state: FL

facility_name: Deep Creek Youth Academy

summary: QI Residential - FY24-25 - 1 finding

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Deep Creek Youth Academy- Borderline Developmentally Disabled
(BDD)/Developmentally Disabled (DD), Intensive Mental Health,
Comprehensive Mental Health, Intensive Medical
Youth Opportunity Investments
765 E Saint Johns Avenue
Hastings, Florida 32145
Review Date(s): February 11-14, 2025
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:
Kristine Harshaw, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Lori Bright, Office of Accountability and Program Support, Regional Monitor (Standard 1,
Interviews)
Jeff Campbell, Office of Education, Northeast Education Coordinator (Standard 6)
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Carlametress Harrell, Florida Youth College, Workforce Education Coordinator (Standard 6)
Jennifer Harris, Regional Compliance Director, Rite of Passage (Standard 5)
Michele Maynard, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Rebecca Smith, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Brad Taylor, Office of Accountability and Program Support, Regional Monitor (Standard 1,
Interviews)
Devon Whitten, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Deep Creek Youth Academy MQI Program Code: 1486
Provider Name: Youth Opportunity Investments, LLC Contract Number: 10677
Location: St. Johns County / Circuit 7 Number of Beds: 77
Review Date(s): February 11-14, 2025 Lead Reviewer Code: 187
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, (5) Safety and Security, and (6) Educational
Services, which are included in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
5.01 Youth Supervision *
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Office of Accountability and Program Support Page 3 of 67 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Non-Applicable
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
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Office of Accountability and Program Support Page 4 of 67 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
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Office of Accountability and Program Support Page 5 of 67 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Satisfactory
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
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Office of Accountability and Program Support Page 6 of 67 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
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Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Limited
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
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Standard 6: Educational Services
Residential Rating Profile
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Satisfactory
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Satisfactory
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Satisfactory
6.08 Florida Youth College (Post-Secondary Contract) Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
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Office of Accountability and Program Support Page 9 of 67 (Revised September 2022)
Program Overview
The Deep Creek Youth Academy is a seventy-seven bed program, for twelve to nineteen year
old males, located in Hastings, Florida. The program is operated by Youth Opportunity
Investments, LLC, through a contract with the Department. The program provides the following
services: Borderline Developmentally Disabled (BDD), Developmentally Disabled (DD),
Intensive Mental Health (IMH), Comprehensive Mental Health (CMH), and Intensive Medical
beds and is co-located with the Deep Creek Youth Academy Mental Health Overlay Services
(MHOS) and Substance Abuse Treatment Overlay Services (SAOS) program. In addition, the
program fosters each youth by providing Skillstreaming the Adolescent, Moral Reconation
Therapy, Living in Balance, and Impact of Crime. Additional treatment services provided include
individual and family therapy, animal assisted therapy, and recreational therapy. Program
administration is comprised of a facility administrator and five assistant facility administrators.
Case management services are provided by a director of case management, three transition
services managers, and six case managers. Mental health staff at the program includes a
designated mental health clinician authority (DMHCA) who is a licensed psychologist, two
assistant clinical directors, psychiatrist one licensed therapist, nine non-licensed therapists, and
two recreational therapists. Medical services are offered twenty-four hours a day and are
provided by a designated health authority (DHA), , health services administrator (HSA), seven
registered nurses, and one medical records clerk. Educational services are provided by the
Florida Scholars Academy. The layout of the program includes: one main building which houses
administration, master control, education, medical, kitchen and dining areas, multi-purpose
space, and two buildings housing a total of four youth modules. The program has 177 security
cameras providing coverage. All cameras were operational at the time of the review. At the time
of the annual compliance review, the program had four vacant therapist positions.
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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.
A review of the staff roster found forty-one staff were hired during the annual compliance review
period. Each staff received a clear and eligible background screening in the Clearinghouse
system and their criminal history reports were reviewed prior to contact with youth or
confidential youth records. One staff required an exemption, which was received prior to the
staff’s hiring. One staff was applicable for a break in service, and a new background screen was
completed. None were applicable for being hired from another provider. Each applicable staff
was administered a pre-employment assessment tool, and a passing score was obtained and
documented in their personnel records. Forty of the forty-one staff were added to the program’s
roster in Clearinghouse and the remaining staff was added during the annual compliance review
week. The program did not have any volunteers, mentors, contract staff, or interns who required
a background screening. The Annual Affidavit of Compliance with Level 2 Screening Standards
was submitted for the program on January 7, 2025, and for the teachers who are provided by
Florida Scholars Academy through a contract with Florida Virtual School on January 28, 2025.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures to ensure all staff are administered background
rescreenings every five years of employment. A review of the staff roster found no staff were
eligible for a five-year background rescreening; however, two staff required new fingerprints,
which were completed within the required timeframe.
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.
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▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to ensure an abuse-free environment which outline
the staff code of conduct, which staff are required to sign upon hire, in addition to the program’s
abuse reporting procedures. The abuse reporting procedures indicate youth shall have
unhindered access to the Florida Abuse Hotline and staff are to notify a supervisor, who
will notify the assistant facility administrator, and immediately allow the youth to make the call.
Ten personnel records were reviewed and confirmed the staff signed their code of conduct upon
hire. A program tour during the week of the annual compliance review confirmed the program
has postings for the Florida Abuse Hotline and the Department’s Central Communications
Center (CCC) throughout the program in areas
accessible to youth. The program last completed a Trauma Responsive and Caring
Environment (TRACE) self-assessment in June 2024. The program had nine incidents of
alleged abuse during the annual compliance review period, all of which were reviewed and two
of which were substantiated. Each of the nine reviewed incidents were reported to the CCC and
one originated from the Florida Abuse Hotline. None of the reviewed incidents involved
allegations of human trafficking
or exploitation. An interview with the facility administrator confirmed the program follows the
abuse reporting procedures and ensure youth have unhindered access to the Florida Abuse
Hotline. Ten youth were interviewed and confirmed they have never been stopped from
reporting abuse and know where the Florida Abuse Hotline number is posted. Each of the ten
interviewed youth reported feeling safe in the program. Eight of ten youth reported staff never
use profanity, and two youth reported they use profanity occasionally but not directed at youth.
None of the interviewed youth had ever exchanged contact or social media information with
staff.
Ten staff were interviewed, and each reported in the event a youth wants to report an
allegation of abuse, the staff notify the supervisor, and the supervisor takes the youth to call the
Florida Abuse Hotline or the CCC. Nine of the ten staff also stated staff can let youth make the
call, and four staff said they would report it to the facility administrator. Five staff additionally
noted youth are always allowed to call if they request it. None of the ten staff reported hearing
other staff deny youth an abuse call or use profanity while speaking with 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 had nine allegations of abuse against staff reported the Florida Abuse Hotline
and/or the Department’s Central Communications Center (CCC) during the annual compliance
review period, five of which were reviewed. Incident reports were provided which confirmed the
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program took immediate action and placed staff on no youth contact pending the investigation
into each incident. In several reports, the staff was unknown, and the report was a result of an
outside entity or person making contact with the CCC. Each of these incidents were investigated
or are currently under investigation. Corrective action was taken based upon the results of the
investigations, with one incident determined substantiated, resulting in the termination of the
staff. During an interview with the facility administrator, it was confirmed the program takes
immediate action and places staff accused of abuse on no youth contact pending an
investigation.
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 had sixty-six incidents reported to the Department’s Central Communications
Center (CCC) during the annual compliance review period, seven of which were reviewed. Each
reviewed incident was called into the CCC within two hours of the incident occurring or
discovery of the incident and was found in the program’s master control logbook. There were no
additional incidents found which should have been reported to the CCC and were not. The
program had a small increase in reports from the previous annual compliance review period,
which the facility administrator noted was due to the increase in outside reports to the CCC.
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 had eleven Right Interactions (RI) incidents during the annual compliance review
period, five of which were reviewed. Each reviewed RI incident report was completed with
statements from all staff involved, before the end of the staff’s workday. Each of the five reports
included documentation the reports were reviewed by the supervisor, RI instructor, and the
facility administrator (FA) within the required timeframe. Two of the five reviewed reports
indicated a need for a RI medical review, of which one record resulted in an injury to the youth.
One reviewed record showed documentation the Department’s Central Communications Center
(CCC) was contacted. None of the reviewed records involved the need for contact to the Florida
Abuse Hotline. None of the incidents involved the use of mechanical restraints. Each RI Report
was filed in a centralized record and submitted to the Department in accordance with Florida
Administrative Code. The program’s RI Plan was last updated on December 10, 2024. The
program’s RI plan was approved by the Department on December 13, 2024. The program has
not experienced an increase in RI incidents of five or more since the last annual compliance
review period. The FA was interviewed and reported the RI escalation matrix should be used
and physical intervention should be used when all alternatives have been exhausted. Each of
the ten interviewed staff reported they utilize RI. Seven of the ten interviewed staff stated they
will use verbal de-escalation and re-direction prior to utilizing physical RI techniques. The
program’s RI rate during the previous quarter was 0.00, which is below the statewide
Residential RI rate of 1.17.
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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.
Ten staff records were reviewed for pre-service training requirements. Each of the ten staff
completed in excess of 120 hours of training in the first 180 days of hire. Each staff completed
all essential skills training prior to contact with youth and all additional required training to be
certified within 180 days of hire. All training was documented in the Department’s Learning
Management System (SkillPro). None of the staff were applicable for re-certification training of
staff who were separated from employment. All staff who could be responsible for the
supervision of youth received the required training. All instructors were qualified to deliver
trainings provided.
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.
Ten staff records were reviewed for in-service training requirements. Each staff completed in
excess of the required twenty-four hours of annual in-service training, which included training in
all required topics. Each staff maintained all certifications that are required, with the exception of
one staff was missing three trainings. These trainings were completed while the review team
was on-site. .. Three staff were applicable for supervisory training. All three received thirty-two
or more hours of supervisor training in coaching, leadership, and personal accountability. All
training was documented in the Department’s Learning Management System (SkillPro). All
instructors were qualified to deliver trainings provided. The program has an in-service training
plan, which was approved by the required individuals, and an in-service training calendar which
is updated as changes occur.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures in place which include the training requirements of
the grievance process. The process includes the informal phase, formal phase, and appeal
phase. Documentation showed the program’s practice correlates with their process and copies
of the grievances are maintained for the past twelve months. Five grievances were reviewed
which showed each of the five grievances were reviewed within the required timeframe. Each of
the five grievances were resolved in the formal phase. Ten youth were interviewed. Two youth
stated they have not needed to submit a grievance but are able to if they need to. All
interviewed youth stated there are grievance forms on the module they have access to. Once a
form is filled out, the youth are able to drop them into the drop box. Each of the ten interviewed
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youth stated they are able to ask for assistance in completing a grievance form. Ten staff were
interviewed, of which each said grievance forms are placed throughout the program and a youth
can request assistance in completing the form. Five staff reported the process has three phases
and each phase has associated timeframes. Four staff noted the supervisor reviews grievances,
while six staff stated the facility administrator (FA) reviews grievances. The FA interview results
revealed each youth has the right to grieve actions of program staff and conditions or
circumstances in the program related to a violation or denial of basic rights. Informal resolution
of complaints is encouraged. All staff are trained in the grievance process and procedures and
youth receive instruction on procedures to file a grievance within the orientation process. Youth
have access to grievance forms and the FA ensures actions are taken to resolve complaints
which are communicated. Grievances are maintained for one year from the date the grievance
was submitted.
1.10 Interventions and Facilitator Training <---Update--->
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures which outline life skills training shall be provided to all
youth and youth are assigned to life skills groups based on the specialized services they
receive. All formal life skills groups are primary services; however, youth participate in a
program called Stop Now and Plan (SNAP), which teaches emotional regulation, self-control,
and problem-solving. This program is a compliment to the provider’s behavior management
system. Youth are able to practice these skills in their community and off-campus during trips
and outside appointments.
Five interviewed youth report they participate in mental health groups, moral recognition
therapy, Skills Streaming, Impact of Crime groups, and vocational groups like Florida Ready to
Work, Occupational Safety and Health Administration (OSHA)-10 training, cardiopulmonary
resuscitation (CPR), first aid, ServSafe and SafeStaff.
The Designated Mental Health Clinician Authority (DMHCA) was interviewed and reported the
program conducts Life Skills group twice per week, Moral Reconation Therapy three times per
week, Impact of Crime (Restorative Justice) weekly, and open mental health groups as needed.
Additionally, youth are able to practice learned skills on daily basis and process during the
following group sessions. The facility administrator reported the majority of the youth’s time is
spent in structured, therapeutic activities, with a minimum of one hour of each youth’s day
devoted to the delivery of treatment services targeted to address the youth’s identified risk,
criminogenic needs and treatment needs.
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1.12 Restorative Justice Awareness for Youth <---Update--->
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at Deep Creek Youth Academy program. For details related specific to IOC
service delivery, please refer to the annual SPEP report.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures regarding the alert process which outline alerts shall
be consistent in the internal alert system and the Department’s Juvenile Justice Information
System (JJIS) and only authorized staff shall update or close applicable alerts. The program
utilizes an alert board in the staff break room to track all internal alerts. Five youth records and
corresponding JJIS records were reviewed. All alerts were placed in JJIS, and none were
entered late. Only authorized staff entered, downgraded, and closed alerts. The nurse was
interviewed and reported nurses update medical alerts as changes are made and they are
reviewed weekly. The facility administrator (FA) was interviewed and reported alerts are
reviewed at the morning briefings. The FA verified the program utilizes an alert board and all
alerts should be reflected on the alert board, in JJIS, and in the logbook. Ten staff were
interviewed, and each reported they knew where to find alerts or who to ask. Eight of ten staff
referred to the breakroom alert board as the location alerts are updated, as well as master
control logbook. Six of ten staff reported they are informed of alerts by word of mouth, one staff
stated the alerts are in the mantraps in each of the dorms, and one said alerts are discussed
during briefings. The FA clarified the only youth information in the mantraps in each dorm are
the youth behavior management system (BMS) levels since these are areas youth pass
through. Alerts for food allergies are posted in the kitchen, inaccessible to youth.
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 Case Management Record
The program maintains separate individual management records, mental health records, and
Individual Healthcare Records. Five youth records were reviewed, and each record is labeled
confidential and maintained in locked cabinets and offices marked as confidential. Each
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individual management record includes all required information and is separated into required
sections.
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 operates a community advisory board which includes representatives from all
required community partners. A review of sign-in sheets and meeting minutes confirmed
meetings were held hybrid in-person and by video conferencing at least quarterly during the
annual compliance review period. The facility administrator was interviewed and verified
meetings are held quarterly with all required parties and invitations are sent to solicit active
involvement from board members. A board member was interviewed and reported they work
with youth inside the program to improve their perspectives of law enforcement.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures which outline performance evaluations will be
conducted ninety days after hire and annually thereafter. Position descriptions for five different
position types were reviewed and compared with five reviewed staff records and confirmed staff
were evaluated according to established performance standards. A review of the program’s staff
roster and contract confirmed all required positions were maintained with the exception of four
non-licensed therapists. The facility administrator was interviewed and reported turnover has
decreased and the program’s staff morale committee has continued retention initiatives which
improved morale and recognizes staff performance. Ten staff were interviewed, and each
reported they receive performance evaluations annually and monthly. Three staff reported they
receive evaluations quarterly.
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’s contract was reviewed for contract-specific requirements. Documentation
confirmed the program is providing each of the fifteen contract-required activities. The program
has agreements, sign-in sheets, and picture documentation of activities with Friends in Blue
through the St. Johns Sheriff’s Office, mentoring through Compassion St. Augustine, animal
assisted programming through the Hands and Feet Foundation, and First Coast Technical. The
program maintains spaces for youth to utilize as part of their behavior management system
including an enhanced basketball court, arcade, barbershop, diverse media center, and music
studio. The nurses taught three classes during the annual compliance review period with an
infant simulator to instruct youth in caring for an infant. Youth are provided all required clothing,
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salads with lunch and dinner, opportunities to receive the iHope patch for fitness achievement,
and input through the youth advisory board. The program provided documentation they have
leases for four passenger vans, exceeding the contract requirement of three. A review of the
program’s staff roster confirmed they have a medical clerk and a physical plant worker with
certifications in heating, ventilation, and air conditioning (HVAC). The program utilizes
recruitment and retention efforts confirmed through their staff handbook. The facility
administrator confirmed the contract-specific opportunities offered to youth. Ten youth were
interviewed and eight of the youth reported participating in Occupation Safety and Health
Administration (OSHA)-10 and cardiopulmonary resuscitation (CPR)/First-Aid trainings, two
mentioned ServSafe certification, and one youth said they have participated in Florida Ready to
Work. Sign-in sheets, pictures, and agreements confirmed the program is providing the activities
as required.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a practice regarding data trend analysis. Satisfaction surveys are incorporated
into the monitoring and verification activities as a part of the program’s quality assurance
program. Satisfaction surveys are provided routinely and are completed on at least a quarterly
basis. Surveys include youth surveys, family surveys, and staff surveys at a minimum. Surveys
target admission activities, topic-specific assessments, and discharge satisfaction. Survey data
is reviewed and evaluated monthly in program-level and corporate leadership meetings. Survey
outcomes are collected and communicated as a part of ongoing program communication and
quality improvement activities. Monthly incident trackers are distributed to the program which
describe trends. Quarterly monitoring and verifications are conducted by the provider’s
compliance team, which formulates a report and provides support, technical assistance, and
coaching to promote improvement, professional development, and implementation and
assurances of corrective strategies, as appropriate.
Program and corporate leadership meetings include monthly quality assurance review
processes which incorporate review of facility data, surveys, and findings of formal monitoring
and verification activities. Within each meeting, progress to date, program strengths,
improvement needs, and corrective action is discussed. Recommendations are made by the
team with ongoing review and follow-up and technical assistance provided, as applicable.
Data gathered by the program and the Department is used for long-term planning, provisions for
staffing, and a system of communication to keep staff. Stakeholders are informed and provided
opportunities for feedback, performance improvement, and budgeting. The program provided
documentation to support this practice.
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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.
Five youth case management records were reviewed for initial contact to the parent/guardian
and court notification. The program notified the parent/guardian by telephone within twenty-four
hours of admission and in writing within forty-eight hours of admission in all five records. The
court, juvenile probation officer, and post-residential services counselor, when applicable, were
notified within five working days of the youth’s admission in all five records.
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.
Five youth case management records were reviewed for youth orientation. The program
provided each youth an orientation beginning on the day of admission, in all five records. The
program’s orientation process includes services available, daily schedule, expectations and
responsibilities of youth, written behavioral management system conspicuously posted or
provided in a resident handbook to allow easy access for youth, including rules governing
conduct, positive and negative consequences for behavior, availability of and access to medical
and mental health and substance abuse services, access to the Florida Abuse Hotline or the
Department’s Central Communications Center, the program’s zero-tolerance policy regarding
sexual misconduct, and special accommodations which are available to ensure all written
information about sexual misconduct policies is conveyed verbally to youth with limited reading
skills or who are visually impaired, deaf, or otherwise disabled. Also included in the youth
orientation is the right to be free from sexual misconduct, right to be free from retaliation for
reporting such misconduct, the agency’s sexual misconduct response policies and procedures,
items considered contraband, performance planning process, dress code and hygiene
practices, procedures on visitation, mail, and use of the telephone, expectations for release from
the program, recommendation to the court for release based on the youth’s performance in the
program and the court’s decision to release, community access, grievance procedures,
emergency procedures, including procedures for fire drills and building evacuation, facility tour,
if applicable, general layout of the facility, assignment to a living unit and room, and treatment
team. No observation could be conducted of a youth orientation as the program had no youth
admitted to the program during the annual compliance review. Five youth were interviewed and
each confirmed their orientation included the required elements, began within twenty-four hours,
and 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.
Five youth case management records were reviewed for written consent of youth eighteen
years or older. One youth was applicable to being eighteen years of age, as such, the program
provided two additional records for review. Written consent was obtained for all three youth
eighteen years of age or older before providing or discussing with the parent/guardian
information related to the youth’s physical or mental health screenings, assessments, or
treatments, as required.
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 utilizes a classification system, in accordance with Florida Administrative Code.
The program’s classification form includes physical characteristics of the youth, age and
maturity level, identified special needs, history of violence, gang affiliation, criminal behavior,
sexual aggression or vulnerability to victimization, youth’s perception of vulnerability, youth’s
history of potential or verified human trafficking, suicide risk, medical risk, escape risk, and
security risk.
Five youth case management records were reviewed for classification factors, procedures, and
reassessment activities. Two of the five records showed youth had suspected risk factors.
Documentation showed the Department’s Juvenile Justice Information System (JJIS) alert list
was reviewed for each youth. All five youth were classified for purposes of assigning to a living
area, sleeping room, and youth group or staff advisor. Two youth were applicable to medical,
mental health, substance abuse, security risk factors, and/or special needs identified during the
classification process and were immediately entered into the program’s internal alert system
and JJIS. Three youth records were applicable for reclassification to increase the youth’s
privileges or freedom of movement and/or participation in work projects, or other activities. The
program’s policy/procedures clearly outline the classification process and include a classification
system which promotes safety and security, as well as effective delivery of treatment services,
based on a determination of each youth’s individual needs and risk factors, which addresses, at
a minimum, items outlined in Florida Administrative Code. The policy states youth may be re-
classified at intervals throughout their length of stay. Staff reclassify youth, when warranted,
based upon changes in the youth’s supervision status, new/updated alerts, behavioral concerns,
and relevant information to the treatment team to ensure safety and security of the youth and
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program. The facility administrator confirmed it is the policy of the program to ensure an
effective classification system which promotes safety and security as well as effective delivery of
treatment services based upon the determination of each youth’s individual needs and risk
factors. Initial classification processes guide the most appropriate room placement, living unit
assignment, and youth group or staff advisor. Youth may be reassessed and re-classified during
placement if warranted, prior to considering an increase in privileges or freedom of movement,
level advancement, room changes, participation in off campus activities, or other activities
involving the use of tools which may be used as potential weapons or means of escape, and/or
for the safety and security of the program and other youth. All program youth are screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
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.
Five youth case management records were reviewed for gang identification. None of the youth
records were applicable to gang affiliation, as such, the program provided the only applicable
record for review. For the one applicable record, local law enforcement was notified of
suspected gang activity prior to the seven-day notice. The youth’s residential commitment
placement is not in their home county, as such, law enforcement in the county of the program
was notified of the youth’s gang affiliation. Gang alerts were entered into the internal alert
system and the Department’s Juvenile Justice Information System, (JJIS) upon identification, as
required. Information on the youth’s gang status was shared with the educational provider,
youth’s juvenile probation officer, and post-residential counselor, as required.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
Five youth case management records were reviewed for gang prevention and intervention
activities. None of the youth records were applicable to gang affiliation, as such, the program
provided the only applicable record for review. The applicable youth participated in gang
prevention and intervention strategies as required. The youth’s performance plan included
relevant goals and objectives related to gang intervention strategies for the youth to complete
prior to release from the program.
The program implements Gang Resistance and Drug Education (GRADE) as their gang
intervention strategy. A review of sign-in sheets confirmed the groups were delivered as
designed. GRADE and Impact of Crime (IOC) are used to provide gang prevention and
awareness to all youth in the program. The program’s policy and procedures address providing
youth an opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang.
An interview with the facility administrator indicated the program works with criminal justice
agencies to coordinate the sharing of information for Florida’s Gang Intelligence System (FGIS),
provides IOC to all youth in the program, and provides GRADE for those who are applicable.
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2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
Five youth case management records were reviewed for Residential Assessments for Youth
(RAY) and re-assessments. A RAY was completed within thirty days of admission for all five
youth and maintained in the Department’s Juvenile Justice Information System (JJIS), as
required. Two of the five youth records were applicable for reassessments and both youth had a
reassessment completed every ninety-days after completion of the initial RAY assessment, as
required. The program maintained all reassessment documentation in both youth’s official case
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.
Five youth case management records were reviewed for the Youth Needs Assessment
Summary (YNAS). All five youth records showed a YNAS was completed within thirty days of
admission. The YNAS was documented in the Department’s Juvenile Justice Information
System (JJIS) in all five records, as required.
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.
Five youth case management records were reviewed for performance plan development, goals,
and transmittals. The Individualized Performance Plan was developed within thirty days of the
youth admission and after the development of the Residential Assessment for Youth (RAY) and
Youth Needs Assessment Summary (YNAS) for all five youth. In all five records, the intervention
and treatment team leader, youth administrative representative, living unit representative,
treatment staff, education staff, Department of Children and Families (DCF) caseworker, when
applicable, and all other parties who have significant responsibility in the goal completion, were
present during the development of the Individualized Performance Plan. None of the
parent/guardian signature sheets were returned to the program; however, documentation
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showed the program mailed the signature sheets to each parent/guardian and requested the
forms be signed and returned. All five youth performance plans included goals which were
individualized and based upon the prioritized needs reflecting the risk and protective factors
identified during the initial assessment process, the youth’s top three criminogenic needs,
delinquency interventions, target court-ordered sanctions which could be reasonably
initiated/completed while in the program, when applicable, transition activities targeted for the
last sixty days of the youth’s anticipated stay, the youth’s responsibilities to accomplish goals,
program staff responsibilities to enable youth to complete goals, and target dates for goal
completion. Within ten working days of completing each plan a transmittal letter and copy of the
plan was sent to the committing court, juvenile probation officer, parent/guardian, and DCF
counselor as required. Five youth were interviewed regarding their participation in the
development of their performance plans, and all five confirmed they participated in the plan’s
development.
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.
Five youth case management records were reviewed for performance plan revisions and the
incorporation of other plans. Three of five records warranted revisions based on Residential
Assessment for Youth (RAY) results. Two of the three applicable records had revisions
completed for demonstrated progress, or lack of progress, toward completing goals. The
remaining record had revisions completed for facilitating transition activities during the last sixty
days of the youth’s stay. All five records incorporated other plans into the performance plan.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
Five youth case management records were reviewed for Performance Summaries and
transmittals, and two of the five records were applicable. The program provided an additional
record for review, for a total of three records. For all three records, summaries were completed
every ninety calendar days following the signing of the performance plan, or at shorter intervals,
if requested by the court. The Performance Summaries were prepared prior to the youth’s
release, discharge, or transfer from the program for all three records. In all three records, the
summaries included the youth’s status on each performance plan goal, overall treatment
progress if the youth has a treatment plan, academic status and credits earned, behavior, level
of motivation/readiness to change, interaction with peers and staff, overall behavior adjustment
to the program, and significant positive and negative events. Documentation regarding
Performance Summaries reflected the youth was allowed to read and add comments prior to
signing, provided a copy of the summary, and the original summary filed in the youth’s case
management record, in all three records. Performance Summaries were signed and dated by
the treatment team leader, facility administrator or designee, and youth in both records. A copy
of each summary was sent within ten working days to the committing court, youth’s juvenile
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probation officer (JPO), parent/guardian, and Department of Children and Families, as
applicable.
Three closed youth case management records were reviewed for the release summary. Each
release summary included the original summary, along with the justification for release, sent
with the Pre-Release Notification (PRN), to the JPO. One of the three youth was a direct
discharge from the program, and the discharge summary was sent. None of the three youth
were at the program for less than forty-five days. As such, the release summary and PRNs were
sent within forty-five days prior to release. A signed copy was retained in each youth’s case
management record. None of the releases were rejected by the court. Once approved, the
program provided written notification to the youth’s parent/guardian regarding the planned
release, and the program completed a Residential Assessment for Youth exit assessment for all
three youth. None of the youth records were applicable for a victim notification.
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.
Documentation showed the program encourages and facilitates involvement of each youth’s
parent/guardian in the case management process to include the assessment process,
participation in the development of the youth’s performance plan, progress reviews, advanced
notice of formal treatment team meeting dates and times, and transition planning. If unable to
attend, each parent/guardian is given the opportunity to participate by telephone/video
conferencing or provide verbal/written input prior to the meeting. The program did not have
treatment team during the week of the annual compliance review, as such, treatment team was
unable to be observed. The program sends out formal treatment team, visitation, family day,
and family forum invites, as well as copies of assessments.
An interview with the facility administrator confirmed the program encourages family
involvement from the time of each youth’s admission to the program. Family is encouraged to
provide input into performance, treatment and transition planning, participate in treatment team
meetings, family therapy sessions, as needed and specified within the individualized treatment
plan, and participate in conferences for family outreach to address family reunification issues.
Five youth were interviewed and each stated their families are involved in their treatment
through treatment teams, family counseling sessions, family days, and visitation.
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.
Five youth case management records were reviewed for treatment team members and formal
and informal reviews. Formal reviews were held at least every thirty days for all five youth, and
documentation of each review included the youth’s name, date of review, all required attendees,
comments from treatment team members, and a brief synopsis of the youth. Also included in the
formal reviews were performance plan revisions, progress on performance plan goals, positive
and negative behaviors, behaviors resulting in physical interventions, treatment progress, and
Residential Assessment for Youth reassessment results, when applicable, for all five youth
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records. Documentation confirmed each youth was provided an opportunity to demonstrate
skills acquired in the program. All formal treatment team documentation was contained in the
youth’s record for all five records. Informal reviews were held biweekly each month. Each
informal treatment meeting documented all the required elements. All informal treatment team
meeting documentation was contained in each youth’s record. All the required parties were
invited and encouraged through advance notification to participate and if participation could not
be arranged, the opportunity to provide input was provided. No treatment team meeting was
able to be observed as none took place during the annual compliance review.
Five youth were interviewed. All five youth confirmed staff talk about their performance including
progress on performance plan goals, positive and negative behaviors, and treatment progress
during treatment team meetings. The youth articulated different ways they are able to show the
skills they have learned in the program.
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.
Three closed youth case management records were reviewed for transition planning,
conference, and Community Re-Entry Team (CRT) meeting. The transition conference was held
at least sixty days prior to the youth’s targeted release date in all three records. The youth,
treatment team leader, program director, and other treatment team members attended the
transition conference for all three records. The treatment team leader invited the youth’s juvenile
probation officer, parent/guardian, education staff, and other pertinent parties, for all three
records. During the transition conference, the participants reviewed transition activities in the
youth’s performance plan, revised the performance plan, identified additional transition
activities, identified target completion dates, and identified persons responsible for completion in
all three records. The treatment team leader obtained attendees dated signatures and a copy of
the plan was sent with a request for return with signature to anyone not in attendance who had
a responsibility for completion of transition goals in all three records. When a plan was
transmitted electronically the return email acknowledgement receipt was printed and filed with
the plan. A Community Re-Entry Team (CRT) meeting was conducted prior to the youth’s
release in all three records. The youth and case manager participated in the CRT meeting in all
three records, and there was evidence of an invitation to participate in the meeting.
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2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three closed youth case management records were reviewed for an exit portfolio. The exit
portfolio was discussed and initiated for the youth during the transition conference in all three
records. All three exit portfolios included a copy of the youth’s transition plan, calendar with
dates, times, and locations of upcoming community appointments, education and/or vocational
certificates, education records, school transcripts, resume, and sample employment
applications. None of the three exit portfolios included the youth’s social security card, birth
certificates, or state identification card; however, there was documentation showing the program
made attempts to obtain the documents from the youths’ parents/guardians. All three exit
portfolios were verified during the exit conference, and documentation indicated each portfolio
was completed and given to the youth upon release. All three records reflected program staff
forwarded the exit portfolio information to the youth’s juvenile probation officer. The program’s
contract states each youth must be given an iHope Experience Transition Portfolio, and the
program is meeting this requirement.
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.
Three closed youth records were reviewed for an exit conference. The conference was
conducted after the program notified the youth’s juvenile probation officer (JPO) of the release
and at least fourteen days prior to release in all three records. Reviewed documentation
indicated the date of the conference, signatures, and a summary of pending transition goals
were included in the exit conference in all three records. Each youth’s date of admission and
date of termination was documented in the case record and correlated with the Department’s
Juvenile Justice Information System (JJIS). The status of transition activities established at the
transition conference and plans finalized for each youth’s release were reviewed. Also included
were provisions for continuation of education and/or employment in all three records.
Documentation showed the youth’s parent/guardian and JPO are aware of the vocational plan
for the youth, and the youth’s case manager and parent/guardian were aware of the plan,
documents, and post-release discharge plans in all three records. The intervention and
treatment team leader, parent/guardian, education representative, JPO, youth, and other
pertinent parties participated in all three youth exit conferences, as required. All three exit
conferences were held separately from the Transition and Community Re-Entry Team meetings,
as required.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program hosts weekly youth advisory board and house meetings on each dorm to promote
constructive input by youth. Documentation was reviewed during the annual compliance review
period which confirmed the program’s efforts to solicit input from youth, through avenues such
as youth advisory board minutes, program surveys, and/or suggestion forms. The program’s
policy and procedures require youth advisory board/student council meetings be completed
biweekly, and the program surpasses the requirement by conducting the meetings each week.
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Five youth were interviewed regarding the ways they are able to provide input to the program.
The youth stated they can provide input through grievance and “Speak Out” forms, house
meetings, or by speaking directly to staff. An interview with the facility administrator confirmed
program participation in community meetings, performance reviews, treatment team forums,
and advisory board meetings.
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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 designated mental health clinical authority (DMHCA) who is a psychologist
with a clear and active license with an expiration date of May 31, 2026, as required by the
program’s contract. A review of the position description confirmed the DMHCA is a full-time staff
who works at least forty-hours a week and is responsible for the coordination and
implementation of clinical services at the program. The program utilizes a back-up DMHCA who
is a licensed psychologist with a clear and active license in the State of Florida expiring May 31,
2025.
The DMHCA was interviewed and indicated they provide clinical supervision for non-licensed
mental health professionals, provide weekly group schedules, monthly fidelity, and feedback.
The DMHCA submits a monthly service calendar of scheduled individual and family sessions to
the clinical director or designee. During the intake process, the licensed mental health
professional (LMHP) gathers current information from each youth within the first five days of
admission. The LMHP also confirms youth reports by referring to collateral information obtained
in the Department’s Juvenile Justice Information System and completes the Brief Behavioral
Health Status Exam. The LMHP completes and/or reviews all Assessments of Suicide Risk
(ASRs). The LMHP also provides any group therapy, individual/family therapy, and any needed
clinical service in the absence of a therapist.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a policy and procedures ensuring mental health and substance abuse
services are provided by individuals with appropriate qualifications. The clinical supervisor
ensures the licensed clinical staff working under their supervision are performing services they
are qualified to provide based on education, training, and experience, which was determined by
a review of job descriptions and an informal interview with the designated mental health clinician
authority (DMHCA). The licensed mental health and substance abuse clinical staffing is in
accordance with the current contract and Florida Administrative Code. Copies of the licenses
were available on-site. Licenses of all licensed mental health professionals and licensed
qualified professionals employed at the program during the annual compliance review period
were reviewed and found to be clear and active. The program’s contract requires two assistant
clinical directors and one additional licensed therapist. A review of the staff roster and licenses
found the program was in compliance with this requirement.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a policy and procedures ensuring mental health and substance abuse
services are provided by individuals with appropriate qualifications. The clinical supervisor
assures the non-licensed clinical staff working under their supervision are performing services
they are qualified to provide based on education, training, and experience based on a review of
job descriptions and an informal interview with the designated mental health clinician authority
(DMHCA). The program had seven non-licensed master’s-level clinical staff at the time of the
annual compliance review. The program had four vacancies for therapist positions; one has
been open for four months and the remaining three for three months. During the annual
compliance review period, the program had five additional non-licensed master’s-level clinicians
and one bachelor’s-level clinician who provided services but were no longer with the program. A
review of the clinician’s credentials found each was qualified to provide services based on their
education, training, experience, and the contractual requirements. The reviewed documentation
reflected each non-licensed mental health clinical staff working under the direct supervision of a
licensed mental health professional received a minimum of one hour a week of on-site, face-to-
face direct supervision by a licensed mental health professional for the purpose of overseeing
and directing the mental health services provided in the program during the annual compliance
review period, as required. Direct supervision was recorded on a form which included all
elements of the Department’s Licensed Mental Health Professionals and Licensed/Certified
Substance Abuse Professionals Direct Supervision Log form. The program has a Chapter 397
license which expires April 1, 2025. The non-licensed mental health and substance abuse
clinical staffing is in accordance with current contract to include the number of hours. All seven
non-licensed mental health clinical staff hold a master’s-level degree from an accredited
university or college in the field of counseling, social work, psychology, or related human
services field. The non-licensed substance abuse clinical staff provide substance abuse
services in the program which is licensed under Chapter 397, Florida Statute. Six applicable
non-licensed mental health clinical staff who conducted Assessments of Suicide Risk completed
twenty hours of training and supervised experience in assessing suicide risk, mental health
crisis intervention, and emergency mental health services, as required. A review of the six non-
licensed staff no longer employed at the program confirmed five applicable staff also completed
twenty hours of training and supervised experience in assessing suicide risk, mental health
crisis intervention, and emergency mental health services, as required.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Five youth mental health and substance abuse treatment records were reviewed. All five youth
had a Massachusetts Youth Screening Instrument – Second Version (MAYSI-2) completed
upon admission to the program. The screener reviewed available information to include the
commitment packet, and reports and/or records for existing documentation of mental health or
substance abuse problems or history of human trafficking. In all five records the screener
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reviewed available information to include the commitment packet, and reports and/or records for
existing documentation of mental health or substance abuse problems or history of human
trafficking. All five records included the date of completion and were completed in full. All of the
records were verified to be completed by trained staff. All five MAYSI-2s indicated further
assessment was required and a referral was made for further evaluation which included the
referral reason. When the MAYSI-2 or other admission information indicated the need for an
assessment, crisis intervention, or emergency services, the facility administrator (FA) or
designee was notified, and a referral was made to alert the designated mental health clinician
authority (DMHCA) in all five records. One of the youth reviewed was in need of further
assessment due to the outcome of the MAYSI-2 for suicide ideation and the FA ensured an
Assessment of Suicide Risk (ASR) was completed within twenty-four hours. None of the
reviewed youth were in crisis, nor were any placed on precautionary observation (PO). The FA
is responsible for developing written facility operating procedures for the implementation of a
standardized admission/intake mental health and substance abuse screening process. The
program’s policy addresses the standardized screening process which includes review of
commitment packet information, reports, and records; administration of the MAYSI-2 in the
Department’s Juvenile Justice Information System (JJIS) or Clinical Mental Health Screening by
a licensed mental health professional and Clinical Substance Abuse Screening by a qualified
professional, and referral of juvenile offenders identified by screenings as in need of further
evaluation or immediate attention. The policy also includes staff training in mental health and
substance abuse issues and administration of the MAYSI-2, and a standardized process for
referral of youth identified as in-need of further mental health and/or substance abuse
evaluation to an appropriate service provider/professional or, when immediate attention is
needed, to a hospital or Baker Act or Marchman Act receiving facility. The FA was interviewed
and reported adherence to written policy and procedures as it relates to admission screenings
and identifying youth at risk and in need of mental health and substance use services.
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.
Five youth records were reviewed for mental health and substance abuse
assessments/evaluations. The program completed a new, combined mental health and
substance abuse evaluation for all five youth. Four of the five youth’s evaluations were
completed within thirty days of admission with one youth’s evaluation completed within forty-four
days of admission. Consent was obtained for all five youth for substance abuse services.
Licensed mental health clinical staff or licensed substance abuse clinical staff completed the
evaluations in four records. The remaining record was completed by non-licensed clinical staff
and then reviewed by licensed clinical staff within ten calendar days of the evaluation being
conducted. All five evaluations included identifying information, reasons for the evaluation,
methods of assessment, patterns of alcohol and drug use, impact of alcohol and drug use on
major life areas, risk factors, relevant background information, behavioral observations, Mental
Status Examination, interview or procedures administered, discussion of findings, diagnostic
impression/formulation including diagnosis, and recommendations. The designated mental
health clinician authority (DMHCA) was interviewed and confirmed, when a youth completes the
intake process to include classification, problem areas are discussed with youth and the
parent/guardian. During the intake process, the licensed mental health practitioner (LMHP)
gathers current information from youth and within five days confirms the youth's reports by
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referring to collateral information obtained in the youth records to complete the Brief Behavioral
Health Status Exam. Each youth receives a comprehensive assessment within thirty days of the
intake based on their current and past behavior by a licensed or non-licensed mental health
professional and it is then reviewed by the clinical director or designee.
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.
Five youth records were reviewed for mental health and substance abuse treatment. The initial
mental health treatment plan or initial substance abuse treatment plan was developed within
seven days of the onset of treatment, or for youth with prescribed psychotropic medication,
within seven days of the Initial Psychiatric Diagnostic Interview for all five youth. All five initial
mental health treatment plans were completed on a form which included all the required
elements of the Department of Juvenile Justice Initial Mental Health/Substance Abuse
Treatment Plan form. The initial treatment plan was signed by the mental health clinical staff or
substance abuse clinical staff completing the form. All five initial treatment plans were
completed by a licensed mental health clinical staff. Each plan was also signed by all required
treatment team members who participated in the development of the plan and the youth.
Individual Treatment Plans and reviews contained within each youth record included the youth’s
psychiatric needs, when applicable, including medication and frequency of monitoring by the
psychiatrist. All five plans were developed within thirty days of admission on a form containing
all the required elements of the Department’s Individualized Mental Health/Substance Abuse
Treatment Plan form. Reviews of the treatment plans were conducted at a minimum of every
thirty days in each of the five youth records. All five records showed the Individualized
Treatment Plan was completed and signed by the applicable mental health or substance abuse
clinical staff. All five Individualized Treatment Plans were completed by licensed mental health
clinical staff. All five Individualized Treatment Plans were signed by the youth, parent/guardian,
and required treatment team members. All five youth plans included services which were
prescribed, including individual, group, and family therapy. Four of five plans included
psychiatric service/medication management requirements. Goals and objectives were
individualized for each youth. Video observation was not conducted as all groups are currently
being monitored by Technical Assistance and are identified as primary clinical services.
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.
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Five youth records were reviewed for treatment and discharge planning. Each of the five youth
records showed each youth was assigned a treatment team upon arrival to the program. A
review of the treatment team documentation showed all required team members were in
attendance. All five youth were determined to be in need of substance abuse treatment and
received individual, group, and/or family counseling provided by a licensed professional with the
required qualifications, or a non-licensed substance abuse clinical staff in accordance with the
youth’s initial or individualized substance abuse treatment plan. All five youth were deemed in
need of mental health treatment and had a properly executed Authority for Evaluation and
Treatment (AET) form. Youth receiving substance abuse treatment provided consent through a
signed Youth Consent for Substance Abuse Treatment form. All the youth signed a Youth
Consent for Release of Substance Abuse Treatment Records form. In all five youth records,
mental health treatment notes or substance abuse treatment notes were documented on a form
which contained all the required elements of the Department of Juvenile Justice’s
Counseling/Therapy Progress Notes form. In all five youth records reviewed, mental health and
substance abuse group therapy included individual psychotherapy or one-to-one counseling
between a youth with a diagnosed mental health disorder and a mental health clinical staff. The
mental health and substance abuse groups included psychosocial skills training. All five
reviewed youth records included documentation of the youth attending psychosocial skills
training groups. A review of progress notes determined all five youth received services as
stipulated in both duration and frequency in their treatment plans.
Three closed youth records were reviewed for discharge planning. The three discharge plans
were documented on the Department’s Mental Health/Substance Abuse Treatment Discharge
Plan form. None of the three applicable youth were released while on suicide alert/precaution so
no notification for suicide risk was necessary. Each of the three Mental Health and Substance
Abuse Treatment Discharge Summaries documented services needed and reflected all were
discussed with the youth, parent/guardian, and juvenile probation officer (JPO) during the exit
conference. Documentation supported a copy of the Mental Health and Substance Abuse
Treatment Discharge Summary form was provided to each youth, JPO, and parents/guardians.
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 provides services for youth with borderline developmental disabilities (BDD),
developmental disabilities (DD), Intensive Mental Health (IMH), and Comprehensive Mental
Health (CMH). The program maintains a written policy and procedures for establishing service
delivery protocols for specialized treatment services. Counselor caseloads for BDD/DD do not
exceed eight youth, and for CMH and IMH caseloads do not exceed ten youth. The program’s
required clinical groups according to the contract include Moral Reconation Therapy,
Skillstreaming the Adolescent, and Living in Balance which are monitored by Technical
Assistance. The program at a minimum provided individual therapy weekly for DD and CMH
youth and once every two weeks for BDD and IMH youth, family therapy monthly, and had a
psychiatrist providing services at least once every two weeks. A licensed psychologist and/or
licensed mental health counselor provided on-site services as needed and group therapy
included five total substance abuse and/or mental health groups each week for all youth with
BDD, CMH and IMH and three groups a week for youth with DD.
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The program maintains the following staffing: a full-time licensed psychiatrist five days a week
for forty hours, mental health clinical staff on-site seven days a week, a psychologist on-site
forty hours a week to provide psychological evaluations and services within the program and for
emergency consultation services, and a registered nurse on-site daily for each shift to ensure
appropriate administration of medication. Any non-licensed staff at the program hold a master’s-
level degree or were currently enrolled in a master’s degree level program. The program had no
youth miss services due to quarantine during the annual review period.
Five youth were interviewed and all five indicated they are receiving family and individual
counseling. Three of the five youth indicated individual sessions occur weekly and the remaining
two youth stated individual therapy sessions occur every other week. All five youth stated family
sessions occur monthly. Five staff were interviewed, and all indicated they do not facilitate any
group sessions. An interview with the facility administrator indicated the program provides IMH,
BDD, DD, CMH, or Medically Complex Overlay services. All program youth are prescreened
and placed by the Department based upon identified treatment needs. The focus of treatment
services will include targeting and reducing/alleviating risk factors and addressing each youth’s
symptoms and co-occurring mental health and substance related disorders, as applicable,
enabling the youth to improve functioning and ultimately functioning within the community.
Ancillary services are provided directly or through referral in instances where the program
cannot or does not provide certain services needed by an individual youth.
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.
Psychiatric services are provided by two psychiatrists who both possess a clear and active
license in the State of Florida, both expiring January 31, 2026. The psychiatrists are available
for emergency consultation twenty-four hours a day, seven days a week. The psychiatrists
providing psychiatric services brief a representative of the treatment team regarding the
psychiatric status of each youth receiving psychiatric services who is scheduled for treatment
team review. The psychiatrists’ evaluations and recommendations for each youth are
incorporated into the mental health clinical staff’s evaluations of the youth and the youth’s
individualized mental health or substance abuse treatment plan. A review of sign-in/out logs
confirmed visits during the annual compliance review period were conducted as required by the
contract for both psychiatrists. The psychiatrists actively participate in, manage, and supervise
psychotropic medication services in the program. The program did not use a back-up
psychiatrist during the annual compliance review period. An interview with one of the
psychiatrists confirmed their role at the program is to complete initial psychiatric exams for all
the patients assigned to their caseload. These are completed within two weeks of admission if a
youth arrived on medications, within thirty days if not on medications. The psychiatrist stated
they also review comprehensive evaluations of each youth prior to completing the initial
examination and obtain parental consent for any significant change or new medication. Follow-
up appointments are scheduled from one week to one month depending on the needs of the
patient. Youth on medications are reviewed in follow-up at least monthly. Youth not on
medication are followed intermittently as needed by self-referral or referral through the youth's
therapist. The psychiatrist also confirmed they perform diagnostic evaluation services and in-
service training when designated. The psychiatrist meets with the designated mental health
clinician authority (DMHCA) weekly and an interview with the DMHCA indicated they meet with
both psychiatrists a total of two times a week.
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Five youth records were reviewed for psychiatric services. Four youth were admitted on
psychotropic medications, but all five received a diagnostic interview within fourteen days of
admission. All five initial diagnostic interviews included the youths’ history, Mental Status
Examination, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)
diagnosis consistent with the youth’s treatment plan, treatment recommendations, prescribed
medications, explanation of the need for psychotropic medication related to the youth’s
diagnosis, target symptoms, initial treatment goals, potential side effects, risks and benefits of
taking the medication, and frequency of medication monitoring/management. In all five records
reviewed, the initial diagnostic psychiatric interview was documented on the Department’s
Clinical Psychotropic Progress Note (CPPN) form. In all five records the CPPN forms were
clearly identified as an “Initial Diagnostic Psychiatric Interview”. When the initial psychiatric
diagnostic interview resulted in the prescription of psychotropic medications or changes to the
youth’s existing psychotropic medication regimen, page three of the CPPN was completed,
regardless of the format used to document the psychiatric interview, in all five records.
Medication reviews were conducted every thirty days as required for the four applicable youth
prescribed medication. When the psychiatric evaluation resulted in the prescription of
psychotropic medication or changes to the youth’s existing psychotropic medication, page three
of the CPPN was completed in all applicable records reviewed. None of the five youth received
an updated psychiatric evaluation as no previous evaluation had been conducted. In the four
applicable youth records when psychotropic medication was prescribed/dispensed/administered
by the psychiatrist, identifying data, diagnosis, target symptoms of each medication, evaluation
and description of the effect of prescribed medication on target symptoms, prescribed
psychotropic medication information including the name, dosage, and quantity of the
medication, normal dosage range, ordered dosage, frequency and route of administration, and
reasons for changes in medication and/or dosage were documented on page three of the
CPPN. The youth’s adherence to the medication regimen, height, weight, blood pressure, most
recent serum drug levels or laboratory findings, when appropriate, telephone contact with the
parent/guardian to discuss medication, signature of the psychiatrist, and date of signature were
also documented in all four applicable youth records. The psychiatrist and nursing staff have
documented monitoring for Tardive Dyskinesia on a monthly basis as indicated on the CPPN in
all applicable records reviewed. Tele-psychiatry was utilized for one of the five youth reviewed
and the standard of care was the same as rendered in-person and appropriate consents were
executed by both youth and parent/guardian.
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 plan detailing suicide prevention procedures. The plan includes
identification and assessment of youth at-risk of suicide, staff training of six hours annually,
suicide precautions, levels of supervision including one-to-one supervision, constant
supervision, and close supervision, referrals, communication, notification, documentation,
immediate staff response, and a review process. The review process for suicide attempts and
mortality review includes circumstances surrounding the event, facility procedures relevant to
the incident, all relevant training received by involved staff, pertinent medical and mental health
services involving the victim, possible precipitating factors, and recommendations, if any, for
changes in policy, training, physical plant, medical or mental health services, and/or operational
procedures. The Suicide Prevention Plan is reviewed annually and was last reviewed March 25,
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2024, by the designated mental health clinician authority (DMHCA) and the facility administrator
(FA).
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
The program has a policy and procedures for suicide prevention services. Five youth records
were reviewed for suicide prevention services. Each of the five youth were screened at
admission utilizing the Assessment of Suicide Risk (ASR) and upon completion, were placed on
standard supervision. None of the reviewed youth were applicable for continuation on suicide
precautions and the program provided three additional records of youth determined to be at risk
upon completion of the ASR. In all three records provided, the ASRs were completed on the
Department’s ASR form and continued on precautionary observation (PO). The youth’s
parent/guardian and juvenile probation officer (JPO) were notified of the youth’s placement on
PO in all three records. Mental health staff continued to provide supportive services while each
youth was on PO. All three assessments were conducted by licensed mental health staff and all
three youth were maintained on PO until the Follow-Up ASR indicated suicide precautions could
be discontinued using the Department’s Follow-Up Assessment of Suicide Risk form. All three
youth were stepped down to close supervision prior to transition to normal routine and standard
supervision. Close supervision was maintained for all three youth until it was determined no
longer necessary by the designated mental health clinician authority (DMHCA) or licensed
mental health professional. All documentation regarding the discontinuation of close supervision
was documented by mental health staff and maintained in each youth’s mental health record. All
three youth records included documentation of a conference held by the facility administrator
and licensed mental health professional to reduce the level of supervision. An alert was initiated
in the Department’s Juvenile Justice Information System (JJIS) when each youth was placed on
PO and each alert was ended following the recommendations of the ASR. All three suicide risks
and precautionary observations were documented in the program’s logbook. All three youth
were able to participate in select activities with other youth in designated safe
housing/observation areas of the program. A review of video was unable to be conducted to
verify PO and compare with logbooks and logs as there had not been any youth on PO in the
program for the last thirty days.
3.12 Secure Observation (Critical) <---Update--->
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated “non-
applicable.
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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 policy and procedures for the use of Suicide Precaution Observation Logs.
Five youth records were reviewed for Suicide Precaution Observation Logs. None of the
reviewed youth were applicable for precautionary observation (PO) logs, as such, the program
provided three additional records. For all three applicable youth, the PO logs were maintained
for the duration the youth was on suicide precautions. In the PO logs reviewed, the appropriate
level of supervision and observations of the youth’s behavior were documented in real time and
did not exceed thirty-minute intervals. Warning signs were noted in two of the three reviewed
logs and notification of the facility administrator or designee, and mental health staff was
documented on the reviewed PO logs. All the reviewed PO logs were signed by each shift
supervisor, reviewed, and signed by mental health staff, and documented the safe housing
requirements. Five staff were interviewed and stated when a youth expresses suicidal thoughts,
direct care staff immediately notifies mental health, searches the youth and their room for any
objects which can be utilized for self-harm, places the youth on constant sight and sound
observation, and documents all actions/observations.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a policy and procedures for suicide prevention training for staff. Ten
staff training records (five pre-service and five in-service) were reviewed for suicide prevention
training. All ten staff received suicide prevention training. The program maintains four suicide
kits in the program. All suicide kits are located on the youth living modules. All dorms have
suicide kits co-located with first-aid kits. Reviewed documentation confirmed the program is
conducting mock suicide drills, at least once a quarter on each shift for all staff who come in
contact with youth. The program conducted mock suicide drills each month for each shift during
the annual compliance review period. All mock mental health drills included a suicide attempt or
serious self-injury. No youth were used during the mental health drills. After each drill, the
program provided training on the emergency response procedures. The program documented
on each drill form “areas of improvement”. This information was then reviewed with the staff who
participated in the drill and during all staff meetings as documented on the reviewed drill forms.
If there were staff who were not present during a quarterly drill, they did have an opportunity to
review the 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. A video observation of drills conducted within the last thirty days
was conducted. The facility administrator reported in addition to drills, the facility has an
emergency response plan to serve as the program’s emergency response procedures and all
staff receive training in this as well. Five staff were interviewed and two stated drills are
completed twice a month while the remaining three stated they are done monthly. Staff
confirmed the suicide response kits are located on the dorms.
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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 crisis intervention plan which includes notification and alert system,
means of referral, including youth self-referral, communication, supervision, documentation, and
review.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a mental health crisis intervention and emergency mental health and
substance abuse services plan which was reviewed and approved by the facility administrator
and designated corporate staff on March 25, 2024. Two of the five reviewed youth mental health
and substance abuse records were applicable for requiring a Crisis Assessment, as such, one
additional youth record was requested. The program reported there were only three applicable
Crisis Assessments conducted since the last annual compliance review. All three applicable
Crisis Assessments were conducted immediately upon emergent notification. Both Crisis
Assessments included the reason for assessment, Mental Status Examination and interview,
determination of danger to self and others, initial clinical impressions, supervision
recommendations, treatment recommendations, recommendations for follow-up or further
treatment, and notification to parent/guardian of follow-up treatment. All three assessments
were conducted by a licensed mental health clinical staff. An alert was not required to be placed
in the Department’s Juvenile Justice Information System (JJIS) for two youth as they were not
placed on precautions after the completion of the Crisis Assessment but an alert was placed for
the third youth who was placed on precautions. Two of the youth were alleged victims of a
Prison Rape Elimination Act (PREA) event, and a Mental Health and Substance Abuse Referral
Summary was submitted for a Crisis Assessment and both were offered ongoing mental health
treatment services.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
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The program has an emergency mental health and substance abuse services plan which
includes immediate staff response, notifications, communication, supervision, authorization to
transport for emergency mental health and substance abuse services, transport for emergency
mental health evaluation and treatment under Chapter 394, Florida’s Baker Act, transport for
emergency substance abuse assessment and treatment under Chapter 397, 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 maintains a policy and procedures for an emergency response plan, which
outlines procedures for emergency mental health services, substance abuse services, Baker
Acts, and Marchman Acts. Five youth mental health and substance abuse records were
reviewed and none of the youth were applicable for Baker or Marchman Acts. The program
provided one additional record for review. No other youth were applicable during the annual
compliance review period. The youth record contained documentation which indicated the youth
was determined to be in need of emergency care based upon a code response/suicide attempt.
There was documentation in the youth record indicating mental health staff was involved during
the process. The youth was taken out of the program and transported by emergency medical
services to the designated emergency mental health and evaluation treatment facility. This
transport was authorized by the psychiatrist and facility administrator. When the youth returned
from the Baker Act, documentation showed the youth was placed on constant supervision and a
mental health referral was completed requesting a Mental Status Examination (MSE) be
conducted. A Crisis Assessment was completed by a non-licensed mental health professional
and reviewed by a licensed mental health staff. The youth was maintained on a minimum of
constant supervision until properly transitioned to a lower level of supervision. The youth’s
supervision was maintained until an appropriate assessment was conducted and mental health
staff conferred with the facility administrator.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a policy and procedures addressing the safety planning process. Five
youth records were reviewed and all five contained safety plans which were completed within
fourteen days of admission. Each of the youth’s parents/guardians provided input on the youth’s
safety plans as evidenced in clinical progress notes. All five safety plans incorporated
recommendations from previous or current clinical assessments or screening instruments and
incorporated trauma responsive practices. All five plans were reviewed and updated as
necessary at least every thirty days. All five plans were reviewed and updated as necessary
following any significant behavioral or mental health event identified by the youth’s intervention
and treatment team. A review of five youth safety plans showed all five plans included warning
signs, youth baseline behaviors as gathered from collateral contacts, parent/guardian input,
youth history, and evaluations, if applicable. All five plans also included crisis recognition,
intervention strategies, debriefing preferences, and crisis recognition. All five plans were jointly
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prepared by the youth, program’s clinical staff, and other applicable staff involved with the
treatment of the youth. The safety plans are reviewed by staff who have contact with youth and
are maintained in each youth’s case management record, mental health record, and in a binder
in master control. Five youth were interviewed, and all five youth stated they were involved in
their safety planning process. An interview with the facility administrator confirmed the safety
plan development and review process as well as what is included in each plan and the process
for updating them.
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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’s designated health authority (DHA) is a licensed physician who holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
Florida. The DHA license expires on March 31, 2026. The DHA’s specialty training is in family
practice with experience in adolescent health. The DHA does not have any disciplinary cases or
public health complaints on record. According to the contract, the DHA is required to be on-site
one hour each day five days a week. A review of the sign-in sheets for the annual compliance
review period indicated the DHA was on-site, as required. The DHA was never not on-site
during the annual compliance review period; therefore, the back-up physician was not utilized.
The DHA reviewed facility operating procedures as documented by signature and date. There
was no inclusion of telemedicine in the facility’s contract. The DHA was interviewed and
confirmed their responsibilities include performing Comprehensive Physical Assessments upon
intake, reviewing health-related history, chart review, lab review, providing medical care, and
reviewing policy and procedures.
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 four licensed practical nurses (LPNs) and eight registered nurses (RNs), one
of the RNs serves as the health services administrator (HSA). A review of each RN’s license
credentials reflected each of the nurses have a clear and active license, in the State of Florida,
according to the Florida Department of Health Medical Quality Assurance website. In addition,
each of the LPNs and RNs had current cardiopulmonary resuscitation (CPR) certifications. The
required on-site hours according to the contract are seven days a week for a total of 220 hours.
The nursing staff was in compliance with the contractual requirements and nursing coverage is
provided twenty-four hours a day as required by the program’s contract.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has a policy and procedures for all health-related protocols utilized at the program.
The designated health authority (DHA) and facility administrator (FA) signed and dated all
treatment protocols. The DHA and FA reviewed and signed protocols and facility operating
procedures (FOPs) on February 5, 2025, and February 4, 2025, respectively. FOPs and
protocols related to psychiatric services and psychotropic medication management are
developed and reviewed by the program’s psychiatrist. The psychiatrist reviewed and signed the
psychiatric protocols on March 25, 2024. The nursing protocols were signed by the nursing staff
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on January 13, 2025. There were no new policies or changes in policy made during the annual
compliance review period. An annual review of all FOPs and protocols was conducted by the
respective individuals from each discipline on February 6, 2025, with a signature signifying their
understanding of the FOPs and any new health-related Department policies. All newly hired
medical staff received a comprehensive clinical orientation to the Department’s healthcare
policies and procedures conducted by a registered nurse (RN). The DHA had written and
authorized approval of treatment protocols and standing procedures which were not delegated
to any other person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) authorizing treatment of youth in the program’s custody. A
review of five youth Individual Healthcare Records (IHCRs) found three were applicable for the
AET forms. Three of the youth had a signed AET form filed in their record with the word “Copy”
legibly stamped on it. The AET is valid for as long as the youth is in the program or until the
youth’s eighteenth birthday. One of the five were eighteen years of age and had a documented
release of information. Two youth were in the care of the Department of Children and Families
(DCF), and a court order was included in both IHCRs authorizing all treatment and procedures.
An interview with the registered nurse (RN) advised the policy for obtaining a new or current
AET is to contact the juvenile probation officer (JPO) to obtain it. When a youth is eighteen, they
must sign the eighteen-year-old consent form.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is notified of any
changes in the youth’s condition and to document informed consent for youth healthcare. A
review of five youth Individual Healthcare Records (IHCRs) found three were applicable for
parental/guardian notifications for over-the-counter (OTC) medications beyond those covered by
the Authority for Evaluation and Treatment (AET). All three of the IHCRs had consent provided
by the parent/guardian. All five IHCRs included documentation of attempted contact to the
parent/guardian in the progress notes when a new medication was ordered. All five IHCRs
contained written notifications documented on the Department’s Parental Notification of Health-
Related Care: General or Parental Notification of Health-Related Care: Medications forms. Four
of the youth were taking prescribed psychotropic medications upon admission. Three of the
youth were applicable for a new psychotropic medication, change in dosage, or discontinuation
of medication which was documented on page three of the Department’s Clinical Psychotropic
Progress Notes (CPPN) form. A staff witness for telephone call attempts was documented in the
three applicable IHCRs. Two youth were in the care of the Department of Children and Families
(DCF), and a court order was included in both IHCRs authorizing all treatment and procedures.
In all five IHCRs, the youth vaccinations were verified within thirty days of the youth’s admission.
An interview with the registered nurse (RN) confirmed parental notifications are required to be
made when medication changes occur. When obtaining consent for new psychotropic
medications, discontinuances, or medication adjustments, the nurse stated the parent/guardian
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is contacted and verbal consent is received by the psychiatrist and witnessed by the nurse. The
parental consent is mailed out along with page three of the CPPN.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures regarding youth healthcare admission screening and
rescreening each time the physical custody of a youth changes. Five youth Individual
Healthcare Records (IHCRs) were reviewed for a Facility Entry Physical Health Screening
(FEPHS) form. All five FEPHS forms were completed on the date of the youth’s admission.
Three were completed by the registered nurse (RN) and two were completed by the licensed
practice nurse (LPN). None of the youth were out of the physical custody of the Department. An
interview with the RN advised notification is received by a management meeting or email when
a youth is admitted to the program. A nurse completes the FEPHS on the day of admission.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures ensuring healthcare service orientation is provided to
all youth when admitted to the program. Five reviewed youth Individual Healthcare Records
(IHCRs) confirmed all youth received a general care orientation upon admission. A review of
The Health Education Forms, signed by all five youth and filed in each IHCR, confirmed
orientation discussion included access to medical care, sick call procedures, what constitutes an
emergency and when to notify staff, medication process, right to refuse care and
documentation, what to do in the case of a sexual assault or attempted sexual assault, the role
of non-disciplinary healthcare providers, and Standard Universal Precautions.
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 notify the designated health authority (DHA) or
designee, by telephone or verbally, of each youth’s arrival at the program and provide
immediate notification when any youth admitted to the program requires emergency care. The
program’s practice is to notify the DHA of all youth admissions including youth with chronic
conditions, medical concerns, or any youth admitted on psychotropic medications. Five youth
Individual Healthcare Records (IHCRs) were reviewed, three of the youth were admitted with a
known or suspected chronic condition or required a referral to the DHA. None of the youth were
identified as in need of an emergency response upon admission. All three records documented
the DHA notification in the youth’s Chronological Progress Notes and the Chronic Conditions
Log was updated after the notification. Four youth were applicable for taking psychotropic
medication upon admission, and notification to the psychiatrist was documented. According to
an interview with the registered nurse (RN), the DHA is notified at intake by the medical staff,
and the notification is documented in the progress notes.
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4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures ensuring the Department’s Health-Related History
(HRH) form is completed prior to the Comprehensive Physical Assessment (CPA) and
healthcare needs are identified. A review of five youth Individual Healthcare Records (IHCRs)
found each HRH was completed on the day of the admission. All five IHCRs indicated the HRH
form was completed prior to the CPA to include the date and signatures. In all IHCRs, the
designated health authority (DHA) reviewed the HRH form as evidenced by a checkbox on the
CPA and a focused note in the admission documentation. An interview with the registered nurse
(RN) confirmed the HRH is completed upon intake.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the acute and chronic healthcare needs of
youth are addressed by completing a Comprehensive Physical Assessment (CPA) within seven
days of youth admission. A review of five Individual Healthcare Records (IHCRs) confirmed the
program utilized the Department’s CPA form. All CPAs were completed by the designated
health authority (DHA) within seven days of the youth’s admission to the program. All five had
the youth’s Medical Grades documented on the CPA. The program completes a new CPA for all
youth, no prior CPAs were utilized. All sections of the CPA were completed in full utilizing “O” or
“X” markings. Four of five youth refused the genital exam which was documented as “youth
refused” on each CPA in the IHCRs, all four youth signed a refusal form which reflected the
refused portion on the CPA. The CPA in all five records included documentation of the most
recent verified Tuberculosis Skin Test (TST), which was administered within the last year to
determine exposure to tuberculosis (TB). The results of the TST were documented on each
youth’s CPA and matched the documentation on the Department’s Infectious and
Communicable Diseases (ICD) forms. The Department’s Problem List was updated for each
youth, when applicable. An interview with the registered nurse (RN) confirmed the DHA
completes a new CPA upon intake and annually thereafter. The youth are screened for TB
within seventy-two hours of admission.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures to ensure all youth admitted to the program are
screened, evaluated, and treated, if applicable, for sexually transmitted infections (STIs) and
human immunodeficiency virus (HIV). The designated health authority (DHA) determines, based
on the youth’s risk factors, screening tool, and evaluation, whether to order testing for STIs. A
review of five Individual Healthcare Records (IHCRs) found all youth were clinically screened
and evaluated for STIs on the date of admission. None of the youth required further evaluation.
All testing, screening, clinical evaluations, and diagnoses were documented on the
Department’s Infectious and Communicable Diseases (ICD) forms, excluding the HIV results,
and were filed in the lab section of the IHCR. None of the youth were out of the Department’s
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physical custody; therefore, a rescreening was not applicable. Two youth consented to receive a
HIV test and had documented consent from the youth. Both youth were offered pre/post-test
counseling, testing, and referral for treatment for HIV and the pre/post-test counseling was
documented on the youth’s Individual Health Education Records. The HIV results were filed
confidentially in a sealed envelop marked “Confidential.” Each of the envelopes were signed by
the DHA indicating their review. The youth’s confidentiality was protected by not including the
youth’s HIV status on the program’s internal alert system. The program’s policy ensures the
youth’s HIV test results are only disclosed to the youth’s legally authorized representative,
healthcare providers during treatment, the Department of Health for purposes of reporting,
health facility staff committees conducting facility monitoring, medical personnel who have been
subject to significant exposure, and healthcare facility personnel or agents for healthcare
provider who have a need to know during patient care. Pre and post-test counseling services
are provided by the DHA. Five youth were interviewed and all five advised they can request
testing. An interview with the registered nurse (RN) confirmed youth are screened for STIs at
intake through a urine sample which is sent to the lab for testing. If the screening indicates a
need for further evaluation, the DHA is contacted immediately, orders are received and then
processed at once. Education is given to the youth. The screenings, evaluations, referrals, and
tests are documented on the ICD form. The RN also confirmed youth can request access to HIV
counseling and testing services and they can sign a written consent to be tested. Results are
documented on the ICD form and the Health Education Record is updated.
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 policy and procedures addressing the program’s sick call process. Two of
five reviewed youth had a sick call request. One additional record was requested and provided
to review. None of the youth presented with a similar sick call complaint three or more times
within a two-week period. All three reviewed sick call requests were addressed by the registered
nurse (RN). Each of the Sick Call Request forms were filed in each youth’s Individual
Healthcare Record (IHCR) in reverse chronological order. None of the youth were in restricted
housing of any kind. The Sick Call Request forms and progress notes were documented in
accordance with Florida Administrative Code, including vital signs, treatment, education, and
follow-up plans. Each of the sick call events were documented on the Sick Call Index and on the
program’s Sick Call Referral Log. All the dates listed on the Sick Call Index corresponded to the
completed Sick Call Request forms located in the youth IHCRs. Sick call occurs seven days a
week, twice a day. Sick call hours are posted on the medical office door, in the dorms, and in
the hallways. Sick call forms are located on each dorm and in the cafeteria. An exam table and
equipment are used to perform sick call. Sick call was not observed during the annual
compliance review as none occurred. Five youth were interviewed, and all advised they can see
a doctor or dentist if needed. Three youth advised being seen within one day for a sick call, one
stated being seen within three days, and one said they never made a sick call request. An
interview with the RN confirms youth may put a sick call request in the sick call box and they
shall be seen within two hours of the request being made. The RN on duty is the one who
usually conducts sick call. If the designed health authority (DHA) is on-site when sick call is
scheduled, they will conduct sick call. The program provides twenty-four-hour medical care.
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4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures to ensure youth have access to episodic and first-aid
care. A review of five youth Individual Healthcare Records (IHCRs) found four youth required
on-site episodic care. In all five IHCRs, the on-site care was provided by a licensed healthcare
staff and was documented in the problem-oriented, subjective, objective, assessment, and plan
(SOAP) elements. The program has a total of twelve first-aid kits located in designated areas
throughout the program. The kits are in the kitchen, medical, maintenance, alpha, bravo, charlie,
delta (dorms), multipurpose room, and four for transport. The program has a process for
ensuring contents of the first-aid kits are maintained and stored in accordance with guidelines to
prevent expiration or deterioration. An observation of three first-aid kits confirmed the kits were
fully stocked with designated health authority (DHA) approved contents. The nurse monitors the
first-aid kits monthly and checks for expired contents, which is documented on the first-aid kits
logs. The program has two automated external defibrillators (AEDs) located in medical and
Charlie dorm. The AED procedures are located with the AEDs. The AED batteries and pads are
checked by a registered nurse (RN) once a month. Documentation confirmed the RN monitored
the AEDs as required. The RN checked the expiration dates of the AED in the presence of the
Monitoring and Quality Improvement regional monitor. The nurse conducted a self-test of the
AED in front of the regional monitor. The batteries of the AED were last changed in March 2024
and expire in September 2029. The AED pads were changed January 2025 and expire in April
2027. The batteries of the AED in Charlie dorm were last changed in July 2023 and expire
March 2027. The AED pads were changed October 2023 and expire in November 2028. A
review of the emergency drills confirmed the program conducted an emergency drill to include
cardiopulmonary resuscitation (CPR)/AED annually. The emergency medical drills simulated an
episodic care event which called for immediate first-aid and/or administration of CPR
techniques, and the initiation of emergency procedures to follow when a life-threatening
emergency does occur. The program had a list of emergency numbers which were inaccessible
to youth. The emergency numbers are posted in master control, medical, and administration. A
review of ten training records confirmed all staff were trained in episodic, first-aid, and
emergency care, and the administration of the epinephrine auto-injector. The program has a
facility operating procedure (FOP) regarding Narcan. The policy states all newly employed staff
and admitted youth shall receive education on recognizing and treating symptoms of opioid
overdose. Training will include risk factors for overdose, strategies to prevent overdose deaths,
overdose recognition and response, and administration of Narcan. The training and prevention
plan also includes emergency response procedures. Narcan is stored in medical and
inventoried along with other medication. Supervisors are trained on the use of Narcan. Five staff
were interviewed and three stated they are allowed to personally call 9-1-1 in the event of an
emergency. One staff said they would notify master control and master control would call 9-1-1
and one staff said they would notify a supervisor and the supervisor would call 9-1-1. Five youth
were interviewed and all confirmed they can see a doctor if needed. The RN was interviewed
and confirmed on-site care is documented on the Episodic Care form with documents the
subjective, observation, assessment, plan (SOAP) elements. The RN confirmed emergency
drills are conducted on a monthly basis on each shift. They stated emergency numbers are
posted in medical and master control and they are inaccessible to youth. An episodic event was
not able to be observed while on-site.
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4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures to ensure for timely referrals and coordination of
medical services to an off-site healthcare provider. A review of five Individual Healthcare
Records (IHCRs) found four were applicable for off-site care. In all applicable IHCRs, there was
an indication the youth required off-site first-aid or emergency care. The Department’s Summary
of Off-Site Care Consultation Report form was utilized and filed in all four youth’s IHCRs. Three
IHCRs had documentation of the parent/guardian notification efforts, one youth was in the
custody of the Department of Children and Families (DCF), who was notified. Two youth were
applicable for discharge documentation and each had the applicable documents filed in the
IHCR. The designated health authority (DHA) reviewed and signed all off-site care findings,
instructions, and information in each of the four applicable IHCRs. Two of the youth required
follow-up testing, referrals, or appointments. The IHCRs had documentation the referrals were
tracked, and both youth received appropriate and timely follow-up care. The registered nurse
(RN) confirmed all completed off-site care forms are flagged for DHA review, and youth are
tracked utilizing a medical tracking log and a white board within the medical area.
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 policy and procedures to ensure any youth admitted to the program who
have chronic conditions receive regularly scheduled evaluations and any as-needed follow-up
care. A review of five youth Individual Healthcare Records (IHCRs) found three were identified
on the Department’s Facility Entry Physical Health Screening (FEPHS) form with a current
chronic condition at admission. None of the youth were identified as having a communicable
disease. All five youth were taking prescribed medication on an on-going basis. None of the
youth were undergoing treatment for a physical health condition. All three youth were classified
with a Medical Grade of two to four and were placed on the program’s Chronic Illness List. Two
youth were applicable to receive periodic evaluations at least every ninety days and both
received the required periodic evaluations. None of the youth were applicable for taking anti-
tuberculosis medications. Three youth had an evaluation conducted off-site and all three
evaluations were documented on the Summary of Off-Site Care forms and filed in the IHCRs. In
all three records, the designated health authority (DHA) followed up with the youth after
receiving off-site care and signed off on the documents. There was no evidence of any lapses in
care or missed periodic evaluations. The Department’s Problem List was updated for each
youth. An interview with the facility administrator advised each youth’s medication regimen shall
be ascertained upon admission to the facility. All prescriptions for youth are immediately
processed to ensure there are no lapses with the administration of medications. All prescribed
medications shall be obtained from a licensed pharmacy, according to a contractual agreement
between the program and the vendor. The DHA was interviewed and confirmed periodic
evaluations for youth with chronic conditions are completed every three months and there is a
chronic condition calendar to keep track of the due dates for evaluations. The nurse confirmed
the periodic evaluations are conducted at a minimum of once every three months and are
tracked on a calendar and in the DHA binder.
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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 policy and procedures to ensure the accurate and safe administration of
youth medications. A review of five youth Facility Entry Physical Health Screening (FEPHS)
forms found four youth were taking medication at the time of admission. All four youth
medications were verified prior to the youth being admitted into the program, and the
prescription notification was documented in the youth’s Chronological Progress Notes. The
designated health authority (DHA) and, when applicable, the psychiatrist was contacted to
obtain an order to resume the specified medications prescribed prior to admission for each
youth. One youth was not admitted with medication; however, was placed on medication while
at the program. Each of the five reviewed youth Individual Healthcare Records (IHCRs)
documented the youth received medication while in the program and all medications were
continued, discontinued, changed, or new medications ordered utilizing the Practitioner Order
form. Each medication had a current and valid prescription or order. None of the youth were in
restricted housing of any kind. Three of five youth were applicable for over-the-counter (OTC)
medications which were administered according to approved protocols. The Department
Medication Administration Record (MAR) was used to document all medications and treatments
for all reviewed IHCRs. The MARs clearly indicated medication start and stop dates of all youth
medications. In all five IHCRs, the staff initialed each administered medication entry. There were
no undocumented explanations for lapses or errors in medication administration for any of the
reviewed IHCRs. The registered nurse (RN) documented side-effects monitoring weekly on the
MAR for all five reviewed IHCRs. There were no medications administered by non-healthcare
staff. One youth had a refusal, which was clearly documented on the MAR. The MAR contains
all required elements. Four of the five youth were admitted to the program on psychotropic
medications, and the psychiatrist was notified in all four IHCRs. Each youth received a
psychiatric evaluation within fourteen days. One youth was applicable for psychotropic
medication subsequent to admission. Five reviewed IHCRs indicate all five youth received
medication monitoring/review every thirty days as required. There were no standing orders for
psychotropic medications, emergency treatment orders for psychotropic medication, or any pro-
re-nata (PRN) orders for psychotropic medications. A medication pass was observed. Youth
were escorted by the direct care staff and approached the nurse individually. The medical
provider identified themself and confirmed the reason each youth was present. The medical
provider prepared each medication and verified each youth’s allergies and alert status. The
medical provider and youth initialed the MAR, and the medical provider observed to ensure the
medication was swallowed. The Six Rights of Medication Delivery/Administration were
maintained for each youth. Five youth were interviewed, and three advised a nurse provides
medication and could explain the process. The other two youth stated they do not receive
medication. An interview with the nurse advised when a youth is admitted, medical staff
completes the Medication Verification form by verifying medications with the youth’s previous
doctor. The nurse confirmed the program has a modified Class II permit and medications are
procured through a vendor all the time. The program has a psychiatrist on-site who provides
medication management, treatment team, and pro-re-nata (PRN) services.
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4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures to ensure medical equipment classified as sharps
and medications are secure and inventoried utilizing a routine perpetual inventory. Reviewed
medical equipment classified as sharps confirmed the items were securely stored and
inventoried utilizing a routine perpetual inventory descending count. Reviewed medications
were identified and secured in a locked, clean, and organized medication cart designated for
storage of medication, located in a secured area inaccessible to youth, with narcotics and other
controlled medications being stored behind two locks, and refrigerated medication being stored
in a secured refrigerator only used for medication. Stock items are kept separate from youth
specific medications. The program’s process for the destruction and disposal of non-controlled
medications is for two nurses to destroy all medication using the chemical drug buster.
Controlled medication is destroyed when the pharmacist consultant is on-site with one
registered nurse (RN). Discontinued medications are sent back to the pharmacy. A review of the
program’s perpetual and weekly inventory of all sharps and stock over-the-counter (OTC)
medications verified completion as required with no discrepancies. Reviewed documentation
verified the nursing staff maintain a shift-to-shift inventory of all controlled substances which is
documented each youth’s Individualized Controlled Medication Inventory Record. Nursing staff
are on-site twenty-four hours a day to provide oversight and the delivery of medication.
Observations were conducted of inventory counts of three controlled medications, three OTC
medications, and three sharps with no discrepancies found. The interviewed nursing staff
confirmed all controlled medication is located behind double locks in the medical office and are
destroyed as witnessed by the pharmacist consultant and one nursing staff. The health services
administrator (HSA) reported if there is a discrepancy in the count, the nursing staff will inform
the HSA and facility administrator (FA) immediately and conduct a recount and inventory to
check and/or find where the discrepancy originated. Once confirmed, a call to the Department’s
Central Communications Center (CCC) will be placed.
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 policy and procedures related to an Infection Control and Exposure Control
Plan. The Infection Control and Exposure Control Plan is signed annually and was reviewed and
signed by the designated health authority (DHA) on February 5, 2025, facility administrator (FA)
on February 4, 2025, and provider corporate on February 4, 2025. The program’s infection
control procedures include common infectious diseases of childhood, self-limiting, episodic
contagious illnesses, viral and bacterial infectious diseases, tuberculosis, Hepatitis A, B, and C,
human immunodeficiency virus (HIV), infectious diseases caused by blood-borne pathogens,
other outbreaks or epidemics caused by any other infectious agent, outbreaks of lice or scabies,
Methicillin-Resistant Staphylococcus Aureus (MRSA) and other antibiotic resistant micro-
organisms, food-borne illnesses, bio-terrorist agents, and chemical exposures. The program
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offers Hepatitis B immunizations to staff, and they have access to personal protective
equipment. The program has a comprehensive process for needle stick post-exposure
evaluation. If necessary, the program would have a separate file containing all documents of
youth and staff who have experienced a program or occupational exposure; however, there has
not been a need as neither youth nor staff have had an exposure or any reportable infectious
disease. The FA was interviewed and confirmed the plan is located in medical and master
control, with staff completing a biannual review of the plan. The nursing staff was interviewed
and confirmed infectious and exposure control plan training is provided by the health services
administrator (HSA) and nursing staff provide training to youth at admission and on an as
needed basis. Nursing staff routinely utilizes the county health department to obtain youth
immunizations.
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 in an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Limited Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures stating how the program shall maintain active
supervision of youth at all times. Active supervision is described as interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of youth
and changes in behavior, and consistently applying the behavior management system.
Additionally, program staff shall be able to account for the whereabouts of youth under their
supervision at all times.
Observations of staff during the annual compliance review week found staff supervising youth
appropriately during all observed activities. According to the policy and procedures provided to
the annual compliance review team, staff-to-youth ratios are one staff to eight youth during
awake hours, one staff to ten youth during sleep hours, and one staff to five youth for off-site
activities. Observed activities made during the week of the annual compliance review were
supervision of youth during school hours, in the dining area, recreation, supervised cleaning
activity, and youth movement through the program. The daily schedules were posted in the
dormitories, common areas, and cafeteria. Youth were observed to be supervised at all times
during the annual compliance review week. Positive interactions were observed between youth
and staff. Youth were observed while they were in their sleeping rooms. Three interviewed staff
were able to immediately know how many youth they were currently supervising. During the
annual compliance review period, the program had two escapes, one of which was found to
have been the result of lack of supervision and maintaining proper ratio. Following consultation
with the Department’s Office of Residential Services, this indicator is receiving a rating of limited
compliance.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program maintains a policy and procedures addressing the implementation and training of
the program’s behavioral management system (BMS), which has not changed since the last
annual compliance review and contains all the required elements. The program utilizes the
iChoose System which is a coordinated system of promoting, monitoring, recognizing, and
rewarding a youth’s progress. It is a program of incentives and consequences which promote
individualized skill building, appropriate behavior, and accountability. Staff use point cards to
monitor how well the youth are progressing in the program. Youth earn points daily for
complying with the program rules. At the end of each day, the points are totaled, and each youth
is rewarded according to the number of points earned.
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Each youth enters the program on an orientation level prior to starting the BMS and progresses
their way up the four levels. A review of the BMS confirmed it is not used solely to increase a
youth’s length of stay, deny basic rights or services, promote the use of group punishment,
allow youth to punish other youth, or include disciplinary confinement. Youth learn about the
BMS during the orientation process, each youth is provided a program handbook which
describes the BMS. A review of the youth handbook indicated the BMS is included and clearly
written, A review of ten staff training records indicated staff were trained on the BMS. Education
staff are employed by Florida Virtual School (FLVS), and each educator received BMS training
by the program’s staff development manager. The education staff is not responsible for the
implementation of BMS, the program staff remains responsible for the implementation of BMS
throughout the school day. A review of ten youth case management records indicated each
youth participated in orientation upon arrival to the program and received a copy of the youth
handbook. Observations found the BMS was posted throughout the program and accessible to
youth. Observations of staff and youth interactions verified staff were adhering to the BMS by
utilizing a ratio of four-to-one positive to negative consequences when redirecting the youth as
indicated in the program’s policy. A review of the program’s BMS indicated a variety of
rewards/incentives: staff verses youth kickball games, candy, snacks, youth night outings, and
pizza. Special provisions were outlined in the program’s contract, assuring ongoing supportive
services for the youth who may experience relapse, incorporate principles and practices related
to trauma informed care, and will ensure positive reinforcement is implemented.
Ten staff were interviewed, and all ten reported they were trained in the BMS. Ten staff stated
the BMS consists of a point system to include different levels with rewards and consequences.
The interviewed staff stated the BMS rewards youth with daily and weekly incentives including
reward parties, extra snacks, hygiene, ice cream, off-site activities, and canteen. Each of the ten
interviewed staff stated nothing can be taken away from a youth as a consequence and youth
are informed of the consequences of their behavior at the time of the incident and are able to
explain. The ten interviewed staff reported the supervisors inform staff on how the BMS should
be utilized and provide feedback during shift briefings, at meetings, and one-on-one if
corrections are needed. Ten youth were interviewed, and each youth stated the consequences
included emergency treatment team, level freezes, privilege restriction, and early bedtime. Ten
youth reported they receive daily and/or weekly incentives such as special meals, snacks, and
canteen. Each youth was familiar with the program’s BMS level system stating upon entering
into the program they start as a Freshman then move up in rank upon completion of a packet
with each level. All ten youth reported staff use rewards the same. All ten interviewed youth
indicated youth are not allowed to punish other youth. An interview with the facility administrator
(FA) confirmed the program utilizes the iChoose System BMS and reiterated the program’s
BMS policy.
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.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures in place to conduct and document ten-minute checks
during sleeping hours or at other times youth are behind a locked door, such as during an
illness. The program has a total of 177 video cameras capable of recording thirty-days of video
footage. During the annual compliance review week, all 177 of the cameras were operational.
Prior to conducting checks, staff are positioned where they are able to see any movement within
the living unit. Staff are required to conduct room checks every ten minutes and document the
time of the check on the Ten-Minute Check Log when youth are sleeping. The program’s
practice is to complete checks at eight-minute intervals, master control initiates the checks using
radio communication, so all dormitories are completed at the same time. A video review of ten-
minute checks, including samples from each of the living units, verified staff were conducting
checks every eight minutes and documented the times accurately on the Ten-Minute Check
Log. In addition, the Ten-Minute Check Logs since the last annual compliance review were
reviewed. A sample of various days, times, and shifts indicated the ten-minute checks were
completed within the required frequencies. Ten interviewed staff verified room checks are
conducted every eight minutes when youth are placed in their rooms for sleeping or non-
punishment reasons. In a formal interview, the facility administrator stated the program has 177
working cameras with video recording capabilities for thirty days.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program maintains a 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 conducts formal head counts each hour and after outdoor activities. The program’s
policy indicates counts are conducted during power outages, escapes, program disturbances, or
any other disruptions which may occur. A review of the policy and procedures and well as 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 situations, and at regular intervals. A review of twelve randomly selected dates and
times in the program’s logbook since the last annual compliance review validated head counts
were conducted at the beginning of each shift, hourly, after outdoor activities, during emergency
situations such as program disturbances, and during actual and/or simulated drills. In addition,
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the program logbooks included documentation of new admissions, releases, transfers, and
youth temporarily away from the program. Observations made during the annual compliance
review week indicated it is the program’s practice to conduct hourly youth counts and to
announce youth counts before all movement. Ten interviewed staff explained formal counts are
conducted every hour. Ten interviewed staff explained formal counts are conducted every hour
and informal counts are conducted with every youth movement. Each staff stated emergency
counts are conducted when youth are missing, after emergency drills, and if there is a
discrepancy in the count.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a policy and procedures to ensure the maintenance of a chronological
record of events, incidents, and activities in a central logbook. The program maintains a bound
logbook with numbered pages for each month. A review of logbook entries
confirmed they were documented in ink with no erasures or white-out areas. Errors were
struck through with a single line, dated, and initialed by the staff correcting the error.
Reviewed documentation of randomly selected days within the logbooks reflected each entry
included the date and time of the event, the name of the staff and youth involved, as well as a
brief description, the name, and signature of the staff making the entry. Logbooks included
entries for emergency situations, population counts, law enforcement access to youth, perimeter
checks, and youth movement. In addition, admissions and releases were documented as well
as transports away from the program. There were no precautionary observations during the
annual compliance review period to review. A review of the activity schedule and logbook
documentation verified there was minimal interference of education instruction. Logbook entries
for education included youth movement to and from the classrooms and school start and end
times. Logbook entries and observations verified recreation was conducted as scheduled. A
review of internal incidents reported to the Florida Abuse Hotline and/or the Department’s
Central Communications Center (CCC) verified each were documented in the logbook. The
program ensures direct care staff, including each supervisor, are briefed when coming on duty.
Each staff signs the shift briefing section of the logbook to acknowledge receiving the
information. Observation of the youth living areas confirmed a copy of shift reports were
maintained in each living area for 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 policy and procedures for assignment, inventory, tracking, and storage of
program keys. Keys are bound on a tamper resistant ring which includes a brass-colored tag
with the number of keys and a tracking number. The facility administrator (FA) is responsible for
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inventory and tracking of all program keys including issuance, verification activities, and tracking
of keys including retrieval of keys from permanent staff. Shift supervisors with the assistance of
the master control operator are responsible for the inventory, issuance, and return of keys from
shift to shift. Observations verified program keys and staff personal keys are maintained in
master control in a secured cabinet with a lock. 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. The program identifies keys as active and restricted which are kept in a locked
drawer below the key cabinet in master control. Active keys are assigned to direct care staff
while restricted keys are designated for medical staff, kitchen staff, case managers, and
therapists. The program’s practice is when staff arrive at the program, personal keys are
collected by master control and placed in the key cabinet. Active program keys are given to staff
by master control who also documents in the key logbook. A review of the key logs since the
last annual compliance review verified this practice. In addition, the program has a list of staff
who are assigned permanent keys. Permanent keys are issued, and staff sign an
acknowledgment form indicating the key identification number and the number of keys issued. A
review of the signed acknowledgment forms indicated each staff signed for the use of
permanent keys. A random check of three staff indicated they had program keys, knew the
number of keys on the key ring, and knew the function of each key. If a key becomes damaged,
a Broken Key Report is filled out which includes the date, reporting staff, key hook number, key
number, description, and attach the broken key with tape. The shift supervisor and key control
manager sign the form and the key is replaced. A review of the Department’s Center
Communications Center (CCC) reports since the last annual compliance review indicated there
was one report made to the CCC for missing keys. The disposition of the CCC indicated the
staff had found the missing keys, the case was closed. An informal interview was conducted
with the safety and security supervisor who reported staff keys are given to master control upon
entry into the facility, those personal keys are securely stored, and program keys are assigned
to the staff. Visitor keys are given to master control upon entry into the facility and are given a
“numbered tab” to return upon their departure. Observations indicated there is a daily tracking
key log, and inventory of keys. The safety and security supervisor stated staff are to notify
master control of missing or lost keys and when keys are damaged. Master control notifies the
assistant facility administrator (AFA) then the program’s physical plant manager has the
damaged/broken key replaced. The CCC is notified of any keys missing. Ten interviewed staff
were able to explain the process in which personal keys and program keys are administered
and tracked. Ten interviewed staff stated they provide master control with their personal keys up
entering the facility, the keys are kept in a secure cabinet, and they are documented into a
logbook when facility keys are provided to them.
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
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materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a policy and procedures to identify materials considered to be
contraband, to prevent contraband from entering the program, and consequences when found
in the possession of youth in the program. The program has a system in place to prevent
contraband entering the facility which includes defining items/material considered contraband,
as well as exemptions, providing youth with a list of contraband, informing youth of
consequences if found with contraband, and searches the physical plant, program grounds,
youth, and incoming and outgoing mail. The facility visitor log and all ten sampled staff
personnel records contained a signed contraband attestation statement. All forty-one new hire
staff records contained the contraband attestation statement. The attestation statement
addresses any staff who is found in possession of contraband in a program will be subject to
disciplinary action up to and including dismissal as outlined in Florida Administrative Code. The
policy also states law enforcement will be contacted if any found item is considered illegal as
defined in Florida Statutes, or if there is evidence of any type of unlawful activity. The program
clearly delineates those items considered contraband and keeps a contraband log documenting
the focus of the search, items found, and the disposition of any items found. A review of the
Department’s Central Communications Center (CCC) reports since the last annual compliance
review indicated one report of contraband being found and turned over to local law enforcement.
The program logbooks, search and contraband logs, and incident reports were reviewed to
determine frequency and quality of searches and the results of each search, and each were
found to be in compliance with policy. An interview with the facility administrator (FA) confirmed
the program’s policy and procedures on how contraband is handled and disposed of is at the
discretion of the FA. Contraband not considered illegal shall be discarded, returned to their
original owner, mailed to the youth’s home, or stored and returned upon release. The FA
confirmed in all cases involving the confiscation of illegal contraband, the confiscated items shall
be turned over to law enforcement authorities and a criminal report filed. Ten staff interviews
were conducted and six staff stated youth room searches are conducted daily. Four of the ten
staff stated the assistant facility administrator conducts youth room searches on a weekly basis.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a policy and procedures to ensure searches, including full body visual
searches, are conducted according to Florida Administrative Code at the time of admission,
after off-site activities, and visitation. Parents/guardians 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 after school, group, outdoor recreation, and meals. Youth who
are a new admission, readmission, returning from visitation, returning from off-site activities
and/or appointments, suspected of contraband, or are a security risk are full body searched.
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Observations made throughout the annual compliance review week and video observations
validated youth are provided instructions regarding the search, youth searches were conducted
by staff of the same gender as the youth, were conducted in a manner so as not to degrade the
youth, and were based on the Protective Action Response (PAR)/Right Interactions (RI) training
manuals. Searches observed during the annual compliance review week verified youth were
searched after every movement. Youth searches were observed upon returning from a transport
and upon intake. All observed searches were completed thoroughly and respectfully. Youth
appeared to be comfortable and accustomed to the process. Ten staff were interviewed and
nine of the staff stated youth are searched at every movement and returning from any transport.
One staff stated youth are searched four to five times a week. Ten interviewed youth confirmed
they are searched upon every movement. Two youth stated the youth are also searched if any
item is missing from the facility or returning from any work detail.
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 center maintains a policy and procedures for transportation, operation, and maintenance of
each vehicle used to transport youth. The center has a total of four vehicles of which all four are
used to transport youth. Two of the vans are Department issued and two are provider-owned.
Each vehicle had an annual safety inspection conducted by a certified automobile mechanic.
Observations of the four program vehicles were conducted. Each reviewed vehicle was locked
when not in use. The four youth transport vehicles have the appropriate number of seatbelts, a
safety screen, a seatbelt cutter, a window punch, up-to-date fire extinguishers, and an assigned
first-aid kit with approved items by the designated health authority (DHA) which is checked out
by staff prior to departure with youth and returned to medical upon the completion of transport.
Weekly visual vehicle inspection checks are conducted on all vehicles as required and
documented on the preventative maintenance check sheets. The four observed vehicles had
working seatbelts and the passenger doors could not be opened from the inside. A random
check of five staff personal vehicles and four program vehicles during the annual compliance
review week found all the vehicles were locked and secured when not in use.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a policy and procedures to ensure the safety and security of youth and
the community when youth are transported outside of the program. Reviewed documentation
verified all approved drivers had a valid driver’s license, human resources conduct a monthly
driver’s license check on all staff to ensure all staff operating a program vehicle have a current
license. The program assigns a ratio of one staff to five youth during transport, not including the
driver. An observation of a transport was conducted, there were two staff with one youth, one
male and one female, all were wearing seatbelts. Logbook entries with names of staff
transporting youth reflects at least one staff of the same gender as the youth is on each
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transport. Ten staff were interviewed, each staff confirmed they are not allowed to use personal
vehicles to transport youth. Ten interviewed staff confirmed they are provided with a cellular
telephone and two-way radio for communication during transport. Nine of the ten interviewed
staff stated youth are secured with shackles, two of the ten staff stated youth are secured in the
vehicles with seatbelts during transport. This was discussed with the program, and they
reported the staff likely heard secured and reported on shackles; however, it is the program’s
policy to ensure all youth and staff have seatbelts secured while in a transport vehicle. Ten
interviewed staff confirmed emergency equipment in the transport vehicle included a first-aid kit.
Three staff stated there was a knife for life in the vehicle, two staff stated there are jumper
cables, and five of the staff stated there was a fire extinguisher inside all transport vehicles.
Each of the ten interviewed staff confirmed the vehicle is searched prior to and after each use
for contraband. Each staff stated in the event of an emergency during transport, they are to pull
over, contact the program, call 9-1-1, and assist the youth if there are any injuries or illnesses.
Seven of the ten interviewed staff stated the staff to youth ratio for transport is one staff to five
youth, one staff stated the ratio is one staff to four youth, and two staff stated the ratio is two
staff to one youth. Ten interviewed youth stated they had never witnessed anyone placing
contraband into the vehicles, and have never been handcuffed to any part of the vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a policy and procedures to ensure safety and security is maintained.
The policy addressed who is responsible for conducting the audits, procedures to implement
corrective actions for deficiencies, and an internal system to verify deficiencies are corrected.
Weekly safety and security audits are conducted by the assistant facility administrator (AFA)
and physical plant manager or designee and documented on the Safety and Security Audit
Inspection form. Any deficiencies are addressed on the form and a work order is submitted to
the appropriate staff for corrections. In addition, deficiencies are discussed during the morning
management meeting. The weekly audit forms are reviewed by the facility administrator (FA). A
review of the Safety and Security Inspection forms since the last annual compliance review
indicated inspections were completed, as required. The program’s Preventive Maintenance
Checklist was reviewed which confirmed maintenance schedules and repairs were conducted
as required. In a formal interview, the AFA stated weekly safety and security inspections and
daily perimeter checks are conducted, and any deficiencies identified are discussed amongst
the management team and addressed, as necessary. There were two assigned safety and
security deficiencies during the annual compliance review period, one for an escape and one for
contraband and ten-minute checks. Both have been corrected and closed. A formal interview
with the FA confirmed all deficiencies identified are reviewed with staff along with corrective
action plans to address the issue.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures to have a tool management system which
ensures youth do not use tools or equipment as weapons or for security breaches. The policy
addresses the issuance, inventory, and control of equipment and tools. A review of inventory
logs and observations verified tools are securely stored when not in use, easily marked for
identification, inventoried prior to, and following work activities. All sharp edged and pointed
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tools are inventoried daily when in use. A review of nine unique tools in the maintenance area
verified the inventory matched the inventory list. The maintenance staff are responsible for
conducting the inventories and securely maintaining all Class A tools and equipment. The
maintenance staff complete a tool inventory list which documents each tool in inventory. All
maintenance tools were inaccessible to youth and were observed to be secured in the
maintenance area. Observations of the tool storage area found it was organized and secure.
Class B tools including mops, brooms, and buckets are maintained in locked closets by each
dormitory and in a locked closet in the kitchen area. The items are used by staff and youth when
performing daily cleanup activities. Staff are required to complete a sign-out and sign-in log
when items are taken and are returned to the designated storage room. Reviewed
documentation verified there were no instances of missing or lost tools since the last annual
compliance review. Prohibited tools at the program include machetes, bowie knives, and other
long bladed knives. According to the program policy, if a tool is broken or inoperable, the
maintenance staff is alerted and makes a notation on the inventory log. The physical plant
manager is responsible for replacing the broken tool. If a tool is missing, staff shall notify
administration, fill out an incident report, document the incident in the logbook, place a tag on
the shadow board, call the Department’s Central Communications Center (CCC), and the
program shall be searched until the tool is found.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. A review of the program’s procedures verified staff
are required to complete a sign-out and sign-in log when Class B tools are taken and are
returned to the designated storage room. A risk assessment is completed by the case
manager prior to youth using any tools. The program’s staff-to-youth ratio during a work project
is no less than one staff to five youth. Program staff search youth after a work detail has been
completed. Ten youth records were reviewed, all youth had risk assessments completed to use
class B tools. No youth were observed utilizing class B tools during the annual compliance
week. Ten youth were interviewed. Nine youth reported they use mops, brooms and scrub
brushes, and one youth stated they are not allowed to use any tools. Ten interviewed staff all
stated the youth are allowed to use brooms, mops, and scrub brushes.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures establishing guidelines for outside contractors who
come on-site to complete repairs. The program's policy stipulates the facility administrator (FA)
is responsible for providing approval and permissions if a personal cellular telephone and/or
equipment/electronic devices capable of taking pictures and/or audio or video records, including
smart watches, are required. The program’s procedures specify tools are restricted to only the
tools needed for the job, tools are checked upon arrival and departure, and youth are restricted
from the work area. When a contractor arrives on-site, they sign the Outside Contractor On-Site
Work Project Log which includes the vendor’s name, date, and time in, a list of tools needed for
the job, the beginning quantity of tools and ending quantity of tools, staff name checking the
tools, and date and time out. The form states the vendor must report any lost tools to
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administration immediately. A review of vendor sign-in sheets since the last annual compliance
review confirmed tools and other equipment were inventoried when the vendor arrived and
inventoried when they left. Three reviewed project invoices showed the date of the project
matched the vendor sign-in sheets. Outside vendors are accompanied by staff to the work area
and youth access is restricted from the work area. Staff must supervise vendors in the work
area where youth are located. No observations of outside contractors were conducted, due to
no outside contractors present at the facility during the annual compliance week.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program’s Continuity of Operations Plan (COOP) addresses fire, safety, and evacuation
emergency processes, and the frequency of conducting drills at random times and under varied
conditions. Reviewed documentation validated emergency drills were conducted for all shifts
each month, as required. In addition, the program conducted emergency drills on each shift
ensuring fire, riot, severe weather, flooding, terrorist threats, chemical spills, medical situations,
and bomb threats were covered on a rotating basis. Drill documentation included the type of
drill, date and time, participants, a brief scenario description, deficiencies identified during the
drill, and applicable corrective actions. Observations of the program during the annual
compliance review week indicated there were twenty-nine annually inspected fire extinguishers
and egress plans are posted throughout the program. Ten staff were interviewed and each
stated they had participated in a fire drill in the last twelve months. Eight of the ten interviewed
staff stated they have participated in COOP drills, seven of the ten staff stated participation of
suicide drills and escape drills, and six of ten stated participation in medical drills. Ten
interviewed youth stated fire and emergency drills are conducted on a monthly basis and
sometimes two or three times a month. An interview with the facility administrator indicated the
program maintains a drill calendar which includes drills for fire prevention, Right Interactions,
medical, suicide, escapes, bomb threats, contraband, COOP, hostage, weather related
incidents, terrorist threats, and disturbances. Drills are conducted randomly on each shift,
monthly in accordance to the program’s contract.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a Department approved Continuity of Operations Plan (COOP) available
for all staff to review. The COOP plan was submitted on April 11th, 2024, and approved by the
Department on April 29th, 2024. The COOP provides for basic care and custody of youth in the
event of an emergency or disaster. The COOP also addresses phases of a disaster plan as well
as emergency management including preparedness, response, and recovery. The COOP
addresses emergencies including fire prevention, bomb threats, evacuations, chemical spills,
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severe weather, and terrorist attacks. A review of the plan indicated alternative housing has
been identified should the program require an evacuation due to an emergency or disaster. The
program also has provisions of equipment and supplies maintained in the kitchen, the
maintenance building, and the assistant facility administrator’s (AFA) office to ensure a
continuous operation of services during emergency or disaster situations. These items include
but are not limited to; clothing, shoes, flashlights, radios, batteries, bedding, raincoats, hygiene
products and nonperishable food items. In addition, the program has a generator to provide
continuous power fror ten to fourteen days. The program maintains identifying information on
each youth in the program, and in the event the program has to evacuate the youth record
accompanies the youth to the temporary location, secured in a locked storage box. A review of
the program’s COOP binder indicated it contains a record of each youth’s name, Department
identification number admission date, gender, race, contact information, emergency contact,
assigned juvenile probation officer (JPO), committing judge, victim information, physical
description, health status, and a photograph. The interviewed facility administrator (FA) reported
the copy of the COOP is maintained in master control and the FA’s office.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures for the storage and inventory of flammable,
poisonous, and toxic materials. Toxic items are stored outside of the program in a locked shed.
Cleaning supplies are located in the locked closets by each dormitory and in a locked closet in
the kitchen area. A list of staff which includes the facility administrator (FA), assistant facility
administrators (AFAs), supervisors, and maintenance staff designates they are authorized to
handle flammable, poisonous, and toxic materials. All flammable, poisonous, and toxic materials
are stored according to type and use. A Safety Data Sheet (SDS) binder is located inside the
storage area with a picture of each material and a number corresponding to the SDS for each
chemical. A perpetual chemical inventory list is maintained, and the chemicals are checked
daily. A review of the inventory list verified this practice. The perpetual inventory form identifies
the chemical number, description, amount used, amount remaining, date chemical is used, and
initial of staff. Observations of the storage area indicated it is clearly marked hazardous
chemicals and securely locked. A review of eight unique chemical inventories were compared to
the actual items in the storage areas and verified the inventory was correctly documented.
The program maintains a policy and procedures to ensure all flammable, toxic, caustic, and
poisonous items are disposed of appropriately. All unused hazardous materials are kept in the
locked storage shed located outside the program and are disposed of according to the Safety
Data Sheet (SDS). The FA was interviewed and indicated disposal of hazardous chemicals is
accomplished within parameters of state, local and federal laws. The maintenance staff is
responsible for the safe and lawful disposal of these items and only maintenance or other
trained staff who have the safety equipment for diluting, handling, and disposing of hazardous
and solid waste are responsible for disposing of hazardous items and toxic materials. The FA
stated there were no chemicals disposed of during the annual compliance review period. Used
kitchen grease and waste is stored in a large container outside the kitchen area and is disposed
of by a local vendor. All liquid waste from work details is disposed down plumbing drains. The
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program’s policy states all chemical spills are reported to master control immediately and the
shift supervisor. An evacuation of the affected area is conducted and a determination by the FA
whether to contact outside assistance to contain the spill. Staff and youth are not allowed to
return to the affected area until it has been deemed safe by a qualified professional. An
interview with the FA indicated disposal of hazardous items and toxic substances or chemicals
is completed by taking them to the local transfer station. Bio-hazardous waste is disposed of at
the local fire department.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedures prohibiting youth from handling any flammable,
poisonous, and/or toxic items or materials. Youth are not to clean, handle, or dispose of any
toxic chemicals, biohazardous bodily fluids, or human waste. Youth are strictly prohibited from
the maintenance area where toxic items and chemicals are stored. Ten youth were interviewed
and eight of the youth stated they do not use any chemicals or cleaning products. Two of the
youth stated staff will spray window cleaner or toilet cleaners and the youth will wipe the
cleaning product up; however, they do not physically spray the substances.
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
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• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a policy and procedures for youth to have visitation and communication
with family members in order to reestablish family and community relationships. Youth are
informed of visitation upon admission during the orientation process. The program encourages
visitation from the parents/guardians by forwarding a welcome letter upon the youth’s admission
notifying the days and time of visitation, who is allowed to visit, and the corresponding rules of
visitation. A list of authorized visitors and correspondence is maintained in the youth’s case
management records and updated, as needed. A review of five youth case management
records verified each record contained an approved correspondence, visitation, and telephone
log. Visitation is held Sundays from 1:00 p.m. through 3:00 p.m. Special visitations are also
provided for parents/guardians who are unable to participate in the regularly scheduled visitation
days. A review of the program logbooks and visitation sign-in logs since the last annual
compliance review verified visitation and special visitation are conducted. Youth are also
provided one fifteen-minute telephone call each week, writing material, and a self-addressed
and stamped envelope to talk with and send letters to approved family members. A review of
the mail logs since the last annual compliance review showed the youth were receiving and
sending mail to approved family members. Youth can have unimpeded access with the courts,
attorneys, their juvenile probation officer (JPO), and/ or the Department of Children and Families
case worker. Ten youth were interviewed, each youth indicated they are given the opportunity to
communicate with family members by mail, telephone, and/ or visitation. In a formal interview
with the facility administrator, it was confirmed the program has an agreement with an
interpreter company, for youth whose primary language is not English.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a daily activity schedule which reflects the youth receive at least one hour of
recreation each day and additional time allotted for leisure activities. The program’s contract
requires two recreation therapists. Recreation therapists have the required credentials outlined
in the program’s contract. The contract does not require special provisions for the incorporation
of recreation into the youth’s performance or treatment plans. The recreation therapist created
monthly activity calendars which reflect the recreation and leisure opportunities available to
youth each day. A review of the activities confirmed they promote social and cognitive skill
development, creativity, teamwork, healthy competition, mental stimulation, and physical fitness.
Logbooks were reviewed for the annual compliance review period and recreation was
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documented each day for at least one hour, as required. Recreation was observed during the
annual compliance review week at its scheduled time and staff were found to be taking
precautionary measures to ensure the health and safety of the youth. Ten youth were
interviewed, all youth confirmed the program allows them the opportunity to exercise, play
outside, or participate in activities indoors for at least an hour each day. Ten youth stated
various activities included basketball, football, volleyball. Ten staff were interviewed and
reported youth are provided recreation time for a minimum of one hour each day. The staff
provided examples of indoor and activities available for the youth to include but not limited to
football, basketball, kickball, card games, stretching exercises.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation rooms; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation rooms; therefore, this indicator is rated non-applicable.
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Standard 6: Educational Services
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
According to the program’s contract, the career and technical education (CTE) services required
to be provided are ServSafe, Occupational Safety and Health Administration (OSHA)-10, First-
Aid/cardiopulmonary resuscitation (CPR), and Florida Ready to Work Soft Skills. CTE services
were provided to the following number of youth: twenty-two youth earned the ServSafe
certification, fifty-four youth earned the First-Aid/CPR certification, sixty-nine youth earned the
OSHA-10 certification, and sixty-four youth completed Florida Ready to Work Soft Skills. Three
staff provide instruction for the ServSafe certification; each has the ServSafe Manager
certification. One staff provides instruction for the First-Aid/CPR certification; the staff is a
registered nurse and has the First-Aid/CPR certification. One staff facilitates OSHA-10 and
Florida Ready to Work; certification is not a requirement because youth earn their certification
from each organization upon passing the web-based modules and assessments. The ServSafe
certification can lead to the Food Safety and Science industry certification identified on the
Master Credentials List (MCL). OSHA-10 serves as a base level certification leading to multiple
industry certification opportunities from American Welding Society (AWS) and National Center
for Construction Education & Research (NCCER), each identified on the MCL. At the time of the
review, nineteen youth were enrolled in coursework towards earning an industry certification in
ServSafe, forty-eight youth were enrolled in OSHA-10, and forty-five youth were enrolled in
Florida Ready to Work. Five youth were interviewed and three reported they are being very well
prepared for high school, high school equivalency diploma (GED), vocational school,
employment, or college, the remaining two reported they were being well prepared. The facility
administrator (FA) confirmed career education services are provided to the youth at the program
including career and technical education (CTE)/C-Tech programming which are special contract
conditions. The FA also confirmed which contract specific pre-vocational and vocational
services are provided at the program.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide educational access. The center
provides education services through Florida Virtual School (FLVS). A review of the facilities'
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activity schedule and the daily academic schedule indicated the facilities' activity schedule
incorporates the daily school schedule. No discrepancies were found. A review of one day each
of eight months of logbook entries found seven of eight days transition to education classes on
time, with one day being five minutes late, and all eight days transition from education classes
on time.Five youth were interviewed, three of the five youth reported there were no interruptions
during school, and the remaining two youth reported the few interruptions are due to youth
behavior. Observations of classroom activity from the program video were made. In each of the
three samples reviewed, the youth were in class for the required amount of time.
6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Education services are provided through a contract with Florida Virtual School (FLVS). The 250-
day calendar is distributed over twelve months and includes twenty days for teacher training and
planning. A review of the daily school schedule and three random days of video and logbook
entries revealed education provided six fifty-minute classes from 8:30 a.m. through 2:45 p.m.
with a sixty-minute lunch break, fulfilling the weekly requirement of twenty-five hours of
instructional time. The interview with the lead teacher indicated all the youth receive credit for
completing a course and the school schedule is adhered to. Three samples of video were
observed, confirming teachers were present during scheduled classroom time.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The education contract provider is responsible for developing a career education program
appropriate for the educational abilities and goals of youth in the program and appropriate for
the length of stay and classification of youth in the program. The career education program
includes Type 1 through Life Management Skills and Personal Finance and Money
Management courses. The career education program includes Type 2 programming through
career and technical education (CTE) course offerings which provide exploration and knowledge
of occupations within those specific careers. The career education program also includes Type
3 programming through CTE course offerings which provide content and competencies for
those specific careers. A career strengths and interest questionnaire is completed by youth at
admission. Each CTE course offering by the education provider includes soft skills for those
specific careers. The education contract provider is also responsible for providing Career and
Professional Education (CAPE) courses leading to pre-apprentice certifications and industry
certification. Youth at this program are enrolled in Digital Information Technology and
Foundations of Programming which are courses leading to the CAPE Industry Certification
Comp TIA A+. The lead educator interview was completed by the instructional leader. The lead
instructional leader reported students take different CTE courses including Digital Information
Technology, Foundations of Programming, and Personal Finance. Students take all state
mandated assessments for Florida Virtual School (FLVS) and Florida Youth College.
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6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
In accordance with the contract, the contracted educational provider is required to develop an
Education Transition Plan for each youth. Upon entering a residential commitment program, an
Education Transition Plan must be developed for each youth. Three closed case records were
reviewed; none contained an Education Transition Plan. Most youth in the program were
admitted prior to July 1, 2024, when the new education provider, Florida Virtual School (FLVS),
started, so they would not have had an Education Transition Plan developed by the new
provider. None of the current youth had an Education Transition Plan developed upon
admission by FLVS, as required; however, FLVS has recently developed an education plan
template and trained its staff to implement an Education Transition Plan for each youth moving
forward. The interview with the instructional leader indicated exceptional student education
(ESE) services are provided for students with disabilities, English language learners (ELL)
services, and intervention groups for those below grade level in reading and/or math are all
offered. The instructional leader reported an Educational Transition Upon Entry form is
completed with each student which discusses their educational needs and goals after leaving
the program.
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The contracted educational provider has policy and procedures in place to provide qualified
instructional personnel. In reviewing the educational instructional staff for the program, including
flex teachers who provide virtual education at the program, it indicated all the teachers have an
active certification, according to the Florida Department of Education website. Flex teacher
certifications suggest all are currently certified in their teaching subjects. Eight teachers were
teaching in the field, and seven were also teaching courses out of the field. The provider sent
parent/guardian notification for those teachers who were also teaching out of the field; however,
the letter did not indicate which subjects were taught out of field. Three teachers are providing
exceptional student education (ESE) services at the program, and the provider has provided
their certification as ESE instructors.
6.07 Florida Youth College (Education Contract Provider) Satisfactory Compliance
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.
The contracted education provider is responsible for referring all youth who receive their high
school diploma or equivalent to Florida Youth College so they can work with a career navigator
on post-secondary courses and/or enrollment in a state or technical college. Three youth
records were reviewed and each youth were referred to Florida Youth College. The Florida
Scholars Academy instructor was informally interviewed regarding post-secondary pathways
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and support offered to youth. The instructor identified Florida Youth College and Britt Technical
Youth Academy as post-secondary pathways and stated support is provided through individual
assessment of students’ academic needs, guided notes, and additional time.
6.08 Florida Youth College (Post-Secondary Contract Provider) Non-Applicable
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.
Each referral received by Florida Youth College (FYC) from the contracted education provider is
assigned a career navigator. The career navigator then connects with youth through the
program to schedule an orientation session. During orientation, the youth and career navigator
develop a career pathway plan to include post-secondary courses and/or enrollment in a state
or technical college. The career navigator continues to assist youth on their career pathway plan
and have incremental follow-up sessions scheduled through the residential contract provider.
Three reviewed youth records found only one of the three documented an orientation was
completed. Only one of the three reviewed youth records documented a career plan and a
thirty-, sixty-, and ninety-day follow-up were completed. Neither of the remaining two youth
records documented a career plan nor follow-ups were completed, however notes reviewed
determine the career navigator was unable to connect with the youth after release.
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source: DJJ

program_name_raw: Deep Creek Youth Academy - Intensive

rule: Indicator 5.01

excerpt: Youth Supervision (CRITICAL)

rating: Limited Compliance