youth and are in the day room of each living area. The program had three
grievances submitted since the start up review. All submitted grievances were maintained in a
designated grievance binder, each of the three grievances were informal, and staff were able to
resolve them before making it to the next phase. The program’s practice correlated with their
policy according to the documentation reviewed. Five interviewed youth were able to explain the
program’s grievance process. Youth stated they can complete a grievance form and place the
form in the box. Each youth stated they can receive assistance if they need help completing a
grievance. Five interviewed staff knew the program’s grievance process. The interviewed facility
administrator (FA) stated the process begins with an informal discussion between the youth and
a designated staff member, allowing for immediate feedback and support. If the issue is not
resolved at this stage, the youth can submit a formal written grievance, which will be reviewed
by a grievance committee within a specified time frame. The committee will conduct a thorough
investigation, ensuring confidentiality and fairness, and will provide a written response to the
youth.
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program’s treatment services include the use of the social and life skills curriculum
Skillstreaming the Adolescent. The group is led by trained, licensed mental health/substance
abuse staff. Skillstreaming the Adolescent is held once a week on Tuesdays. A review of the
program’s activity schedule and group sign-in sheets confirmed the life skills groups were held
as required. In addition to the groups, the program incorporated additional life skills for the youth
through a gender-specific barber class for youth, career days, mock interviews, mentoring, and
family days. Five youth were interviewed, and four stated they participate in life skills
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groups/activities. One youth stated they have not started yet. An interview with the facility
administrator (FA) stated the program specifically addresses the needs of a targeted gender
group by implementing tailored interventions which recognize and respond to the unique
challenges faced by young individuals. The program provides responsive programming which
incorporates discussions around issues such as identity, peer relationships, and societal
expectations. Activities are designed to empower participants by promoting self-esteem,
resilience, and leadership skills. Additionally, the program facilitates mentorship opportunities
with role models who share similar backgrounds. This aids in fostering a supportive network, by
creating safe spaces for open dialogue and addressing concerns. An interview with the
designated mental health clinician authority (DMHCA) stated youth are able to practice skills
through their daily use of the positive performance system and how they navigate advancement
through the level system. Youth participate in daily meetings where they are provided an
opportunity to appropriately air their grievances and issues, can demonstrate their leadership
skills, present for their levels, where they are encouraged to recognize and address their
strengths and weaknesses or areas in need of improvement. Many of the youth utilize conflict
resolutions as a means to formally problem solve with peers to safely express their feelings and
work together to solve problems. Youth are provided opportunities to take turns in leading
stretching exercises before beginning recreational activities. The youth advisory board is an
opportunity for youth to demonstrate their ability to advocate for self and others. Additionally,
during the quarterly Trauma Responsive and Caring Environment (TRACE) champion’s team
meeting the youth will have an opportunity to be incorporated as a part of the champion’s team.
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 only restorative justice awareness group offered is Impact of Crime (IOC). The
program’s restorative justice intervention provides a delinquency intervention which is a
promising practice. The program’s restorative justice activities are designed to assist youth to
accept responsibility for harm caused by their past criminal actions, challenging them to
recognize and modify their irresponsible thinking. The activities are designed to teach youth
about the impact of crime on victims, their families, and their communities, to expose youth to
victim’s perspectives through victim speakers, in person, on video, audio, or through victim
impact statements. The program provides opportunities for youth to participate in reparation
activities intended to restore victims and communities, such as restitution activities and
community service projects. Restorative justice awareness activities are provided Mondays and
Wednesdays from 6:00 p.m. until 7:00 p.m. Sign-in sheets, handouts, projects and logbooks
were reviewed to confirm groups were conducted, with no issues noted. In addition to the
restorative justice groups, the program incorporated community service project activities for the
youth. The facility administrator (FA) reported the youth participate in restorative justice projects
through career day, family day, and they also have weekly activities with volunteers to
reconnect with members of the community. Five youth were interviewed, and three youth stated
they participate in IOC which helps them with overcoming obstacles and conflict resolution. Two
youth stated they have not started IOC yet due to being new admissions into the program. An
observation of restorative justice activities was not made during the annual compliance review
week, as none were scheduled while the annual compliance review team was on-site.
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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 for an internal alert system designed to inform
staff of youth with health-related concerns, mental health concerns, and/or safety and security
risks. The program maintains an on-going alert system to ensure information pertaining to a
youth’s special conditions, suicide risks, safety, and/or security risks are effectively
communicated to staff in a manner which protects the youth’s privacy. Alerts are identified
during an interview with the youth at the time of admission and/or a review of documentation in
the admission packet. Alerts are entered into the Department’s Juvenile Justice Information
System (JJIS) and added to the program’s internal alert system. The internal alert list is posted
in master control, the supervisor’s office, logbooks, and in shift briefing reports. The alerts
identify the youths’ allergies, security risks, suicide risks, health conditions, mental health status,
medications, and dietary restrictions. During the annual compliance review week, five youth
identified with alerts were reviewed. Documentation confirmed all youth were placed on the alert
system with the name and title of staff entering or removing an alert. Documentation of alerts
and dates were entered in the program’s logbook. The center’s internal alert system coincided
with JJIS. The interviewed facility administrator (FA) stated if a medical emergency happens,
nurses notify the FA as soon as possible. The FA meets with the medical staff daily in the
management meeting and as needed. The FA stated all staff in the case management, clinical,
and medical departments are responsible for entering and closing out alerts in JJIS. An
interview with the nurse stated all nurses are responsible for updating the medical alert system.
An interview with five staff stated they are informed of the youth's alerts including mental health,
medical, and security, during briefings at the beginning of shift, and/or through documentation in
master control and the staff supervisor’s office.
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 for record management. The program
maintains two separate youth records which include individual healthcare and an individual case
management record. A review of five youth Individual Healthcare Records (IHCRs) confirmed
each contained the youth’s name, Department identification number, date of birth, county of
residence, and committing offense. A review of five youth individual case management records
confirmed each contained sections including the legal information, demographics and
chronological information, correspondence, case management and treatment activities, and
miscellaneous information. Records were observed to have been marked “Confidential.” Youth
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records are secured in a designated office within the program which is inaccessible to youth.
The program clearly identifies any file cabinet used to store official youth records as
“Confidential.”
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 established a community advisory board (CAB) which meets at least every ninety
to 120 days to serve as a support to the program. During the annual compliance review week, a
review of the program’s advisory board binder and sign-in sheets confirmed meetings were
being conducted at least every 120 days and there was documentation reviewed confirming
meetings were held within the quarter. The facility administrator (FA) solicited active
involvement from a law enforcement representative, judiciary, community, business community,
school board, faith community, victim advocate or victim services, and a parent/guardian whose
child was previously in the juvenile justice system. Sign-in sheets from quarterly advisory board
meetings were reviewed to confirm the program’s practice. Board members who were unable to
attend the meetings in person appeared virtually. During the annual compliance review week, a
board member was interviewed by telephone and confirmed involvement in the program’s
activities. The interviewed FA stated the CAB meetings are conducted once quarterly and all
information and invites are sent out for members to attend the meetings.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a written policy and procedures to ensure staff annual performance
evaluations are based on their established performance standards. The program’s policy and
procedures were reviewed to determine the program’s system for evaluating staff, performance
standards, and frequency of evaluations. Five job/position descriptions were reviewed to ensure
each staff’s performance standards were clearly identified. A sample of five performance
evaluations were reviewed to ensure evaluations were completed as outlined in policy.
Evaluations were completed at ninety days and annually thereafter. Performance standards
matched the job descriptions for each staff. The program’s contract was reviewed to ensure all
specific contractually required positions were maintained and performed as outlined in the
contract, and documentation ensured all requirements were met. An interview with the facility
administrator (FA) indicated a morale committee meets every month to coordinate events in the
program based off what the staff recommend. When turnover occurs, the FA attempts to have
individuals meet the standards of the program. Ninety-day reviews are conducted and then an
annual evaluation occurs according to the FA. Five staff were interviewed and two staff stated
performance evaluations are done yearly, two staff stated every six months, and one staff stated
as needed.
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1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program implements special contract conditions as outlined in the program’s contract. The
program’s contract had a Memorandum of Negotiation (MON) during the procurement process.
The special contract conditions include a certified behavior analyst, who shall be on-site for two
hours each week. The behavior analysts’ services were provided by a licensed psychologist
who was on-site at least two hours weekly, as confirmed by the sign-in log. The program’s MON
requires a current independent contractor agreement with a registered dietitian to include the
program location. Reviewed documentation confirmed the contractor agreement was active.
The program’s contract requires the position description for the transition services manager to
state they will work in conjunction with the community relations director in the recruitment of
volunteers and mentors. This was confirmed by reviewed job descriptions. The community
relations director shall be on-site monthly and/or as needed. Reviewed sign-in sheets confirmed
the community relations director was on-site once a month. The program’s contract required a
revision of the number of youth specialist positions to provide opportunity for advancement. The
reviewed documentation confirmed revisions were made for the number of youth specialist
positions. The contract requires, within 180 days of hire, mental health therapists to complete
specialized online training offered through the University of South Carolina. Certificates
confirmed mental health staff completed the training within 180 days. The program shall obtain
a memorandum of understanding (MOU) with a specific mentoring services agency, and
documentation confirmed a MOU was obtained. Within ninety days of contract execution, the
program was required to obtain a Florida Chapter 397 substance abuse license. Documentation
confirmed the program obtained the license. The program shall facilitate two career days every
year. Documentation confirmed the first career day was held on February 24, 2024, and the
second career day is upcoming. The program shall provide families with financial hardship bus
tickets, gas cards, and/or hotel accommodations to promote visitation. Reviewed documentation
supported these services are offered and were declined by parents/guardians. The program
shall provide each youth two dry-fit shirts, two pairs of pants, two pairs of shorts, three boxers,
three pairs of socks, one pair of tennis shoes, one pair of shoes, and one sweatshirt upon
admission. Observations of an intake during the annual compliance review confirmed the youth
received each item at the time of admission. Finally, the program’s contract requires the
program to provide a dress shirt to youth, as needed, for mock interviews or other transitional
activities. Observed pictures confirmed youth were provided with dress shirts for mock
interviews. An interview with the facility administrator indicated all expected contract items are
being offered by the program to the youth.
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1.18 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 uses several systems for the purpose of tracking data and outcome measures.
The program has implemented an internal database and dashboard system which allows for
daily data entry by every program. This daily process and outcome information is aggregated
into weekly and monthly totals, displayed in interactive dashboards specific to each program,
and provided back to their corporate team as well as program management for the purposes of
tracking trends and informing risk management. The movement of data vacillates freely through
multiple management levels. Data is shared by facility administrators during their monthly one-
on-one meeting with senior leadership and then with all staff during monthly all staff meetings.
The program’s practice in sharing information with providers and stakeholders on a quarterly
basis is through quarterly advisory board meetings, residential meetings, and reports sent
monthly to contract managers. A review of analysis, data usage and additional documentation
confirmed the program’s practice. The program is implementing collected data to improve their
processes through tracking trends, compliance, and practices.
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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 which require notification to the youth’s
parents/guardians by telephone within twenty-four hours of each youth’s admission, followed by
written notification within forty-eight hours of admission. In addition, the program must notify the
youth’s committing court, the assigned juvenile probation officer (JPO), and post-residential
services case manager, if applicable, in writing within five working days of any admission. Five
youth case management records were reviewed, and all contained documentation which
confirmed the parents/guardians were contacted by telephone within twenty-four hours of
admission. All five case management records contained a copy of a written notification which
was mailed to the parents/guardians on the day of intake informing the parents/guardians of the
youth’s admission. In addition, all five case management records contained written notification
of intake to the court and JPO.
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 which state the program shall provide each
youth an orientation to the program’s rules, expectations, goals, and services, which is to begin
on the day of, or prior to, each youth’s admission. Five youth case management records were
reviewed, and all contained documentation verifying the youth received an orientation on the
day of admission. During the annual compliance review week, there was an admission.
Observations of the orientation process confirmed the completion of the orientation which
included all the elements as outlined in the program’s policy. The orientation included services
available, daily schedule, expectations and responsibilities of youth, the written behavior
management system which was provided in a youth handbook, access to medical, mental
health, and substance abuse services, access to the Florida Abuse Hotline and the
Department’s Central Communications Center, the program’s zero tolerance policy regarding
sexual misconduct, how to report sexual misconduct, and rights to be free from retaliation for
reporting such misconduct. Orientation also included items considered to be contraband,
including illegal prohibited items, performance plan process, dress code and hygiene practices,
procedures on visitation, mail, use of telephone, expectations for release from the program,
community access, grievance procedures, emergency procedures, general layout of the facility,
and assignment to a living unit and room. Five youth were interviewed, and each said
orientation started within twenty-four hours of their admission, and the orientation to the
program included program rules, procedures, and schedules. Each youth was able to explain
the orientation process.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a written policy and procedures requiring 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 parents/guardians any information related to
the youth’s physical or mental health screenings, assessments, or treatment. Five youth case
management records were reviewed, and none were applicable for the youth being over the age
of eighteen. Three additional applicable records were requested and reviewed. A review of the
three applicable case management records confirmed each contained documentation signed by
the youth allowing the release of information regarding physical or mental health screening,
assessment, and/or treatment with their parents/guardians.
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 outlining the classification process for youth
upon admission to the program and the completion of reassessments for activities. The
classification system is used for assessing each youth admitted to a living unit, sleeping room,
and group or staff advisor. Youth are also 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. The procedure also requires all admitted
youth to 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 program’s classification forms included the physical
characteristics of the youth, age, maturity level, identified special needs, history of violence,
gang affiliation, criminal behavior, sexual aggression or vulnerability to victimization, the youth’s
perception of vulnerability, any history of potential or verified human trafficking, suicide, medical,
escape, and/or security risks. Five youth case management records were reviewed, and each
contained a copy of the admission classification form, which was completed on the day of
admission, and addressed all suspected risk factors. A review of the Department’s Juvenile
Justice Information System (JJIS) confirmed alerts were entered for any issues affecting
classification. All youth were classified for purposes of assignment to a living area, sleeping
room, and youth group or staff advisor. Any youth identified with a medical, mental health,
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substance abuse, security risk factors, and/or special needs during or after the classification
process had the appropriate alert entered into the program’s internal alert system and JJIS.
Three of the five reviewed youth records contained documentation which confirmed re-
assessments were completed whenever there was an increase of the youth’s privileges,
participation in work projects, or other activities involving tools or instruments which may be
used as weapons to provide a means of escape. Two records were not applicable for re-
assessments. Youth at the program do not participate in off-campus activities. The interviewed
facility administrator (FA) reported the living unit assignment is conducted by the Department
and based off the youth’s history and room availability.
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 in place to gather information on youth with
any involvement in gangs and share this information with law enforcement. Five youth case
management records were reviewed, and no youth were applicable for gang involvement. Three
additional records were requested and each of the applicable records contained documentation
which confirmed notifications were made to the local sheriff’s office. These notifications were all
made prior to the seven-day notice of the annual compliance review. All three applicable youth’s
residential commitment placements were not in their home county. In each case, law
enforcement in the youth’s home county was notified of the youth’s gang affiliation. In all three
applicable youth records, alerts were updated in the Department’s Juvenile Justice Information
System (JJIS) and the program’s internal alert system. Information of each youth’s gang status
was shared with the education department and the youth’s juvenile probation officer. The
program’s practice is to conduct a gang screening by completing a security threat questionnaire
during admission for each youth. The program also completes a criminal and street gang
association criterion which is submitted to the local law enforcement agency.
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 for the implementation of gang prevention and
intervention activities and gang disaffiliation. The program provides 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. Five youth case management records were
reviewed, and no youth were applicable for gang affiliation/membership. Three additional youth
case management records were requested and reviewed. The three applicable youth case
management records confirmed each youth was identified as a gang member or affiliated gang
member. The three applicable records contained written documentation showing each youth
participated in gang prevention and intervention strategies. Each of the applicable youth had
performance plans which included relevant goals and gang intervention strategies for the youth
to complete prior to release from the program. Gang intervention strategies implemented at the
program included Impact of Crime (IOC) activities and productive work sheets, and Gangs: Fifty
Plus Stories of Fractured Lives - ARISE Foundation curriculum. A review of sign-in sheets
validated each youth was participating in the gang intervention groups as required. The
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program’s practice is to review gang alerts during the program morning management meetings,
and the program dashboard reflects youth identified as a suspected, affiliated, or gang member.
The interviewed facility administrator (FA) reported there is a curriculum which is followed and
once a month the program conducts gang groups with the identified youth.
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. Five initial RAYs were
reviewed, and each was completed within the required time frame. A review of the Department’s
Juvenile Justice Information System (JJIS) validated each initial RAY was maintained in JJIS for
all five youth case management records. Five youth case management records were reviewed
and three were applicable for RAY Reassessments to be completed at least every ninety days.
Two youth had not been in the program for ninety days at the time of the annual compliance
review. All initial RAYs and reassessments were completed as required and were in each
youth’s case management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a written policy and procedures requiring the Youth Needs Assessment
Summary (YNAS) to be completed within thirty days of admission. Five youth case
management records were reviewed, and all had the YNAS completed within the first thirty days
of each youth’s admission. All YNASs were 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 which require the intervention and treatment
team, including the youth, to meet and develop the performance plan, based on the findings of
the youth’s initial assessment, within thirty days of admission. The Individualized Performance
Plan (IPP) shall include the target date for completion of each goal, in addition to the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth to
complete the goal. 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 parents/guardians,
and the Department of Children and Families (DCF) case manager, if applicable, within ten
working days of completion of the IPP. Five youth case management records were reviewed,
and all records contained documentation of the IPP being developed within thirty days of each
youth’s admission. Each IPP was developed following the youth’s initial Residential Assessment
for Youth (RAY) and the Youth Needs Assessment Summary (YNAS). All members of the
treatment team were present during the development of the IPP, as indicated by their signature
on the plan. One youth was under the care of DCF, and the assigned caseworker participated in
the development of the IPP. The four remaining youth had their parents/guardians attend by
telephone, and a copy of the signature sheet was mailed to each parent/guardian; however,
only one was returned. The signature sheets for all youth were filed in each youth case
management record. In all five youth case management records reviewed, the IPPs included
the individualized goals which were based upon the prioritized needs, reflecting the risk and
protective factors identified during the initial assessment process. The youth’s three top
criminogenic needs, delinquency interventions based on RAY results with measurable
outcomes which are intended to decrease the youth’s criminogenic risk factors, promote
strengths, supports to reduce the likelihood of the youth re-offending, target court-ordered
sanctions which could be completed while in the program, transition activities targeted for the
last sixty days of the youths stay, youth and program staff responsibilities to accomplish and
complete goals, and target dates for completion were included in each IPP. Reviewed
documentation confirmed a transmittal letter and copy of the IPP were sent to the committing
court and the JPO within ten days of completing the plan. Five youth had a copy of their IPP
mailed to their parents/guardians within ten days of completing the plan. A copy of the IPP was
mailed to the DCF caseworker for one applicable youth within ten days of completing the plan.
Five youth were interviewed, and each youth reported participating in the development of their
IPP goals.
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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 to ensure the performance plans are
reviewed resulting 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. Five youth case management records were
reviewed, and three records had performance plans completed based on the RAY
Reassessment results. Two records did not warrant the need for a RAY Reassessment due to
the youth not being in the program for more than ninety days. Reviewed documentation
reflected new information which was acquired/revealed, demonstrated progress toward
completing a goal, and demonstrated lack of progress toward completing a goal was
documented. Each reviewed youth’s Individualized Performance Plan (IPP) had transition
activities to be completed during the last sixty days of the youth’s stay. Each youth’s IPP was
reviewed for the incorporation of other plans which included the education plan, mental health
treatment plan, and vocational plan. One youth had a case plan through the Department of
Children and Families (DCF), which was also incorporated.
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 which require the treatment team to 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. The treatment team shall also prepare a Performance Summary prior to the youth’s
release, discharge, or transfer from the program. These summaries shall be distributed within
ten working days of signing. Five youth case management records were reviewed, three were
applicable for Performance Summaries, and all contained documentation confirming
Performance Summaries were being completed every ninety days following the signing of the
performance plan. Each of the three applicable Performance Summaries included the youth’s
status on performance plan goals, youth’s overall treatment progress, youth’s academic status,
behavior, level of motivation/readiness for change, interaction with peers, interaction with staff,
overall behavior adjustment to the program, and any significant positive or negative events. All
three youth case management records indicated each youth could read and add comments to
the Performance Summary prior to signing, and verified the youth received a copy. The original
Performance Summary was maintained in each youth’s case management record. Each of the
three reviewed records found the Performance Summaries were signed by the treatment team
leader, staff who prepared the summary, the facility administrator or designee, and the youth. A
copy of each summary was sent to the committing court, Department of Children and Families
(DCF) case worker, and the juvenile probation officer (JPO) within ten working days. A sample
of three closed youth case management records was reviewed to ensure release summaries
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were being completed as required. A review of three records confirmed the release summaries
included the original summary, along with justification for release, which were sent with the Pre-
Release Notification (PRN) to the JPO. The release summary and PRN were sent at least forty-
five days prior to the youth’s planned release, with a signed copy retained in each youth’s case
management file. The court did not object to the youths’ release in any of the three closed youth
case management records reviewed. There were no youth applicable for the Sexually Violent
Predator Program or victim notification. Once the release was approved, the program provided
written notification to each youth’s parent/guardian and completed an exit Residential
Assessment for Youth (RAY) for each youth.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a written policy and procedures to encourage and facilitate the involvement of
each youth’s parents/guardians in the case management process. The program encourages
parent’s/guardian’s involvement in the assessment process, in the participation of the
performance plan, during progress reviews, during treatment team meetings, family day, career
day, weekend visitation, weekly telephone calls, and during transition planning. If the
parents/guardians are unable to attend any of these meetings in person, an opportunity is given
to participate by telephone and they can provide verbal or written input as well. Treatment team
meetings for three youth were observed during the annual compliance review week. In each
instance, the parents/guardians actively participated by telephone. The facility administrator was
interviewed and reported parents/guardians are encouraged to participate during admission.
Letters are sent with the program schedules, directions to the program, parent/guardian
handbook, and treatment team meeting dates. The parents/guardians receive virtual
participation invitations by email to participate in all aspects of the youth’s treatment in the
program. Five youth were interviewed and reported their parents/guardians are involved in their
case management activities.
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 outlining the required treatment team
members. The procedures require treatment teams to meet bi-weekly, alternating between
formal and informal meetings, to review each youth’s performance, to include Residential
Assessment for Youth (RAY) results, progress on Individualized Performance Plan (IPP) goals,
and positive and negative behaviors. Five youth case management records were reviewed for
formal and informal treatment team meetings. All youth had formal reviews conducted at least
every thirty days. Reviewed documentation for formal treatment team meetings included the
youth’s name, date of review, required attendees, comments from members, a brief synopsis of
the youth’s progress in the program, applicable IPP revisions, positive and negative behavior,
and any behaviors which resulted in physical interventions. Each youth was provided the
opportunity to demonstrate skills acquired in the program and comment on progress, treatment
progress, and three out of the five applicable RAY Reassessment results. All formal treatment
team documentation was contained in each youth record reviewed. Documentation was
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reviewed and confirmed informal treatment team meetings were conducted for each youth bi-
weekly each month, alternating with the formal treatment team meetings, which resulted in each
youth having an informal or formal treatment team meeting every two weeks. The informal
treatment team meetings documented the youth’s name, date of review, required attendees,
comments from treatment team members, a brief synopsis of the youth’s progress in the
program, applicable IPP revisions, progress of the goals, positive and negative behavior, any
behaviors which resulted in physical interventions, treatment progress, and three out of the five
applicable RAY Reassessment results. In all informal treatment team meetings, each record
documented the youth was provided an opportunity to demonstrate skills acquired in the
program and comment on progress. All informal treatment team documentation was contained
in each youth record reviewed. Each youth’s juvenile probation officer, parents/guardians,
applicable Department of Children and Families (DCF) case worker, and any other pertinent
parties were invited and given the opportunity to provide input. During the annual compliance
review week, a treatment team meeting was observed for three youth. In each instance, all
required staff were present, and there was a review of the treatment plan to determine each
youth’s anticipated release date. Education staff were not present; however, the case manager
reported information was submitted in writing prior to the meeting. Five youth were interviewed,
and all five youth reported staff reviewed youth performance to include progress on IPP goals,
positive and negative behavior, and treatment progress. One youth reported learning to deal
with coping skills and change behavior, one reported through they show the skills they have
learned through their actions, one reported by writing books, one reported writing goals on
paper or they are given a specific goal to demonstrate, and one youth stated they haven’t had a
treatment team meeting.
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 to ensure the intervention and treatment team
is planning for each youth’s successful transition to the community upon release from the
program. The policy outlines the process for transition planning, conferences, and Community
Re-Entry Team (CRT) meetings. Three closed youth case management records documented
each youth had a transition conference at least sixty days prior to the youth’s targeted release
date. Transition conference documentation reflected the youth, treatment team leader, facility
administrator or designee, and other applicable team members were in attendance. Notification
documentation supported the youth’s juvenile probation officer (JPO) and parent/guardian were
encouraged to participate. Education staff provided written input. Transition documents
supported the conference included a review of transition activities, necessary performance plan
revisions, additional transition activities, target completion dates, and persons responsible for
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transition activities. Transition conference documentation contained acknowledgements of
transition goals and responsibilities of members through signatures of participants. A copy of the
plan was sent with a request for return with signature from anyone who did not attend the
meeting, and the plan was transmitted electronically to the JPO, with the return email
acknowledgement printed and filed with the plan. CRT meetings were also conducted prior to
each youth’s release. Each closed youth record contained copies of the invitation for
participation in the CRT meeting, and each CRT meeting was attended by the youth and case
manager at a minimum. Emails were reviewed, confirming invitations to participate in the CRT
by all attendees.
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 requiring the assembly of an exit portfolio for
each youth to assist them once released back into the community. Three closed youth case
management records were reviewed, and all contained an exit portfolio which had been
discussed and initiated for each youth during the transition conference. The exit portfolios
contained a copy of the youth’s state-issued identification card, a copy of the transition plan, a
calendar with dates, times, and locations of upcoming community appointments, a copy of the
youth’s Social Security card, a copy of each youth’s birth certificate, educational and vocational
certificates, educational records, résumé, and sample completed employment applications. All
exit portfolios were verified during each youth’s exit conference, and the documentation
indicated the exit portfolio was completed and given to the youth upon release, with the exit
portfolio information forwarded by mail to the assigned juvenile probation officer.
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 which require an exit conference to be
conducted, in addition to a formal or informal meeting to review the status of any goals
developed during the transition conference, and to finalize release plans. Three closed youth
case management records were reviewed, and all had an exit conference which was conducted
at least fourteen days prior to the youth’s release, and after the program notified the juvenile
probation officer (JPO) of the youth’s release. A review of the documentation confirmed the date
of each conference, signatures of the attendees, and a summary of transition goals. Each
youth’s date of admission and date of termination documented in the case record matched with
the dates in the Department’s Juvenile Justice Information System (JJIS). Documentation
supported the status of transition activities established at the transition conference and plans
finalized for each youth release and provisions for continuation of education and employment.
Each youth’s closed case management record contained documentation the youth,
parent/guardian, case manager, and JPO were aware of the vocational plan. Each record
documented the youth’s case manager and parent/guardian were aware of the plan documents
and post-release discharge plan. Exit conference attendees included the team leader,
parent/guardian, education representative, JPO, youth, and other pertinent parties. The exit
conference was held separately from the transition conference and Community Re-Entry Team
(CRT) meeting for each youth.
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2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a formal process which promotes constructive input from youth. The program
uses monthly youth advisory board meetings, Let’s Talk forms, grievance procedures, quarterly
youth surveys, Trauma Responsive and Caring Environment (TRACE) assessments, and
quarterly family days. Youth advisory board meeting agendas, minutes, notes, Let's Talk forms,
grievance logs, and youth surveys were reviewed during the annual compliance review week
which confirmed the program’s practice for youth input. Five youth were interviewed regarding
the process for providing youth input and two reported talking to staff, one reported through
writing a grievance report, one reported during group meetings, and one reported asking staff to
contact the facility administrator (FA)/assistant FA to express concerns. The FA was interviewed
and advised youth input is presented by the living unit president and vice president during the
youth advisory board meetings, which are conducted monthly.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program has a written policy and procedures requiring a designated mental health clinician
authority (DMHCA) to work as a full-time staff who is on-site at least forty hours each week. The
DMHCA is responsible for the coordination and implementation of mental health and substance
abuse services in the program. As part of the assigned responsibilities, the DMHCA shall
ensure consistent and appropriate mental health and substance abuse services are provided in
addition to being on call twenty-four hours each day for emergency consultation. The program
has had two DMHCAs since the program started receiving youth on June 27, 2023. The
program’s current DMHCA was hired/transferred on June 6, 2024, and was in the position for
two months prior to the annual compliance review. The current DMHCA is a licensed mental
health counselor (LMHC) with a free and clear license in the State of Florida with an expiration
date of March 31, 2025. The current DMHCA’s license was displayed within the program, as
required. The previous DMHCA is a licensed mental health counselor (LMHC) met the
Department requirement with a free and clear license in the State of Florida with an expiration
date of March 31, 2027, and was on the program roster as a pro-re-nata (PRN) licensed mental
health staff during the week of the review. The interviewed DMHCA verified the program
provides Mental Health Overlay Services (MHOS) and Substance Abuse Treatment Overlay
Services (SAOS) with a specialized emphasis on Comprehensive Services for Co-Occurring
Disorders. Reviewed documentation showed the previous and current DMHCAs were on-site for
forty hours a week, as contractually required. The back-up DMHCA is a licensed mental health
counselor (LMHC) in the State of Florida with a free and clear license which expires on March
31, 2025. An interview with the current DMHCA verified the DMHCA was on-site weekly to
ensure appropriate coordination and implementation of mental health and substance abuse
services provided to the youth, as required by the contract. The DMHCA stated the program
provides individual, family, and group clinical services to the youth. The DMHCA also reported
crisis intervention, ongoing clinical supervision and support to the therapeutic staff, and support
to each youth are provided as needed. Additionally, the DMHCA reported meeting with the
clinical staff once a week for at least an hour or more and being available seven days a week
either in person, by cellular telephone, and by email to the program staff.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program’s
designated mental health clinician authority (DMHCA) serves as the program’s supervisor for all
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on-site clinical staff. The program is licensed under Chapter 397 by the Department of Children
and Families to provide substance abuse services to adolescents. The Chapter 397 license
expires on September 6, 2024. A review of mental health licenses found one therapist was a
licensed mental health counselor (LMHC) with an active and clear license expiring on March 31,
2025. The program’s licensed mental health staffing was in accordance with contract
requirements. The psychologist is on-site weekly or as needed. The psychologist has a license
which is active and clear in the State of Florida with an expiration date of May 31, 2026.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The designated
mental health clinician authority (DMHCA) confirmed their responsibility for ensuring non-
licensed clinical staff are working under their supervision and performing services they are
qualified to provide based on education, training, and experience. The program’s practice is to
complete group and/or individual clinical supervision for the two non-licensed clinicians and one
licensed therapist. A review of clinical supervision logs from July 20, 2023, to August 7, 2024,
verified clinical supervision was documented on the program supervision logs which included all
elements on the Department’s Licensed Mental Health Professionals and Licensed/Certified
Substance Abuse Professionals Direct Supervision Log form. Documentation verified each non-
licensed clinical staff received clinical supervision for each week they provided services. The
program is licensed under Chapter 397 through the Department of Children and Families to
provide substance abuse services to adolescents. A review of the license reflected it was
displayed in the lobby with the program’s physical address listed. The reviewed license expires
on September 6, 2024. The program’s contract requires one DMHCA, one registered behavioral
technician (RBT), one licensed therapist, and two non-licensed mental health clinicians. The
program’s RBT position was vacant at the time of the annual compliance review and has been
vacant since April 25, 2024. A review of the two non-licensed staff’s education documentation
reflected each held a master’s-level degree from an accredited university or college in the field
of counseling, social work, psychology, or a related human services field. Each of the two non-
licensed clinical staff received training in the administration of the Assessment of Suicide Risk
(ASR) or Crisis Assessments conducted on-site in the physical presence of the licensed mental
health professional. All training was documented on the Department’s Non-Licensed Mental
Health Clinical Staff Person’s Training in Assessment of Suicide Risk form.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a written policy and procedures which establish the system for gathering
important treatment and emergent information prior to each youth’s entry into the general
population. The program’s policy requires the staff to administer a mental health and substance
abuse screening, including a suicide risk screening, upon a youth’s admission to the program.
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The program utilizes the Massachusetts Youth Screening Instrument, Second Version (MAYSI-
2) for initial screening. Two of the five reviewed MAYSI-2s reflected the screenings were
completed in the Department’s Juvenile Justice Information System (JJIS) on the day of the
youth’s admission. Three youth MAYSI-2s were completed manually on the day of each youth’s
admission due to Department-wide system outages. All five records documented staff
conducting mental health and substance abuse admission screenings reviewed each youth’s
commitment packet information and records for existing documentation of mental health and
substance abuse problems or history of human trafficking. The program’s designated mental
health clinician authority (DMHCA) administered each youth’s MAYSI-2. Documentation verified
the DMHCA was trained on the use of the MAYSI-2, and the training was entered in the
Department’s Learning Management System (SkillPro). A review of five youth records verified
each MAYSI-2 included the date, name of staff completing the MAYSI-2, was completed on the
day of admission, and was completed in full. All five screenings indicated further assessment
was required, and a referral was made for further evaluation or immediate attention in all five
records reviewed. Four of the five reviewed MAYSI-2s indicated an assessment was needed
due to the suicide ideation category, and one was not applicable. All four applicable youth’s
Assessments of Suicide Risk (ASRs) were completed during intake and within twenty-four hours
by the program’s DMHCA. All five youth records verified each youth was referred for a
comprehensive evaluation and each included the reason for the referrals. The program does not
utilize a separate clinical mental health and substance abuse screening. The program’s facility
administrator (FA) is responsible for the implementation of the standardized admission/intake
mental health and substance abuse screening process. The reviewed policy confirmed the
process includes a review of commitment packet information, reports and records,
administration of the MAYSI-2 in JJIS by a qualified professional, and a referral of youth
identified by screenings as in need of further evaluation or immediate attention. The policy
outlines administration staff training and a standardized process for youth requiring immediate
attention and transfer to a Baker Act or Marchman Act receiving unit. The interviewed FA
reported upon entry into the program, clinical staff conduct a full evaluation of the youth and put
all necessary documents in the youth 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 has a written policy and procedures to address the provision of mental health and
substance abuse assessments/evaluations. A review of five youth mental health and substance
abuse records found each youth received a comprehensive mental health assessment prior to
admission into the program. The program’s practice is to complete a new or an updated
comprehensive mental health and substance abuse evaluation within thirty calendar days of
each youth’s admission. Reviewed records indicated four youth received a new evaluation and
one received an updated evaluation. Documentation supported all five youth evaluations were
completed within thirty calendar days of their admission to the program. In all five youth records,
signed consents were documented for substance abuse treatment. Two of the five youth
evaluations were completed by non-licensed clinical staff and three evaluations were completed
by the designated mental health clinician authority (DMHCA). Documentation indicated each of
the two evaluations completed by non-licensed clinical staff were reviewed and signed by the
DMHCA within ten calendar days of the evaluation being conducted. The mental health
evaluation included youth demographics, reason for the evaluation, relevant background
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information, behavioral observations, Mental Status Examinations, interview or procedures
administered, discussions of findings, diagnostic impressions/formulation including a Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, patterns of alcohol
and other drug use, impact of alcohol and other drug abuse on major life areas, risk factors of
continued alcohol and other drug abuse, and recommendations. The updated mental health
evaluation was clearly identified as such and was attached to the previous comprehensive
evaluation. The updated evaluation included new and additional information based on current
information provided by the youth, youth’s parent/guardians, and the youth’s records. The
updated evaluation was dated within the past twelve months, addressed problems identified at
screening, updated information was documented in all areas, including findings, and addressed
the original referral reasons.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a written policy and procedures outlining the program’s mental health and
substance abuse treatment services. A review of five youth records reflected an initial treatment
plan was developed within seven days of each youth’s admission. Each reviewed initial
treatment plan was documented on the program’s form and included all elements of the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Three records were
applicable for youth being admitted on prescribed psychotropic medications, and each included
the youth’s psychiatric needs, medication, and frequency of monitoring by the psychiatrist. All
five youth initial treatment plans were completed by the designated mental health clinician
authority (DMHCA). Each initial treatment plan was signed by all treatment team members who
participated in the development of the plan. Each plan was signed by the youth and
documented the juvenile probation officer (JPO) and parent/guardian participated by telephone.
Each of the five reviewed youth mental health and substance abuse records contained an
Individualized Mental Health and Substance Abuse Treatment Plan. The Individualized Mental
Health and Substance Abuse Treatment Plans were developed on a provider form containing all
the requirements from the Department’s Individualized Mental Health/Substance Abuse
Treatment Plan form. All five individualized plans were completed by the DMHCA. Each of the
five plans were signed by all treatment team members who participated in the development of
the plan. Reviewed documentation indicated each youth’s plan was mailed to the
parent/guardian for signature and none were returned with a signature. Three youth were
applicable for being on medication at the time of the individualized plan development. Each plan
clearly listed the medication details and monitoring frequency. In the five records reviewed,
documentation verified each treatment plan review was completed every thirty days. Each
treatment plan review was signed by the youth and all treatment team members who
participated in the review of the plan. Prescribed services included individual, family, and group
therapy for all five youth. Three youth were applicable for psychiatric services and medication
management. The treatment plan goals and objectives were individualized for each youth. A
review of the program’s group sign-in sheets, group video observations, and a review of logbook
entries, indicated the program conducted mental health groups for the required group
time/length.
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3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program has a written policy and procedures addressing treatment and discharge planning.
A review of five youth records reflected each youth was assigned a treatment team on the day
of arrival to the program. Reviewed treatment plan documentation and the treatment team
assignment form for each reviewed record confirmed the treatment teams were comprised of
the youth, program administration, residential living unit staff, education staff, vocational training
staff, medical staff, mental health and substance abuse staff, and parent/guardian. A review of
the five youth records reflected each was applicable for a substance abuse diagnosis and
treatment. The program is licensed through the Department of Children and Families under
Chapter 397 to provide substance abuse services to adolescents. Each record contained an
executed Authority for Evaluation and Treatment (AET) form or a court order. Each youth record
contained a signed Youth Consent for Substance Abuse Treatment and Youth Consent for
Substance Abuse Treatment Records form. All reviewed mental health or substance abuse
treatment notes were documented on the program’s form and included all the information on the
Department’s Counseling/Therapy Progress Notes form. Reviewed progress notes confirmed
treatment services included individual psychotherapy and psychosocial skills training. A review
of treatment plans in comparison with progress notes confirmed each youth received services
as stipulated on their treatment plan. A review of three closed records was conducted for
discharge summaries. All three discharge summaries were completed on the Department’s
Mental Health/Substance Abuse Treatment Discharge Summary form. None of the three closed
records were applicable for the youth being released while on suicide alert/precautions. Each of
the three reviewed summaries documented the services needed for the future. A review of
documentation reflected the discharge plan was discussed with the youth, parent/guardian, and
juvenile probation officer (JPO) during the exit conference, in all three records reviewed.
Reviewed documentation verified the program emailed a copy of the summary to each assigned
JPO and provided a copy to the youth and parent/guardian upon release.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program has a written policy and procedures ensuring mental health and substance abuse
services are provided through the provision of Mental Health Overlay Services (MHOS) and
Substance Abuse Treatment Overlay Services (SAOS) with a specialized emphasis on
Comprehensive Services for Co-Occurring Disorders. The program provides daily group
therapy, weekly or bi-weekly individual therapy, bi-weekly or monthly family therapy, and
psychiatric services. All youth with co-occurring substance abuse disorders receive substance
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abuse services by licensed therapists. Treatment services are guided by an Individualized
Mental Health and Substance Abuse Treatment Plan addressing the youth’s needs in
accordance with their individualized plan. At the time of the annual compliance review, the
program had two licensed mental health counselors (LMHCs) and two master’s-level therapists.
A review of the clinician’s credentials validated each met certification requirements to provide
treatment services at the program. One LMHC serves as the designated mental health clinician
authority (DMHCA), and one LMHC serves as a licensed therapist and the back-up DMHCA.
The program’s contractually required clinical groups are New Direction, process group, Group
Treatment for Substance Abuse, and Mental and Emotional Health Series. A review of the
program’s contract and an interview with the DMHCA confirmed the program was providing
groups as required. The DMHCA is on-site five days a week for a minimum of forty hours and
on-call for consultation twenty-four hours a day. A review of therapist caseloads verified the
caseloads are limited to less than sixteen youth for MHOS/SAOS youth. Reviewed caseload
assignments showed a minimum of five and a maximum of twelve youth for each therapist.
Caseloads did not exceed eight youth for Comprehensive Services for Co-Occurring Disorders.
A review of the psychiatric visitor logs from June 27, 2023, to August 13, 2024, confirmed the
psychiatrist was on-site every week during the annual compliance review period and was
available for emergencies and consultation twenty-four hours a day, seven days a week. The
program has an agreement with a psychologist to provide on-site services weekly or as needed.
Documentation indicated the psychologist provided on-site services weekly or as needed from
April 2 to August 13, 2024, and the position was vacant from June 27, 2023, to April 1, 2024. An
interview with the DMHCA verified clinical staff are on-site seven days a week, and group
services are provided. Four of the five interviewed youth reported they participated in family
and/or individual counseling. One youth was new to the program and reported they had not
started counseling yet and did not know when counseling would start. Five interviewed staff
stated direct care staff do not facilitate any mental health or substance abuse groups and only
therapists facilitate groups.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a written policy and procedures for the provision of psychiatric services within
the program. The program’s contracted psychiatrist is responsible for psychiatric evaluations,
consultation, medication management, and medical supportive counseling. The program
maintains an agreement with a medical doctor for psychiatric services. The reviewed license
showed it was free and clear in the State of Florida with an expiration date of January 31, 2025.
Reviewed documentation confirmed the completion of psychiatric evaluations, medication
reviews, and treatment team participation. The program does not utilize a psychiatric advanced
practice registered nurse (APRN). The psychiatrist is scheduled to be on-site weekly and
provides medication evaluations and on-going monitoring of psychiatric medications. A review of
the attendance logs from June 27, 2023, through August 13, 2024, documented the psychiatrist
has been providing on-site services weekly. Each reviewed attendance log documented the
psychiatrist signed-in and signed-out. The psychiatrist is available for emergency consultation
twenty-four hours a day, seven days a week. Five youth records were reviewed and three were
applicable for psychiatric services. Documentation in all three applicable youth records indicated
the psychiatrist was actively managing and supervising each youth’s psychotropic medication
services. The program has a back-up psychiatrist with a clear and active license expiring on
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January 31, 2025. The program did not utilize a back-up psychiatrist since the program started
receiving youth on June 27, 2023. An interview with the psychiatrist reported upon admission, a
notification of youth taking psychotropic medication is emailed/called to the psychiatrist. Each
youth is discussed weekly with the clinical and medical team before any evaluation. The
psychiatrist reported psychiatric evaluations are provided, as well as medication management
and education, Baker Act, and follow-up as necessary. Five youth mental health and substance
abuse records were reviewed, and three were applicable for youth admitted on prescribed
psychotropic medications. Documentation indicated each youth entering the program received a
diagnostic interview within fourteen days of admission. Each youth’s initial diagnostic psychiatric
interview included history of the youth, a Mental Status Examination, the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, prescribed medications,
and explanation of the need for psychotropic medication related to the youth’s diagnosis. Each
diagnostic interview included target symptoms, initial treatment goals, potential side effects, risk,
benefits of taking the medication, and the frequency of medication management. The initial
diagnostic psychiatric interview was documented on the Department’s Clinical Psychotropic
Progress Note (CPPN) which was clearly identified as the Initial Diagnostic Psychiatric Interview
for each applicable youth. Each of the three applicable youth records documented youth were
seen for medication reviews by the psychiatrist at least once every thirty days and medications
were continued. The Department’s CPPN included the youth’s identifying data, diagnosis, target
symptoms of each medication, effect of prescribed psychotropic medication on target
symptoms, side effects of the medication, and the youth’s adherence to the medication regime.
In addition, each of the three CPPNs included the youth’s height, weight, and blood pressure.
The psychiatrist signed and dated each of the three reviewed CPPNs. Two of the three youth
prescribed psychotropic medications required the monthly monitoring of Tardive Dyskinesia and
reviewed documentation supported the nursing staff documented monitoring on a monthly
basis. The program does not utilize tele-psychiatry services.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a written policy and procedures regarding the implementation of a Suicide
Prevention Plan. The plan shall provide guidelines for the identification, management, and
assessment of potentially suicidal youth. The program maintains a Suicide Prevention Plan,
which was last signed and reviewed by the facility administrator (FA) on July 11, 2024. A review
of the plan included identification and assessment, staff training, suicide precautions, levels of
supervision, referral, communication, notification, documentation, immediate staff response, and
a review process. The review process for suicide attempts and mortality review included
circumstances surrounding the event, procedures relevant to the incident, all relevant training
received by involved staff, pertinent medical and mental health services involving the victim,
possible precipitating factors, and recommendations.
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3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
The program has a Suicide Prevention Plan which outlines the methods used for suicide
precautions which include observing, monitoring, and housing youth identified as a suicide risk.
A review of five youth records indicated two were applicable for suicide prevention services. The
program provided one additional applicable record for review. Each of the three applicable youth
were identified as a suicide risk through self-reporting and/or staff observations. All three
applicable youth were placed on precautionary observation (PO) status and assessed the same
day, and each Assessment of Suicide Risk (ASR) was completed on the Department’s ASR
form. One of the three youth’s ASRs was completed by the designated mental health clinician
authority (DMHCA), and two were completed by the non-licensed clinical staff and were
reviewed by the DMHCA within twenty-four hours of completion. Two of the three applicable
youth were maintained on PO or constant supervision, and one was placed on standard
supervision upon completion of their ASR. Documentation verified one record included
notification of the youth’s potential suicide risk to the parent/guardian and assigned juvenile
probation officer (JPO) and two youth records did not document a notification was sent to the
parent/guardian and assigned JPO. Each youth’s record documentation supported mental
health staff provided supportive services. The two youth who remained on PO had a Follow-Up
ASR completed on the Department’s Follow-Up ASR form indicating they could be stepped
down prior to their removal from PO. Each Follow-Up ASR indicated suicide precautions could
be discontinued for both applicable youth. Each youth was stepped down to close supervision
prior to the transition to standard supervision. Each youth was maintained under close
supervision until it was determined no longer necessary by a licensed mental health
professional. The discontinuation of close supervision was documented in accordance with the
program’s Suicide Prevention Plan in each youth’s record. Each youth’s reviewed ASR and
Follow-Up ASR clearly documented the time, date, and results of a conference held with the
facility administrator (FA) and the licensed mental health staff prior to stepping the youth to
close supervision. A review of the Department’s Juvenile Justice Information System (JJIS)
reflected alerts were initiated and closed, as required. A review of the program’s logbooks and
assessments supported the administration staff provided instructions regarding suicide
precaution decisions. Documentation supported all three youth on suicide precautions were able
to participate in select activities with other program youth in the specified safe housing areas. A
review of PO video footage for three youth on three different days verified staff were observing
youth in the living area day room.
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3.12 Secure Observation (Critical) Limited Compliance
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program has a written policy and procedures addressing secure observation. The program
had one youth applicable for secure observation since the program started receiving youth on
June 27, 2023. The youth was placed in secure observation due to at-risk or suicide risk
behavior and was authorized by the facility administrator (FA) or designee and the designated
mental health clinician authority (DMHCA). There was no documentation indicating if the
Department’s Health Status Checklist was completed prior to placing the youth in secure
observation. Documentation indicated the secure room was not inspected immediately prior to
the youth’s placement to ensure it was safe and secure. Documentation did not indicate if a staff
of the same gender conducted a visual check of the youth to determine if there were any
observable injuries which would make placement in the secure observation room inappropriate.
The youth was maintained on one-to-one supervision while in the secure observation room and
the Department’s Suicide Precautions Observation Log was completed in its entirety. A Follow-
Up Assessment of Suicide Risk (ASR) was completed for the youth within eight hours of
placement and the youth was removed from secure observation within twenty-four hours.
Documentation supported mental health staff provided supportive counseling services during
secure observation status. The youth’s supervision level was reduced only after a conference
with the FA and a licensed mental health professional. There was documentation reflecting
authorization was received from the FA and a licensed mental health professional who both
concurred with the removal from secure observation for the youth. The discontinuation of secure
observation and step-down to close supervision was documented in the program’s logbook for
the youth. Reviewed camera footage and corresponding documentation for the date and times
of the youth placed on precautionary observation or secure observation status showed the
program staff ensured proper supervision was maintained for the youth. Due to a change of the
program’s computer server, not all thirty days of video footage were available for review of
secure observation information.
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 has a Suicide Prevention Plan which outlines levels of supervision and the
process for recording observations of youth on suicide precautions. A review of five youth
records indicated two were applicable for suicide risk. One additional youth record was provided
by the program and reviewed for suicide prevention services. Each youth record contained
documentation where a Suicide Precautions Observation Log was maintained for the duration
the youth was on precautions. Youth behaviors were documented in real time and did not
exceed thirty-minute intervals for each youth. One youth was applicable for warning sign
observations and notification to the mental health clinician was clearly documented on the log.
Each of the reviewed logs were reviewed and signed by the shift supervisors and mental health
staff. All three youth logs documented safe housing requirements.
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3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a written Suicide Prevention Plan which outlines suicide prevention training
requirements. The program’s Suicide Prevention Plan requires six hours of annual training
which includes two hours of training in the Department’s Learning Management System
(SkillPro) and four hours of instructor-led training. A review of five pre-service and five in-service
training records documented program staff completed the required six hours of suicide training.
The program has a total of three suicide kits which were located in the conference room, master
control, and the supervisor’s office. The suicide kits are co-located with the program’s first-aid
kits. The program is required to complete one mock suicide drill for each shift at least quarterly.
A review of suicide drills since the program started receiving youth on June 27, 2023, reflected
the program conducted monthly drills on each shift. Reviewed drills consistently included the
use of lifesaving measures to include the use of cardiopulmonary resuscitation (CPR), suicide
kits, first-aid kits, and an automated external defibrillator (AED). All drills were simulated, and
the program youth were not utilized in the simulated drills. The program has a practice to review
drill scenarios and procedures with staff during monthly staff meetings. A review of drill
documentation found semi-annual drills were held including the use of cardiopulmonary
resuscitation (CPR). Staff who were not present during a drill have the opportunity to review
each drill scenario and procedures in an effort to understand the process and receive the
necessary training to respond to an incident of a suicide attempt or incident of serious self-
inflicted injury in the program. The interviewed facility administrator (FA) reported monthly mock
drills are conducted for all staff which include fire, medical, different Continuity of Operations
Plan (COOP) drills, and mental health drills. Five staff were interviewed, each reported medical
emergency and suicide drills are conducted monthly on each shift and they had knowledge on
what they were responsible for when a youth expressed suicidal thoughts. All five staff knew the
location of the suicide response kits. A simulated suicide drill video observation was conducted
and showed staff responded with the first-aid kit and AED.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a written policy and procedures to outline operation procedures for crisis
intervention. The program’s Crisis Intervention Plan addresses mental health crisis intervention
services and Crisis Assessments. A review of the plan verified it included notification and alert
systems, means of referrals including youth self-referral, communication, supervision,
documentation, and review.
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3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program’s Crisis Intervention Plan addresses mental health crisis intervention services and
Crisis Assessments. A review of five youth records found none were applicable for a Crisis
Assessment. An informal interview with the regional compliance 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 has a written policy and procedures outlining the mental health and substance
abuse procedures for youth who are believed to be an imminent danger to themselves or others
because of mental illness or substance abuse impairment. The Emergency Response Plan for
mental health and substance abuse emergencies requires youth to receive the highest quality of
care, safety, and management. The program’s Emergency Response Plan was signed and
dated by the designated mental health clinician authority (DMHCA) and the facility administrator
(FA). A review of the plan validated it included immediate staff response, notifications,
communication, supervision, authorization to transport for emergency mental health and
substance abuse services, transport for emergency Baker Act, transport for emergency
Marchman Act, documentation, training, and review.
3.18 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program has a written policy and procedures ensuring youth who are believed to be an
imminent danger to themselves or others because of mental illness or substance abuse
impairment receive emergency mental health or substance abuse services. A review of five
youth records indicated two were applicable for Baker Acts. The program provided one
additional applicable record for review. Documentation supported all three applicable youth
were referred and placed on one-to-one supervision when they were determined to be in need
of emergency care. Mental health staff were involved in each instance, and each youth was
taken out of the program and transported by law enforcement to a receiving mental health
facility. Transportation was authorized by mental health staff in all three instances. All three
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youth were placed on constant supervision when they returned from their Baker Act.
Documentation supported a mental health referral was completed indicating a Mental Status
Examination (MSE) needed to be conducted for each youth. Two of the three youth
Assessments of Suicide Risk (ASRs) were completed by a licensed mental health professional
and one ASR was completed by the non-licensed clinical staff. Documentation indicated the
ASR completed by non-licensed clinical staff was reviewed and signed by a licensed staff.
Documentation supported all three youths’ supervision levels were maintained until an
appropriate assessment was conducted. The program had no youth applicable for Marchman
Acts during the annual compliance review period.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a written policy and procedures to address safety planning processes for each
youth. A review of five youth mental health records was conducted in reference to safety
planning. Each youth’s safety plan form included the youth’s warning signs, baseline behaviors
gathered from collateral contacts, crisis recognition, jointly developed coping strategies,
intervention strategies, and debriefing process. The initial planning process is initiated by each
youth’s therapist within fourteen days of each youth’s admission to the program. Thereafter, the
youth’s safety plan is reviewed and updated every thirty days to include signatures and date of
the youth and staff. All five youth had updated safety plans which documented any significant
behavioral or mental health event identified by the youth’s intervention and treatment team
Documentation supported each youth’s safety plan was reviewed and updated every thirty-days
to include dated signatures of the youth and staff. Documentation supported all five safety plans
were jointly prepared by the youth, parent/guardian or family members, behavioral specialist,
and the program’s clinical staff. All five youth safety plans incorporated recommendations of
previous and current clinical assessments, as required. The youth’s safety plans were
maintained in the youth’s mental health and substance abuse records and within a centralized
binder inside the master control room easily accessible to all staff. Five interviewed youth
reported they contributed to the development of their safety plan. An interview with five staff
indicated they were aware of the process for reviewing each youth’s safety plan. The
interviewed facility administrator (FA) reported each youth’s safety plans are updated monthly.
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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 requires a contracted health authority to
provide on-site medical services to youth being provided service 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 has a clear and active license in the
State of Florida, expiring on January 31, 2026, with specialty training in pediatrics with
experience in adolescent health. A review of the Florida Department of Health records
documentation showed the DHA had no disciplinary cases and/or public complaints on record at
the time of the annual compliance review. The DHA is required by contract to be on-site for a
minimum of two hours a week with no more than nine days passing between on-site visits.
Reviewed sign-in sheets showed the DHA was on-site as required. The program has a back-up
DHA who has a clear and active license in the State of Florida expiring on January 31, 2025. An
interview with the facility administrator and nursing staff stated the back-up DHA was not utilized
during the annual compliance review period. The program does not utilize an advanced practice
registered nurse (APRN) or physician’s assistant (PA). A review of the program’s contract and
policy and procedures showed there was no inclusion or approval from the Department’s Office
of Health Services for tele-medicine/telehealth services. An interview with the DHA stated their
role in the program is to complete Comprehensive Physical Assessments (CPAs) within seven
days of youth arrival to the program and yearly thereafter. Youth with chronic problems are seen
every two months, and sick and/or episodic care youth, who have been escalated, will be seen
weekly by the DHA or nursing staff as required. The DHA confirmed being on-site weekly and
being available by telephone twenty-four hours a day, seven days each week. The DHA is also
available by telephone if an emergency needing their assistance occurs. The DHA stated the
nursing protocols are reviewed and nurses are advised pertaining to medical issues.
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 regarding health-related procedures and
protocols utilized. The program has one health services administrator (HSA) who is a registered
nurse (RN), two additional RNs, and one licensed practical nurse (LPN). Reviewed
documentation revealed all nurses providing services during the annual compliance review
period licensure credentials were clear and active according to Florida Department of Health
Medical Quality Assurance website. Each nursing staff had a current cardiopulmonary
resuscitation (CPR) certification with expiration dates of January 2025, April 2025, September
2025, and December 2025. The program provides on-site medical coverage seven days a week
from 7:00 a.m. to 7:00 p.m. for twelve-hour shifts, to include weekends and the program’s
contract confirmed the required schedule. The nursing staff meet the contracted requirements.
The HSA is required to work eight hours a day Monday through Friday and the other nursing
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staff are required to work one hundred and twenty hours weekly. The HSA is on-call twenty-four
hours a day.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized. The program’s designated health authority (DHA) and facility administrator
(FA) sign and date all respective treatment FOPs and conduct an annual review of all health-
related policies, procedures, and protocols. Reviewed documentation showed the DHA
reviewed, signed, and dated the FOPs on July 11, 2024, the psychiatrist signed on July 11,
2024, and the FA signed on December 25, 2023. The nursing staff signed a cover page
acknowledging their review of all FOPs and treatment protocols on March 11, 2024, and March
13, 2024. There were no new policies or changes in policies made during the annual
compliance review period. The program had three registered nurses (RNs) and one licensed
practical nurse (LPN) at the time of the annual compliance review. Reviewed documentation
revealed all four nurses received a comprehensive clinical orientation. All approval of treatment
protocols or standing procedures were written and authorized by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program 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 five
Individual Healthcare Records (IHCRs) revealed the original AET form was filed in four of the
five youth’s IHCRs. Each AET was stamped “copy.” Each of the five reviewed youth AETs were
signed by the youth’s parent/guardian. One of the five reviewed youth had a court order filed in
their IHCR. Each of the five youth’s AETs were signed by a Department representative and
each was noted to be valid. The program utilizes a separate form for youth eighteen years of
age or older providing consent for release of specific information as noted on the Release of
Information Authorization for Youth Eighteen Years of Age and Older form and to whom the
information can be released and shared. None of the reviewed records were applicable for the
youth being eighteen years of age or older. There was one youth applicable for being in the care
of the Department of Children and Families (DCF) and the court authorized treatment as
needed. An interview with nursing staff revealed new admissions are given notification to the
facility administrator and case management staff prior to the youth arrival, and if needed the
juvenile probation officer (JPO) or juvenile probation officer supervisor (JPOS) would be
contacted through case management to obtain a new AET. The policy for youth eighteen years
or older is for the youth to fill out two release of information forms to give consent to release
medical information.
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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 the youth’s condition and obtain consent when new medications and
treatments are prescribed. Five Individual Healthcare Records (IHCRs) were reviewed, and four
documented consent was provided by each youth’s parent/guardian for over-the-counter (OTC)
medications beyond those covered by the Authority for Evaluation and Treatment (AET) and the
other youth’s consent was provided by the court. Three of the five youth were applicable for new
medication ordered, and there was documentation of attempted contact to the parent/guardian
in the progress notes. Three of the five youth had written notifications sent utilizing the
Department’s Parental Notification of Health-Related Care form. Three of the five youth were
taking psychotropic medications at admission. Documentation showed staff witnessed all
telephone calls and/or attempts whenever a new psychotropic medication was prescribed or
discontinued, or the drug dosage was significantly changed. One youth was applicable for being
in the care of the Department of Children and Families (DCF) and the record contained a court
order allowing the continuation of treatment. Each of the five reviewed IHCRs documented the
program received and verified the youth’s vaccination records on the date of admission. None of
the five reviewed youth were applicable for requiring new vaccinations or requesting religious
exemption. An interview with the nurse revealed verbal or written consent is obtained for any
OTC medication which is not listed on the signed AET, for new prescriptions, significant dosage
changes, or discontinuation of a medication. The nursing staff also complete a follow-up with a
telephone call and mail a written parental/guardian notification letter. Immunization records are
obtained and updated on the electronic commitment packet maintenance form, as well as on the
youth’s Florida Shots record. Administered vaccinations are documented on the Health-Related
History form.
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 readmitted to the program. A review of five youth Individual
Healthcare Records (IHCRs) indicated each youth received an initial admission screening
utilizing the Department’s Facility Entry Physical Health Screening (FEPHS) form. The FEPHS
form was completed for two youth by a licensed practical nurse (LPN) and the other three were
completed by a registered nurse (RN) on the date of the youth’s admission to the program. Two
of the five reviewed records indicated there was a change in physical custody greater than
twenty-four hours. One additional record was requested and reviewed. The three reviewed
records indicated the program completed a new FEPHS re-screening for the youth on the date
of return. The program’s practice is for the youth not to be placed into the general population
until their healthcare needs are identified and deemed not to require immediate medical
attention and/or a referral for further assessment by healthcare staff.
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4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a written policy and procedures to ensure all youth are oriented on the general
process of healthcare delivery services at the program. The program’s policy states
orientation/admission health education shall be provided by the healthcare staff, in writing, and
during an individual session with the youth to ensure youth with identified disabilities can
understand the information provided. Five youth Individual Healthcare Records (IHCRs) were
reviewed for healthcare orientation. Each youth received a general care admission orientation
on the day of admission. The program’s healthcare orientation included all required topics
including access to medical care, sick call, what constitutes an emergency and when to notify
staff, medication process to include side-effect monitoring, the right to refuse care and how it is
documented, what to do in the event of sexual assault or attempted sexual assault, the non-
disciplinary role of healthcare providers, and standard universal precautions. Each of the five
youth signed the orientation package. Reviewed documentation indicated the program’s
contract requires health education to be completed monthly. The program’s health education
included seatbelt usage, alcohol and drug related problems, sexually transmitted
diseases/infections, tobacco products, including smoking cessation, dental hygiene and dental
care, basic personal hygiene, immunization, 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 policy and procedures to ensure the designated health authority (DHA) is
notified when youth are admitted to the program. Five youth Individual Healthcare Records
(IHCRs) were reviewed, and one was applicable; therefore, two additional records were
requested for the review of chronic conditions requiring DHA notifications. Each IHCR had
evidence of a referral to the physician and a notification to the DHA documented in the youth’s
chronological progress notes and the DHA was notified within twelve hours of admission. The
nursing staff updated the Chronic Conditions Log after the notification was completed. The
interviewed health services administrator (HSA) stated nursing staff notify the DHA by
telephone, or in person if on-site, regarding youth history and chronic conditions once the initial
nursing assessments and record reviews are complete. An interview with nursing staff indicated
when youth are admitted with serious chronic conditions, the DHA is made aware immediately,
and the notification is documented in the youth’s progress report.
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 complete the
Department’s Health-Related History (HRH) form prior to the Comprehensive Physical
Assessment (CPA). A review of five youth Individual Healthcare Records (IHCRs) indicated
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each had a completed and/or updated HRH form, within seven days of admission. A review of
the program’s practice supported the HRH form was completed on the day of admission for
each youth. Each of the reviewed IHCRs indicated the HRH form was completed prior to the
CPA. Each HRH was reviewed by the designated health authority (DHA). This was evidenced
by a checkbox on the CPA, indicating the HRH was reviewed for each youth. The program’s
practice is to complete a new HRH and CPA annually. An interview with the program’s health
services administrator (HSA) confirmed the practice of completing the HRH upon admission.
The HSA confirmed the program’s practice is for the DHA to complete a CPA during admission
and on a yearly basis.
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 completed no later than seven calendar days of admission into the
program. A review of five youth Individual Healthcare Records (IHCRs) found a new CPA form
was completed by the designated health authority (DHA), on the Department’s CPA form, within
seven days of admission for each youth. Each youth’s Medical Grade was documented on their
CPA. There was no indication of any missing or incomplete elements on any of the reviewed
CPAs. All sections of the CPA were completed in full utilizing an “O” and/or applicable “X”
markings. Each of the five youth refused part of the examination; therefore, a refusal form was
completed by the youth and documented by the clinician. The Department’s Problem List was
updated, as required for each youth. Each of the five youth had at least one verified
Tuberculosis Skin Test (TST) completed and documented within a year of their admission. Each
youth’s results were documented on their CPA and on their Infectious and Communicable
Disease form, and each youth’s test results matched on both forms. An interview with the
program’s health services administrator (HSA) reported youth are assessed at the time of
admission and the CPA is completed by the DHA during admission and on a yearly basis. An
informal interview with nursing staff indicated there were no current youth with symptoms
suggestive of active tuberculosis (TB) and there were no youth prescribed anti-TB medications
during the annual compliance review period.
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). The designated health authority (DHA) makes
the decision based on the screening tool and medical evaluation to order testing for STIs. A
review of five youth Individual Healthcare Records (IHCRs) reflected each youth was identified
as sexually active and was clinically screened and evaluated for STIs utilizing the Sexually
Transmitted Infections Screening form. Testing was ordered and performed for four of the five
youth, as the fifth youth refused testing. Testing, screening, clinical evaluations, and diagnoses
were documented accordingly on the Department’s Infectious and Communicable Disease
(ICD) form, excluding HIV results, and filed within the lab section of the IHCR, for all four youth.
There were no applicable youth who were out of the Department’s custody for over thirty days
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and/or required a rescreening due to presenting symptoms. The program maintains a written
policy and procedures ensuring all youth at-risk for HIV infection are offered counseling, testing,
education, prevention counseling, and a referral for medical treatment, as indicated. All five
youth were offered counseling and testing. Four youth consented to testing; however, three later
refused. The one applicable youth received HIV testing with consent documented. The
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 the youth’s
IHCR. The youth’s confidentiality was protected, as their HIV status was 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 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-test and counseling
services are provided by the DHA on-site. Five interviewed youth stated they can ask for an HIV
test. The health services administrator (HSA) was interviewed and stated every youth is
screened for STIs, regardless of their risk. If further evaluation is needed, consent is gained
from the youth, and the evaluation is completed within twenty-four hours. Screening forms and
results are in each youth’s IHCR under the ICD and laboratory sections. The HSA stated
rescreening is conducted if the youth is out of the Department’s custody for thirty or more days.
HIV results are documented in the lab section of the IHCR. The results are in an envelope
marked “confidential”, which is reviewed by the DHA. All youth consenting for testing are
tracked on the program’s HIV testing tracking log maintained by the nursing staff. The program
utilizes the DHA to provide pre and post-test counseling. The program has a procedure which
states HIV test results are only disclosed to the youth, and those entities outlined within Florida
Administrative Code.
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 can 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. The sick call process is intended to
provide care in response to complaints of illness or injury of non-emergent nature; however,
requires some form of assessment and/or decision-making by a licensed nurse and/or licensed
physician. Sick call care is provided by licensed healthcare professionals pursuant to their
scope of practice and according to protocols approved by the designated health authority
(DHA). Each youth is oriented to the program’s sick call process upon admission. Five Individual
Healthcare Records (IHCRs) were reviewed, and one was applicable for sick calls; therefore,
two additional IHCRs were requested. None of the three reviewed youth presented with a
similar sick call complaint three or more times within a two-week period. A Sick Call Request
form was completed for each of the sick call requests reviewed. Each of the reviewed Sick Call
Request forms were completed by a licensed practical nurse (LPN) and reviewed daily with the
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DHA. Each youth’s Sick Call Request form was filed in their IHCR in reverse chronological
order. Each Sick Call Request form was 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. None of the
reviewed youth were in restricted housing. 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 call encounters 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. A review of the daily schedule, posted sick call schedule, and
nurse interview found sick call is held daily from 7:00 a.m. to 7:30 a.m., and 5:00 p.m. to 5:30
p.m. Sick call hours are posted in the medical clinic and in between each living unit. Sick calls
are conducted in the medical clinic at the program. Completed forms are submitted by youth into
a box in the dayroom. If there are no nursing staff on-site, the program’s policy indicates Sick
Call Request forms should be turned into the shift manager for review no longer than two hours
after being submitted. An interview with the program’s health services administrator (HSA)
indicated youth are seen by the nurse within twenty-four hours of submitting a Sick Call Request
form; however, if the sick call request was submitted after hours, the youth will be seen at the
next sick call time. The HSA validated the program’s practice, indicating youth with three or
more repeated sick call complaints within a two-week period are referred to the DHA. Five
interviewed staff stated nursing staff review, respond to, and conduct sick calls. Five interviewed
youth stated they see a nurse within one day when a sick call is requested. A sick call
observation was not completed, as no sick calls took place during the annual compliance review
week.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program 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. Five youth Individual Healthcare
Records (IHCRs) were reviewed and three of the five were applicable for episodic care. On-site
care was provided by licensed healthcare staff for each event. Each event was documented in
the required subjective, objective, assessment, and plan (SOAP) format. All events were
documented on the Episodic Care Log, which corresponded with the on-site events documented
in the IHCRs. The episodic or first-aid care date was documented on the Department’s Report
of On-Site Health Care by Non-Health Care Staff form. None of the three youth applicable for
episodic or first-aid care needed a follow-up. The program has a written operating procedure
which addresses episodic and emergency care practices and documentation indicated the
program’s episodic and emergency care procedures. The program has a total of six first-aid kits
located in the supervisor’s office, one in each of the program’s transport vans, conference room,
master control, and in the medical office. The first-aid kits for the vans are stored in master
control until the vans are used for transport. The program’s process for ensuring contents are
maintained and stored in accordance with guidelines to prevent expiration or deterioration and
replenished as needed, is to have the kit checks conducted by nursing staff on a weekly basis.
Additionally, kits are replenished as needed. An observation of three first-aid kits revealed each
kit was fully stocked with the designated health authority (DHA) approved contents. The
program has two automated external defibrillators (AEDs) located in the conference room and
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the supervisor’s office and the procedures are located on each of the two AEDs. Reviewed
documentation supported the on-site nursing staff check to ensure the AED batteries and pads
are operable. At the time of the annual compliance review the health services administrator
(HSA) conducted a self-test of both AEDs and there were no noted issues. The expiration date
of the AED batteries in the supervisor’s office is December 31, 2027, and December 31, 2028,
for the conference room AED. The two AEDs’ batteries were changed last on June 14, 2023.
The expiration date for each of the AED pads is April 11, 2025, and the AED pads were last
changed on June 14, 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.
Reviewed documentation indicated a list of authorized direct care staff who were appropriately
trained in the administration of the epinephrine auto-injector. A review of five staff records
revealed staff training requirements were met regarding episodic, first-aid, and emergency care.
The program has three operational shifts. A review of the program’s emergency medical drills
reflected a drill was conducted on each shift monthly for the last fifteen months. The review
confirmed each shift conducts emergency medical drills at a minimum monthly. Emergency
medical drills which include the demonstration of cardiopulmonary resuscitation (CPR), first-aid,
and 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 drill logbooks and sign-in sheets showed direct care staff participated in
at least one drill which included the use of CPR annually. An observation of the program’s video
system 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 does occur. The program maintains documentation for
emergency drills. Additionally, an effort was made to ensure, at a minimum, all staff with direct
contact on a day-to-day basis have the opportunity to participate in at least one emergency
“man-down” drill annually. The program has a written policy and procedures which step out the
use, access, and inventory of NARCAN®. The nurse secures the NARCAN® in the locked box,
behind a locked door. Each staff with access to NARCAN® has been trained on when and how
to use NARCAN® by the health services administrator (HSA). The program’s inventory process
of NARCAN® is to conduct weekly counts by medical staff. An interview with the HSA confirmed
episodic care is documented in nursing progress notes and on the Episodic Care Log. If non-
healthcare staff provided episodic or first-aid care, it is documented on the Department’s Report
of On-Site Health Care by Non-Health Care Staff form. Five interviewed staff stated they can
call 9-1-1 if a youth has a medical emergency; however, they stated they must make the call by
two-way radio to master control or the shift supervisor, as there is no telephone on the living
units. Nursing staff confirmed the process for conducting emergency medical drills, indicating all
emergency drills are conducted on each shift, every month. Five interviewed youth indicated
they can see a dentist or doctor, if needed. An episodic care event was not observed during the
annual compliance review week as one did not occur.
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 form. The designated health authority
(DHA) reviews, signs, and dates the off-site care instructions. Five youth Individual Healthcare
Records (IHCRs) were reviewed; however, only one was applicable for off-site first-aid or
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emergency care. Additional youth records were requested; however, the health services
administrator (HSA) stated at the time of the annual compliance review, the program did not
have more than one youth in need of off-site care; therefore, only one youth was reviewed.
Documentation supported the designated health authority (DHA) reviewed the completed
Summary of Off-Site Care form and discharge paperwork as evidenced by signature and date.
The form was filed within the youth’s IHCRs. Reviewed documentation supported the
parent/guardian was notified, as required. Applicable discharge documents were found to be
filed within the youth’s IHCR. The one reviewed youth required follow-up testing, referral, and/or
an appointment. The youth was still receiving treatment and appointments, as required. An
interview with the program’s HSA indicated medical staff document and track follow-up
appointments using a white board and a medical tracker which is updated as needed for all off-
site care. Additionally, medical staff notify and provide the DHA with the youth’s hospital orders
upon the youth’s return, for follow-up.
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.
The purpose of the periodic evaluation is to ensure the youth requiring ongoing treatment or
who have experienced changes in condition or treatment regimen are adequately monitored.
The frequency of the periodic evaluation is determined by the youth’s condition, clinical needs,
and clinically appropriate medical standards. A review of three youth Individual Healthcare
Records (IHCRs) indicated one youth was identified with a chronic condition as documented on
the Facility Entry Physical Health Screening (FEPHS) form; therefore, two additional records
were requested. None of the youth were identified as having a communicable disease. One
youth was taking prescribed medication on an ongoing basis and the other two youth had an
identified chronic health condition, were undergoing treatment for a physical health condition.
Each youth was classified as a Medical Grade two through four. Each of the three youth were
placed on the program’s chronic illness list. A review of progress notes found each youth
received periodic evaluations at least every ninety-days. The program maintains a tracking log
for youth with chronic conditions and evaluation dates. The tracking log indicated each youth’s
next scheduled appointment. None of the youth were applicable for taking anti-tuberculosis
medications. Each of the three identified youth had an evaluation completed prior to a
prescription renewal, change, or expiration. None of the reviewed records were applicable for an
off-site evaluation and each youth was being monitored for body mass index (BMI). 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 the Florida
Administrative Code. The program’s facility administrator (FA) was interviewed and stated they
meet with healthcare staff daily. The FA indicated medical staff review youth information prior to
admission to identify any medical issues. The designated health authority (DHA) was
interviewed and stated periodic evaluations are completed every two months. The DHA stated
they ensure the periodic evaluations are completed by utilizing a tracking system. The health
services administrator was interviewed and stated youth with chronic conditions are placed on
the medical tracker for monitoring and tracking of due dates.
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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 of how medications
are to be received, stored, inventoried, and administered in a safe and effective manner. When
a youth arrives to the program with medications or orders/prescriptions for medications, the
healthcare staff conduct a preliminary assessment and interview to determine if the medication
is verified as indicated. Nursing staff complete the Facility Entry Physical Health Screening
(FEPHS) form to determine medical needs. All prescribed medications are obtained from a
licensed vendor according to a contractual agreement. The program maintains a policy and
procedures ensuring medical staff verify any medications arriving with a newly admitted youth
and continue all currently prescribed medications. A review of five youth Individual Healthcare
Records (IHCRs) indicated three of the five youth were admitted on prescribed medications.
Documentation revealed each youth’s medication was verified prior to the youth being admitted
into the program utilizing the Department’s Prescription Medication Verification Checklist form.
Additionally, if a youth is admitted with prescribed medications the medication is verified and
documented on the program’s medication verification checklist. The remaining youth were not
taking medications upon admission. All medications for each of the three youth were observed
to have a current, valid order. Each time a medication was continued, discontinued, changed, or
a new one was ordered, the designated health authority (DHA) placed an order on a Practitioner
Order form. None of the five reviewed youth were in restricted housing during the annual
compliance review period. Three of the five 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 three reviewed MARs met all requirements outlined within the Florida
Administrative Code. The nursing staff documented side effect monitoring at a minimum of
weekly on each MAR. There were no instances where trained non-healthcare staff assisted in
the delivery of medications. There were no undocumented explanations for a lapse or errors in
medication administration for any of the reviewed youth. Three youth refused medication, and
each refusal was clearly documented on the MAR, and each youth’s IHCR included a refusal of
treatment form for each refusal. There were no youth in need of parenteral medication during
the annual compliance review period. Three of the five reviewed youth were prescribed
psychotropic medication upon admission, and the DHA and psychiatrist were notified on the day
of admission. The psychiatrist conducted an initial diagnostic psychiatric interview with the youth
within fourteen days of admission. All three youth received a medication monitoring/review
every thirty days, as required. There were no standing orders, emergency treatment orders, or
pro re nata (PRN) orders for psychotropic medications. Medication administration was observed
for one youth during the annual compliance review week. Medication delivery was the sole
responsibility of the nurse during the time of administration. The youth was escorted to the
medical clinic by direct care staff. Nursing staff asked the youth their name and allergies. The
nurse identified themselves, 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 include the right youth, right medication, right dosage, right
time, right route, and right documentation. 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. Both the nurse and youth initialed the MAR once the medication was
ingested. Five youth were interviewed, and two of the five youth stated a nurse dispenses their
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medication. The other three youth reported not taking any medications while at the program.
Five interviewed staff stated nursing staff dispense medication. The health services
administrator (HSA) was interviewed and stated medications are verified upon arrival with the
pharmacist. Medications are also verified with the parents/guardians during the youth’s
admission. The HSA indicated the program utilizes a pre-printed pharmacy MAR which includes
all required elements. The HSA stated medication administration is held daily at 7:30 a.m. and
5:30 p.m. Any non-healthcare staff who provide medications are trained by the HSA.
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.
Narcotics and other controlled medications are securely stored in a locked box located within
the medication cart. Medications such as injectables, topicals, drops, and liquids are stored
separately. A review of sharp inventories at the time of the annual compliance review found the
program is utilizing a perpetual inventory which is completed as any sharp is utilized and
disposed of or added. Weekly inventories are then completed by nursing staff. All medications
were identified and secured in a locked area designated for storage of medications in the
medical office. Prescribed medications are kept in the locked medication cart, with all over-the-
counter (OTC) medications stored in a locked cabinet in the medical clinic. Observations of
areas where items are kept confirmed each item was secured and inventoried utilizing a routine
perpetual inventory. The medication cart was observed to be clean and organized, with stock
items separate from youth specific medications. Observations found all medications securely
stored in the medical clinic and inaccessible to youth. All controlled medications would have
been stored in a separate, secure, locked medication cart; however, at the time of the annual
compliance review, the program did not have any youth on controlled medication. Narcotics and
other controlled medications are securely stored and double locked within the medication cart.
The program has a dedicated refrigerator for medication only; however, the program did not
have any refrigerated medication at the time of the annual compliance review. The program
maintains a written policy and procedures ensuring all chemical products, medicines, and
medical and dental instruments assigned to the medical department are securely stored,
regularly inventoried, and disposed of in a manner consistent with federal and state laws.
Observations validated oral medications were not stored with injectable or topical medications.
All observed perpetual and weekly inventories of sharps and stock OTC medications were
completed as required with no noted issues. The health services administrator (HSA) stated if
there was an inventory discrepancy, they would notify the facility administrator (FA), conduct a
recount, check all documentation, and conduct a search. The HSA confirmed medications are
inventoried daily with a perpetual count. Medications are locked within the medical clinic and
medication administration room, and controlled medications are secured behind two locks. The
HSA confirmed the process for the destruction of medications. The HSA stated the program
utilized a consultant pharmacist who destroys medications, audits the medication cart, and
discusses issues. A review of three OTC medications and three sharps was conducted during
the annual compliance review week. Observations confirmed counts matched the inventories.
All supervisory-level, non-healthcare staff were trained in the delivery and oversight of
medication self-administration by the HSA. Five reviewed training records confirmed this
practice.
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4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a 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 program’s policy and procedures
specifically address prevention, containment, treatment, and reporting requirements related to
infectious diseases. The plan is in accordance with Occupational Safety and Health
Administration (OSHA) federal regulations and the Center for Disease Control and Prevention
(CDC) guidelines. The plan also 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 anti-biotic 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. The interviewed facility administrator (FA) stated the Exposure Control Plan is in the
operating procedure binder in the human resource area and is reviewed with staff twice a year.
An interview with the health services administrator (HSA) confirmed the Exposure Control Plan
is in the policy binder. The HSA stated the training department conducts Exposure Control Plan
training and infection control training for staff. Infection control education is provided to each
youth twice a year.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has 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-six during awake hours and one-
to-eight during sleep hours. The ratio for off-site activities and transportation 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, youth
searches, youth using Class B tools, and outdoor/indoor recreation activities. 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; however, the front
gate was not closing. The program submitted a work order to have the gate fixed. 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. An informal interview with three staff verified each staff knew the number of
youth they were supervising. Video observations of youth were conducted during sleep hours
and the observations verified youth to staff ratios were in compliance, staff were awake and
alert, and staff observed youth while they were in their sleeping rooms.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program has a written policy and procedures addressing the implementation and training of
the program’s behavior management system (BMS) which has not changed since the program’s
start up review. The program uses the Positive Performance System (PPS) for the BMS. A
review of the program’s policies and procedures verified there is a protocol where staff are
provided feedback regarding the implementation of the BMS. There is an agreement between
the program and the school system related to the BMS. Documentation verified the facility
administrator (FA) trained the education staff on the use of BMS on July 19, 2024. A review of
five youth case management records verified youth were oriented to the system through the
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handbook during their admission. A review of eight staff position descriptions confirmed their job
functions included the implementation of the program’s BMS. A review of five staff training
records indicated each staff was trained in the implementation of the BMS. A program tour was
conducted, and observations verified the BMS was posted throughout the program. A review of
the policy, youth handbook, and BMS documentation demonstrated a system which outlines
youth behavioral expectations, rewards and consequences, and a level system which has a
gradation component. The policy does not allow for the use of room restriction. Provided
documentation detailed youth are monitored daily throughout each activity and assigned points
based on adherence to the expectation. A review of the program’s BMS confirmed it includes
promoting safety, respect and fairness, promoting and protecting youth rights, positive and
negative consequences, opportunities for positive reinforcement, promoting socially acceptable
means for youth to meet their needs, has a process for explaining to youth the reasons
sanctions are being imposed, youth have the opportunity to explain their behaviors, provides
reasonable reparations for harm caused to others, discussions of alternative behaviors,
promoting positive dialogue, and separation of youth from the population is minimized. The BMS
does not include an increased length of stay, denial of basic rights or services, promotion of
group discipline, punishment by other youth, or disciplinary confinement. Rewards are offered at
a minimum of four positive to one negative consequence and demonstrate youth can purchase
snacks from the canteen store, earn extra telephone calls, have a later bedtime, have access to
the game room, and become a member of the youth advisory board. Five staff were
interviewed, and each staff was able to articulate an understanding of the BMS system. Each
staff stated youth can receive nightly, weekly and monthly incentives such as buying snacks
from the canteen, using the game room, having extra telephone calls, and participation in family
day. Five interviewed staff stated nothing can be taken away from a youth as a consequence. In
addition, each staff stated youth are informed of consequences by verbal communication and
during treatment team meetings. Five youth were interviewed regarding the consequences the
program utilizes for negative behaviors. The youth stated the program uses a level freeze, early
bedtime, they will have to write an essay, and may lose incentives. All five youth stated the
program rewards youth for positive behaviors by providing incentives, canteen, weekly activities,
and access to the gaming room. Each youth stated staff are consistent when giving rewards and
consequences. Each youth was able to explain the BMS, describe the levels, and knew how to
move from level to level. All five youth verified youth are not allowed to punish other youth. The
interviewed FA indicated an understanding of the program’s BMS. The BMS lists clear
expectations, consistent consequences, and positive reinforcement to encourage desirable
behaviors among the youth. The program utilizes tools like behavior charts, reward systems,
and regular feedback to track progress and motivate the youth. By fostering a culture of respect
and accountability, these systems aim to reduce disruptive behaviors, enhance youth
engagement, and ultimately support academic success. Through collaboration among
educators, youth, and parents/guardians, the BMS helps cultivate a supportive community
which prioritizes personal growth and social responsibility. Staff are trained to consistently
recognize and document instances of good behavior, using tools such as behavior logs and
point books, which facilitate real-time updates. To ensure rewards outnumber consequences by
at least four to one, the program emphasizes a proactive approach, where positive
reinforcement is prioritized. Staff are encouraged to identify and celebrate youth achievements,
both big and small, fostering an environment where positive actions are frequently
acknowledged. Youth consequences are based off the consistency of those who are conducting
the referrals.
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5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, and practice confirm the 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 has a written policy and procedures to ensure ten-minute checks are conducted
when the youth are asleep or in their rooms. The program has a total of sixty cameras and all
cameras were operating at the time of the annual compliance review. The program’s video
recording has a thirty-day storage capacity. 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. Checks are documented on the program’s Ten-Minute Check Logs with the time of
each check noted in real time along with the initials of the staff conducting each check. A review
of six separate video footage samples which included two shifts and two living units of ten-
minute checks and Ten-Minute Check Logs documented by staff, reflected one discrepancy. On
August 5, 2024, during shift C, in the Hurricanes living unit, there was no check completed
between 2:51 a.m. and 3:19 a.m. A sample of ten-minute logs was reviewed to verify ten-minute
checks throughout the annual compliance review period which included one sample of thirty-
minute increments from each shift from each month. The reviewed ten-minute check logs were
documented correctly. An interview with the facility administrator (FA) and observations
confirmed all the cameras were functional during the week of the annual compliance review.
Five staff were interviewed, and all indicated room checks are completed every five minutes
when the youth are sleeping in their rooms.
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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 has 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 is to conduct at least six formal counts within each twenty-four-hour period.
Staff are to document the results of all formal counts in the shift logbook to include the time the
count was called, location and number of all youth, and time the count was cleared. In addition,
staff are to document all emergency counts in the shift logbook to include the reason why the
emergency count was called, the time the count was called, the location and number of all
youth, and the time the count was cleared. Staff are to document informal counts in the shift
logbook to include the time the count was called, the location and number of all youth, and the
time the count was cleared. Staff are to document a running count in the shift logbook, noting
admissions, discharges and releases, transfers, and youth temporarily away from the program
such as for court, appointments, hospitalizations, and escape status. 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, and at
regular intervals. Twelve 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 and during actual and/or simulated drills. In addition, the program logbooks
included documentation of new admissions, releases, daily census counts, emergency
situations, youth movements, and youth temporarily away from the program. Observations
made during the annual compliance review week verified staff conducted youth counts. Five
interviewed staff verified formal counts are conducted every half hour, and before every
movement. Each staff stated the procedures for when a youth count cannot be reconciled are
for a code to be called and master control to be contacted. An emergency headcount will be
conducted, and youth will line up in the designated area. Staff will remain in the ratio with youth
until code is cleared and all movement is documented in the master control logbook. Each staff
stated emergency counts are conducted anytime a code is called, a power outage occurs, if
there is a discrepancy in the count, and during drills.
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5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a written policy and procedures requiring a chronological record of routine
events, incidents, activities, and emergency situations in a logbook in accordance with the
Florida Administrative Code. A review of the program logbooks confirmed the program’s
logbooks were bound with pre-printed numbered pages. Observations and a review of logbooks
during the annual compliance review period found logbook entries were documented in ink with
no erasures or white-out errors. Errors or blank areas were typically struck through with a single
line, dated, and initialed by the staff correcting the error or notating there were no additional
entries for the day. Reviewed documentation of twelve randomly selected days within the
logbooks reflected each entry included the date and time of the event, the names of the staff
and youth involved, a brief description of the event, and the name and signature of the staff
making the entry. The program does not utilize a living unit logbook. The program utilizes shift
reports to summarize the events, incidents, and activities documented in the program’s logbook
and to brief all incoming staff. A review of the logbooks and shift reports demonstrated staff
documented the required events, incidents, and activities. The logbook included documentation
of incidents, counts, perimeter checks, youth transports, emergency situations, admissions,
releases, and calls to the Florida Abuse Hotline and the Department’s Central Communications
Center (CCC). A copy of the shift report was available for staff to review for at least forty-eight
hours.
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 key/tracking number. Program keys are maintained in
master control in a wall cabinet with the corresponding key number which can be locked if
necessary. Master control is secured, and youth do not have access. 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 interview with
master control staff indicated the program’s practice is when direct care staff arrive to the
program, personal keys are given to the master control operator, staff are given program keys,
and sign the key logbook. Medical staff, case managers, and therapists receive their respective
restricted keys from master control after their personal keys are turned in to master control. Both
the master control operator and the staff receiving a program key initial the key log before and
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again at the end of the shift when the keys are returned. A review of the key logs during the
annual compliance review period verified this practice. In addition, the program has a list of staff
who are assigned permanent keys. Permanent keys are authorized in writing by the facility
administrator (FA). Staff issued permanent keys will sign a Permanent Key Assignment Sheet
acknowledging receipt. The physical plant manager is responsible for disposal of broken keys
and cutting new keys. A random check of three staff verified the number of keys on the key ring
matched inventory and each staff knew their function. A review of the Department’s Central
Communications Center (CCC) reports during the annual compliance review period indicated
there were no incidents related to key control. Five staff were interviewed and were able to
explain the program’s key control process.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a written policy and procedures to identify materials considered to be
contraband, to prevent contraband from entering the program, and consequences for when
contraband is 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 each is 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
includes 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 or 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 for youth if they are 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 way any unauthorized or contraband item is to
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be disposed, 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 and common area searches are conducted daily on each shift at
irregular and unpredictable times. A review of the master control logbook, visitation forms, and
incident reports validated the program’s practice of monitoring areas of the program, grounds,
and youth rooms for contraband. A review of the program’s visitor log verified it included the
contraband attestation statement. A review of fifteen newly hired staff records verified each
signed a Contraband Attestation form. The program’s policy and procedures, with orientation
training provided to all new staff, stipulates staff, including supervisors and administrators, found
in possession of contraband will be subject to disciplinary action up to and including dismissal.
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 indicated there were no instances of contraband found
at the program which was turned over to law enforcement. In an interview, the facility
administrator (FA) verified the program follows the policy and procedures regarding contraband.
Five staff were interviewed, and each stated the youth are removed from their room and rooms
are searched thoroughly. Additionally, searches are conducted daily.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a written policy and procedures 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 all movement, during a new admission, during
readmission, after returning from visitation, when returning from off-campus activities and/or
appointments, when suspected of having contraband, or when a youth is determined to be a
security risk. The program conducts searches as a method to prevent the introduction of
contraband and unauthorized items into the program. Policy indicates searches of youth are
conducted after off-site transports, after visitation, before moving youth from an outside area
into the building, and prior to moving youth from the building to an outside area. During the
annual compliance review week, the program did not have any visitations; therefore, an
observation of a visitation search was not conducted. There were observations of searches
made during line movements, and during a new youth admission being transported during the
annual compliance review week. Observations made throughout the annual compliance review
week validated youth are provided instructions regarding the search, searches were conducted
by staff of the same gender as the youth, were conducted in a manner as to not degrade the
youth, and were based on the Right Interactions (RI) training manual. In-person observations for
staff searches were conducted during the annual compliance review week. The master control
supervisor used the wand, conducted pat down searches with permission, had staff remove
their shoes and check for contraband, and checked all bags coming into the program. In
addition, a video review of staff entering the program was conducted and verified the search
protocol was followed. Five interviewed staff stated youth are searched before and after all
movements. Staff reported youth are full body and frisk search after visitation, before and after
transports, and during intakes. Five youth were interviewed, and four reported youth searches
occur before any movement, three youth said after outdoor activities, one youth said after
visitation, and three youth said after meals.
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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 has a written policy and procedures requiring the program vehicles to be properly
maintained, to contain safety and emergency equipment, and to be operated in a safe manner.
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 seatbelts, a seatbelt
cutter, a window punch, a fire extinguisher, and an approved first-aid kit. At the time of the
annual compliance review, the program had two operable vans used to transport youth. Both
transportation vans were equipped with fire extinguishers, approved first-aid kits, a seatbelt
cutter, window punch, and the appropriate number of seatbelts. Both vehicles had a safety
screen between the driver and passengers. Both vans passed inspections during the annual
compliance review period. The program maintains a log which had documentation of completed
weekly vehicle inspections. The results of the vehicle inspections are documented and stored in
the program’s vehicle maintenance log/binder. A review of the weekly inspections showed all
were completed, as required. A random check of seven personal vehicles and the program’s
transportation vehicles was conducted during the annual compliance review. The staff vehicles
and two of the transportation vehicles were found to be locked; however, there were two staff
vehicles with the windows down. This was reported to the facility administrator (FA) and was
corrected. An observation of a youth transportation was conducted during the annual
compliance review week, and no issues were noted.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a written policy and procedures to ensure the safety and security of youth and
the community during transportation of youth, and to ensure the appropriate staff-to-youth ratio
is maintained while youth are transported off program grounds. The program has an approved
transport list which is updated monthly to ensure staff driver’s licenses are valid. Reviewed
documentation verified all approved drivers had a valid driver’s license. An observation was
conducted of the vehicles, and they were found to be in working order. Observations of a
transport during the week of the annual compliance review confirmed the staff-to-youth ratio
was within the contract requirements, both staff and youth wore seatbelts, and one staff was the
same gender as the youth. The youth had handcuffs and shackles during transportation. The
staff had a two-way radio and cellular telephone during the transport. The program provides
secure transportation for secure high-risk youth. Both vehicles used to transport youth had a
safety screen. An interview with the facility administrator (FA) and the program’s policy verified
youth are not allowed to drive program or staff vehicles. The FA verified each vehicle used to
transport youth has a safety screen. Five staff were interviewed, and each staff indicated youth
are secured within the vehicle with shackles, handcuffs, and seatbelts. Each staff stated a
cellular telephone is provided to staff during transport. Five staff were interviewed, and each
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indicated the safety equipment in the transport vehicles includes a fire extinguisher, first-aid kit,
and seatbelts. All staff reported transport vehicles are searched for contraband prior to and after
each use, and they are not allowed to use personal vehicles to transport youth. Five staff were
interviewed regarding the staff-to-youth ratios maintained during transport. Each was able to
articulate the correct ratio. Each staff indicated the emergency response process consists of
notifying the program, administration, calling master control, making sure all youth are safe, and
calling emergency services 9-1-1. All staff verified there is a safety screen in the transportation
vehicles. Five interviewed youth verified they have never been handcuffed to any part of the
vehicle. Each of the five youth stated they have never seen anyone place contraband in the
transportation vehicles.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a written policy and procedures requiring the maintenance of a safe and
secure physical plant, grounds, and perimeter. The program has designated the facility
administrator (FA) and/or designee as the person responsible for conducting the weekly safety
and security audits. The weekly safety and security audits include the inspection of the
program’s cameras, radios/communication devices, keys, locks and doors, vehicles, and living
areas, to include youth rooms and bathrooms. A review of the programs Facility Security Audit
and Safety Inspection forms during the annual compliance review period confirmed the assistant
facility administrator (AFA) conducts weekly safety/security inspections. All deficiencies are
tracked, and efforts are made to correct any deficiencies noted. During the annual compliance
review period, there were no inspections missing or any discrepancies. The forms documented
safety and maintenance repairs needed and the date and time the repairs were completed, or
due to be completed. All inspection forms were reviewed and signed by the FA. The program
had ongoing efforts for any repairs which included the non-functioning front gate. An interview
with the FA confirmed safety and security audits are conducted on a weekly basis.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a written policy and procedures to address the proper identification, control,
and management of tools to ensure youth do not use tools or equipment as weapons or security
breaches. The reviewed policy addresses the issuance, inventory, and control of equipment and
tools. The policy prohibits specific tools including machetes, bowie knives, and long blade
knives. The program has identified the physical plant manager as the program’s tool control
manager. The policy classifies tools into two categories, Class A tools and Class B tools. Class
A tools are hazardous with sharp edges or points with a high potential to be used as a weapon
to inflict serious bodily harm such as knives, hammers, screw drivers, and electric drills. Class B
tools do not have sharp edges or points such as brooms, mops, and scrub brushes. A review of
inventory logs and the tool storage room verified tools are securely stored when not in use,
easily marked for identification, inventoried prior to, and following work activities. Class A tools
are secured in the maintenance office and are inventoried daily when in use. Observations
found the maintenance office to be organized, neat, and clean. All tools were observed to be
maintained in a secure location. All Class A tools were stored on the maintenance office walls
with an outline of the tool and a number to identify the tool was stored in the proper place. All
Class A tools are inventoried daily by the physical plant manager except on days when the
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maintenance office is not accessed. Class B tools are inventoried daily by program staff and
stored in a secured closet in the administration building and in a secured closet in the multi-
purpose building. The facility administrator (FA) reviews the inventories monthly. A review of the
inventory sheets validated this practice. The program has a sign-in and sign-out log for Class A
and Class B tools. All tools were properly identified and inventoried during the annual
compliance review period. The program has a policy and procedures for missing/lost tools and
for tools requiring disposal. During an informal interview, the FA stated if a tool is missing staff
will immediately notify the FA and the assistant facility administrator (AFA). Staff will also notify
the physical plant manager of the missing tool. The program will ensure all youth movement is
stopped and complete an emergency head count. Staff are to document the incident on an
Internal Incident Report form and in the logbook. Documentation must be thorough and provided
no later than the end of the shift. A staff of the same gender as the youth complete frisk
searches immediately of all youth in the presence of another staff and document the findings on
the Youth Search Documentation form. Staff will complete an area search of the work project
site immediately and document findings in the logbook. If a tool becomes dysfunctional, the
program’s policy states a request is submitted to the physical plant manager in writing. If a tool
cannot be repaired, it is permanently removed from the inventory. If a tool is out for repair, a tag
indicating the tool is out for repair shall be hung on the wall, if applicable, until it is returned. A
review of ten tools and corresponding inventories validated inventories were accurate. The
program does not have a kitchen; therefore, a kitchen tool inventory review could not be
conducted. A review of five pre-service training records indicated all staff were trained in the
safe use of tools.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries to themselves, other youth, and staff. The program’s
policy and procedures included supervision requirements, issuing tools to youth and staff, and
activities involving tools. Class B tools which include mops, brooms, toilet brushes, and scrub
brushes are inventoried daily by staff to ensure each is accounted for. A review of the Class B
Tool Inventory Log sheets confirmed the program’s practice. During activities which require a
youth to use a tool the ratio of supervision is one staff to five youth. In addition, the ratio is one
staff to five youth during vocational training. A risk assessment of each youth’s risk to self and
others is required to determine their eligibility to use Class B tools. Use of Class B tools and
participation in work projects is based upon each youth’s level within the program’s behavior
management system (BMS). Five youth case management records were reviewed, and all
indicated youth have been trained in the proper usage of tools. In addition, a review of five youth
records verified each youth had a risk assessment completed prior to the use of tools. During
the annual compliance review week, video footage was observed which involved youth and the
use of tools. Two youth were observed sweeping and mopping the common area, and their
rooms in the living unit, with staff supervising the youth. Based on the observations, the staff to
youth ratios when youth were using tools was in compliance. Five youth were interviewed and
three stated they are allowed to use mops, and brooms. Two youth stated they did not use
tools. Five staff were interviewed, and each confirmed youth are allowed to use mops, scrub
brushes, and brooms.
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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 Written Notification and Guidelines for Outside Contractors form which lists contraband
and unauthorized items. In addition, the contractor or vendor fills out the Vendor/Outside
Contractor Tool Inventory List listing all the tools needed to complete the work. 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 program’s
Vendor/Outside Contractor Tool Inventory List 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
Vendor/Outside Contractor Tool Inventory List 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 and an inventory of
tools was completed and documented. Documentation for the outside contractor forms verified
the forms were completed and all requirements were met. A review of the work project logs
during the annual compliance review period verified the contractors signed the Written
Notification and Guidelines for Outside Contractors form confirming notification of what items
are considered unauthorized. A review of the program’s policy verified personal cellular phones
and/or equipment/electronic devices capable of taking pictures and/or audio/video recordings
including smart watches are prohibited in the secure area. 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 has a written policy and procedures to ensure fire safety and evacuation drills are
conducted, and youth and staff are prepared for immediate implementation or mobilization in the
event of an emergency or disaster. A review of the program’s Continuity of Operations Plan
(COOP) revealed the program conducts monthly fire drills and COOP drills on each shift. A tour
of the program, during the annual compliance review, found fire evacuation routes and egress
plans were posted throughout the program. The program has fifteen fire extinguishers and
reviewed documentation reflected all were inspected annually. A review of drill documentation
for the annual compliance review period indicated the program conducted one monthly fire drill
and one COOP drill on each shift. The program conducted COOP drills which included riots,
disturbances, active shooter, chemical spills, medical situations, and severe weather. Reviewed
documentation for all drills contained the type of drill, date and time, participants, brief scenario,
findings, and recommendations. Five youth were interviewed and four reported they have been
instructed on what to do in case of a fire and four youth reported drills are conducted once per
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month. One youth stated they have not participated in a fire drill because they were new to the
program. Five interviewed staff said they have participated in COOP drills, fire drills, mental
health, and medical drills. An interview with the facility administrator (FA) confirmed the program
conducted all drills on a monthly basis.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program has a written policy and procedures requiring the development of a Continuity of
Operations Plan (COOP) which is updated as necessary and maintained for the continuity of
mission essential functions of the provider in the event an emergency prevents occupancy of
the primary program location, in compliance with state law and the Department’s policy. The
COOP addresses phases of a disaster plan as well as emergency management including
preparedness, response, and recovery. The COOP addressed emergencies including fire
prevention and evacuation, severe weather, major disturbances, bomb threats, hostage
situations, chemical spills, flooding, terrorist threats or acts, staff roles and responsibilities, any
equipment and supplies needed, information about youth which may be needed, alternative
housing arrangements, provisions for continuity of care and custody of youth, and provisions for
public protection. The COOP details alternative housing plans in case the program is required to
vacate due to an emergency or disaster. The COOP plan was reviewed by the program on April
11, 2024, and was approved by the Department on May 22, 2024. The interviewed facility
administrator (FA) and observations verified the COOP plan was located in master control and
all staff have access to view the plan. The program has the necessary supplies readily available
in case of an emergency evacuation maintained within the maintenance storage room,
conference room, and FA’s office. The program maintains an administrative hard copy record
for each youth in case of an emergency in master control. The program’s hard copy records are
easily accessible and mobile in the event of an emergency resulting in the program relocating
quickly or in the event needed information cannot be accessed electronically for all youth in the
program. A review of five youth case management records confirmed each contained the
youth’s name, a photograph, Department identification number, admission date, date of birth,
gender and race, overall health status, address, and parent/guardian contact information which
included name, address, telephone number of the person with whom the youth resides and their
relationship to the youth, and person(s) to notify in case of an emergency. In addition, the
records contained the youth’s assigned juvenile probation officer (JPO), committing judge, state
attorney, public defender, victim notification contact information, and personal physician.
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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 addressing storage and inventory, to ensure
all youth and staff are safe from the effects of the unauthorized use of flammable, poisonous,
toxic, and caustic materials. The program’s physical plant manager maintains a monitoring
system to ensure compliance with flammable, poisonous, and toxic items. The chemical
inventory is completed daily and documented on the Chemical Inventory Sheet form. A tour of
the program and observations found the program stored the flammable materials in a flame-
resistant locked cabinet located in the maintenance room. Toxic cleaning items and materials
are located in the secure maintenance room, secured closet in the administration building, and
secured closets in the multi-purpose room which was inaccessible to youth. Copies of each
current Safety Data Sheet (SDS) was maintained with the chemicals. The program has an
approved list of staff authorized to handle flammable, poisonous, and toxic items which include
the facility administrator (FA), the assistant facility administrator (AFA), staff mentors, physical
plant manager, and youth care workers. The program’s policy and procedures on the disposal of
flammable, toxic, caustic, and poisonous items states at no time toxic or caustic substances are
to be disposed of by pouring on the ground, flushing into sewers, or any other unsafe method.
Proper disposal is completed according to biohazard guidelines is required. The program does
not ever mix hazardous chemicals, except as directed by the Material Data Safety Sheet. The
program ensures all hazardous materials needing to be disposed of are prepared for proper
disposal according to the Occupational Safety and Health Administration (OSHA) specification.
The program is to ensure caustic acids or explosives are not utilized or stored at the program.
Chemicals are to be taken to a waste disposal site for disposal. In a formal interview the FA
stated all chemicals are disposed of according to the SDS sheets. There have been no
chemicals which required disposal during the annual review period. All liquid waste from work
details is disposed of in the plumbing drains. The program does not have a kitchen; therefore,
there was no kitchen grease to dispose of. The program’s policy states upon becoming aware of
a chemical spill, staff will notify master control of the location. The shift supervisor/master
control operator directs the shut-down of all air handlers and ventilation systems and assistance
from outside the program will be contacted, as necessary, consistent with emergency
procedures. A review of ten unique chemical items verified all ten matched the inventory sheets
and SDS sheets were present with each item.
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5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a written policy and procedures prohibiting youth from handling any
flammable, poisonous, and/or toxic items or materials. Program youth are strictly prohibited from
using, handling, or cleaning with dangerous or hazardous chemicals, respond to chemical spills
or clean, handle, or dispose of any other person’s biohazardous material, bodily fluids, or
human waste. Observations confirmed all chemicals were maintained behind locked doors and
youth do not have access to areas where items are being stored. Youth do not have access to
these items and are supervised by staff during daily cleaning. During the annual compliance
review week, video footage was observed which involved youth and the use of tools and
chemicals. Two youth were observed mopping using a mop and mop bucket in the common
area. During the work detail, youth did not handle any chemicals. Five youth were interviewed,
and each stated they do not use chemicals/cleaning products.
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5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
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 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 also maintains a list
of approved visitors; however, attorneys, representatives of the court, juvenile probation officers
(JPOs), 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 consideration 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. The visitation procedures are posted outside of the
program. Visitation is held two days a week on Saturdays and Sundays from 1:00 p.m. to 3:00
p.m. Youth are given opportunities to communicate with their family in person, by telephone,
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and by mail. Each youth is provided an opportunity on a regular basis to correspond with
identified individuals specified on their Approved Correspondence List form and legal
representatives. The program provides postage for two letters each week for each youth within
the program and does not limit the number of letters a youth is able to mail each week. All
outgoing and incoming mail is searched. Youth are permitted weekly telephone calls. Youth’s
use of telephone is documented in each youth’s case management chronological
documentation. 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
such as parents, stepparents, legal guardians, siblings, grandparents, and spouses. The JPO
must approve the immediate family members. A review of the telephone chronological notes
verified youth have consistent telephone communication with 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 youth applicable with a history of human
trafficking during the annual compliance review period. The interviewed facility administrator
(FA) stated for youth whom English is not their primary language the program uses language
assistance programs, or bilingual staff can help youth communicate effectively and understand
important information. Five youth were interviewed, and each confirmed they can call and/or
send letters to their parent(s)/guardian(s).
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. Recreation therapy was separate
from large muscle activities. 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, football, and
exercise. The indoor activities consist of board games, card games, watching television, or
playing video games. Five youth were interviewed, and each youth indicated they are allowed to
participate in basketball, football, or soccer, while outside.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 71 of 75 (Revised September 2022)
5.23 Search and Inspection of Controlled Observation Room Failed Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program has a written policy and procedures to ensure youth are searched and the
observation control rooms are inspected prior to placing a youth in controlled observation and
must be documented on the Controlled Observation form. The program has a designated area
to house youth who have been placed on controlled observation. Observation of the rooms
indicated the program meets the measurement and construction required by Florida
Administrative Code. The program has had twenty-three controlled observation placements
during the annual compliance review period. Five Controlled Observation Reports were
reviewed, and documentation did not indicate staff conducted an inspection of the room and
searched the youth prior to placing youth in the room. The program noted the findings, and
ensured they would immediately correct their prevailing practice by documenting the frisk
search of youth and the search of the controlled observation room on the Controlled
Observation Report in the section entitled “Narrative Report” and the master control logbook.
5.24 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program has 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 of 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 twenty-three controlled observation placements during
the annual compliance review period. None of the reviewed youth exhibited behaviors indicative
of a mental health crisis or suicide. A review of five Controlled Observation Reports verified
supervisors or administration authorized the placement of youth in controlled observation. Youth
placed in controlled observation were identified as an imminent risk to the youth harming
themselves or others, the youth were causing major damage to the program which may have
caused a security risk, or the youth were physically out-of-control, less restrictive methods were
ineffective, and staff needed to quickly gain control for program safety. All five Controlled
Observation Reports indicated staff advised youth the reason for controlled observation and the
expected behavior to be released. A review of five Controlled Observation Reports indicated
staff did not check off a Health Status Checklist was completed. All five Controlled Observation
Reports indicated none of the youth complained or had injuries, requiring healthcare staff to
conduct an assessment. A review of five Controlled Observation Reports indicated one youth
remained in controlled observation for over two hours and the facility administrator (FA)
approved the continued placement over two hours.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 72 of 75 (Revised September 2022)
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 has 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
appropriate to be released from controlled observation, the facility administrator (FA) or
designated supervisor gives approval for the youth’s release. The release is documented in the
Controlled Observation Report. The program has had twenty-three controlled observation
placements during the annual compliance review period. Five 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 five Controlled
Observation forms indicated the 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 five Controlled Observation Reports verified the FA or designee approved
the report within fourteen days of the youth’s release from controlled observation. Staff made a
determination if an alert was warranted after the youth was released from controlled
observation. Documentation showed the Controlled Observation Report and Controlled
Observation Safety Check forms were maintained in an administrative file and in the youth’s
individual management record. Staff designations for controlled observation are the chief of
operations, vice president of operations, FA, assistant facility administrator, and staff mentor,
which are included in the program’s policies and procedures.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 73 of 75 (Revised September 2022)
Standard 6: Safety and Security
6.01 Contract Specific Career and Technical Education Services
TBD
(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.
This indicator was moved to standard six. This indicator will be evaluated and rated later in the
review cycle due to the recent initiation of Florida Scholars Academy.
6.02 Educational Access (Residential Contract Provider) TBD
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.
This indicator was moved to standard six. This indicator will be evaluated and rated later in the
review cycle due to the recent initiation of Florida Scholars Academy.
6.03 Educational Access (Education Contract Provider) TBD
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.
This indicator was moved to standard six. This indicator will be evaluated and rated later in the
review cycle due to the recent initiation of Florida Scholars Academy.
6.04 Career Education (Education Contract Provider) TBD
Staff shall develop and implement a career education competency development program.
This indicator was moved to standard six. This indicator will be evaluated and rated later in the
review cycle due to the recent initiation of Florida Scholars Academy.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 74 of 75 (Revised September 2022)
6.05 Education Transition Plan (Education Contract Provider) TBD
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
This indicator was moved to standard six. This indicator will be evaluated and rated later in the
review cycle due to the recent initiation of Florida Scholars Academy.
6.06 Qualified Instructional Personnel (Education Contract
TBD
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.
This indicator was moved to standard six. This indicator will be evaluated and rated later in the
review cycle due to the recent initiation of Florida Scholars Academy.
6.07 Florida Youth College (Education Contract Provider) TBD
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.
This indicator was moved to standard six. This indicator will be evaluated and rated later in the
review cycle due to the recent initiation of Florida Scholars Academy.
6.08 Florida Youth College (Post-Secondary Contract Provider) TBD
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 pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
This indicator was moved to standard six. This indicator will be evaluated and rated later in the
review cycle due to the recent initiation of Florida Scholars Academy.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 75 of 75 (Revised September 2022)

report_type: QI Residential

program_name_raw: South Florida Youth Academy

rule: Indicator 3.12

excerpt: Secure Observation (Critical)

rating: Limited Compliance

rule: Indicator 5.23

rating: Failed Compliance