summary: QI Residential - FY23-24 - 3 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Palm Beach Youth Academy
Rite of Passage, Inc.
(Contract Provider)
9680 Weisman Way
West Palm Beach, Florida 33411
Review Date(s): January 23-26, 2024
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Sharon Wong, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Rob Aguis, Career and Technical Education Deputy Director (Standard 1)
Nicos Antonakos, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Christine Calvert-Joyner, Office of Accountability and Program Support, South Region
Supervisor (Standard 4)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Standard 1
and Interviews)
Peter Keelan, Office of Education, Southeast Region Education Coordinator (Standard 2)
Abraham Ruiz, TrueCore Behavioral Solutions, LLC, Regional Compliance Manager (Standard
2)
Program Name: Palm Beach Youth Academy MQI Program Code: 1417
Provider Name: Rites of Passage Contract Number: 10341
Location: West Palm Beach County / Circuit 15 Number of Beds: 78
Review Date(s): January 23-26, 2024 Lead Reviewer Code: 181
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
2.08 Youth Needs Assessment Summary
(YNAS)
2.09 Performance Plan Development,
Goals and Transmittal *
2.20 Educational Access*
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 76 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 76 (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) Limited
2.09 Performance Plan Development, Goals and Transmittal * Limited
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Limited
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 76 (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 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 76 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 76 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Satisfactory
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 and Inventory 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 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Satisfactory
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Satisfactory
5.25 Controlled Observation Satisfactory
5.26 Controlled Observation Safety Checks and Release Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 76 (Revised September 2022)
Program Overview
Palm Beach Youth Academy is a seventy-eight-bed high-risk residential treatment program, for
thirteen to eighteen-year-old males, located in West Palm Beach, Florida. The program is
operated by Rite of Passage, Inc. through a contract with the Department. The program
provides safe supervision of youth, provides youth with clinical services including Mental Health
Overlay Services (MHOS) and Substance Abuse Treatment Overlay Services (SAOS). In
addition, the program fosters each youth by providing delinquency programming including
Thinking for a Change (T4C), Impact of Crime (IOC), Aggression Replacement Therapy (ART),
Coping with Stress: a Cognitive Behavioral Therapy (CBT) Guide for Teens with Trauma,
Adolescent Coping with Depression (CWD-A), Trauma focused CBT, Seeking Safety, and
Health and Sexuality Education. Additional treatment services provided include individual,
group, and family therapy, pre-vocational and vocational services, job training placement, self-
sufficiency planning, recreational and leisure time activities, religious/spiritual opportunities, as
well as restorative justice philosophy programming. According to the program’s staff roster, the
management staff includes a facility administrator (FA), an assistant facility administrator (AFA)
of operations, an AFA of administrative services, a designated mental health clinician authority
(DMHCA) who serves as the clinical director, an assistant clinical director, a registered nurse
(RN) serving as the health services administrator (HSA), a director of case management (DCM),
a business office manager, a program manager, a training manager, and a food services
manager. Case management services are provided by the DCM, five case managers, and three
transition services managers. Mental health staff at the program includes a DMHCA, an
assistant clinical director, six master’s-level therapists, and one recreation therapist. Medical
services are offered and are provided by a contracted licensed medical doctor (MD) who serves
as the designated health authority (DHA), an HSA, and two RNs. Educational services are
provided through the Palm Beach County School District. The program is divided into two living
phases comprised of six total living units. At the time of the annual compliance review, one living
unit was not in use due to continuing renovations. The program’s staff-to-youth ratio is one-to-
eight during daytime activities, one-to-twelve during sleeping hours, and one-to-five for
transports. The program had a total of 103 motion sensitive video cameras capable of recording
thirty-days of video footage. At the time of the annual compliance review one camera was not
operational and was pending repair. The one inoperable camera was located in the recreation
area. At the time of the annual compliance review, the program had six vacant positions
including one health service administrator, one registered nurse, a licensed therapeutic
manager, and two therapeutic managers.
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Office of Accountability and Program Support Page 9 of 76 (Revised September 2022)
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Office of Accountability and Program Support Page 10 of 76 (Revised September 2022)
Strengths and Innovative Approaches
• Youth speak out International is a Prime-time sponsored program which works with Inner
City Youth. The program ran a sixteen-hour course over the span of two weeks in which
the youth were taught about goal setting and determining their mission and purpose in life.
At the end of the program each youth receives a stole.
• Youth participated in several residential collaborative competitions such as a super bowl
celebration, Halloween decorating contest, and a winter holiday decoration party.
• The youth participated in making blankets and created hygiene to-go bags for veterans.
The to-go bags included a drawstring bag, toothpaste, toothbrush, lotion, and mouthwash.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 76 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program maintains a written policy and procedures to ensure a background screening is
conducted for all staff, volunteers, mentors, and interns with access to youth or confidential
youth records. The program had thirty-nine new staff hired since the last annual compliance
review. A review of background screenings verified each staff received an initial background
screening completed by the Department’s Background Screening Unit (BSU)/Clearinghouse
prior to contact with youth or access to confidential records. There were no staff screenings
which required an exemption prior to working with youth. A review of the thirty-nine staff records
reflected each new direct care staff completed a pre-employment assessment and received a
passing score. Reviewed documentation confirmed the program reviewed the Department’s
Central Communications Center (CCC) Person Involvement History Report, the Staff
Verification System (SVS), and the Florida Department of Law Enforcement (FDLE) results for
each new staff prior to hire. The program reported there were eleven new applicable volunteers
since the last annual compliance review, and initial background screenings were completed and
reviewed with no discrepancies. All newly hired staff, volunteers, and contracted staff were
added to the program’s Clearinghouse Roster. The Annual Affidavit of Compliance with Level 2
Screening Standards was signed and submitted to the BSU on December 5, 2023, meeting the
annual requirement. Teachers who are paid or funded by the school board or Department of
Education, received an annual screening, which was completed on December 6, 2023, meeting
the annual requirement.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program maintains a written policy and procedures detailing the background screening
process. Five-year rescreening due dates are based upon the initial hire/start date for all staff,
contracted providers, volunteers, mentors, and interns. Staff rescreening’s are to be submitted
to the Department’s Background Screening Unit (BSU)/Clearinghouse at least ten business
days prior to each staff’s five-year anniversary date. A review of the program’s staff roster found
there were no staff, contracted providers, volunteers, mentors, or interns applicable for a five-
year background rescreening since the last annual compliance review period.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 76 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
 The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
 All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
 Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
 The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
 A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program maintains a written policy and procedures to ensure the addressing of each
youth’s rights, staff rights, and other’s rights to feel safe and secure in an abuse-free
environment. The facility operating procedures (FOPs) for abuse and neglect reporting, along
with the program’s manual, address the code of conduct. Staff are required to sign the manual
acknowledgment form indicating the information required is reviewed. Seven reviewed staff
personnel records reflected each staff reviewed the program’s code of conduct and signed the
acknowledgement form. The program completed a Trauma Responsive and Caring
Environment (TRACE) self-assessment in June of 2023. The Florida Abuse Hotline and the
Department’s Central Communications Center (CCC) telephone numbers were observed to be
posted throughout the program. The program’s policy outlines the reporting procedures for all
staff to follow when a youth requests to report abuse. Staff must notify the shift supervisor or
master control if a youth requests access to the Florida Abuse Hotline or the CCC, as
appropriate. Youth can freely communicate with the Florida Abuse Hotline or the CCC operator.
Once the call has been completed, staff are to notify the shift supervisor or master control. A
youth’s refusal to make the abuse call themselves does not relieve the staff from their mandate
to call the Florida Abuse Hotline, if the staff has reasonable suspicion abuse has occurred. The
program had a total of five incidents alleging abuse against a staff since the last annual
compliance review. None of the reviewed allegations were substantiated. There were no Prison
Rape Elimination Act (PREA) investigations and no investigations with the Department’s Office
of the Inspector General (OIG) pending at the time of the annual compliance review. There were
no applicable cases for any potential human trafficking victims, children of sexual exploitation, or
labor trafficking reported. An interview with the facility administrator (FA) reported the program’s
staff code of conduct is outlined within the employee's handbook and addresses physical abuse,
threats, and profanity towards youth. These examples of rule infractions or misconduct may
result in disciplinary action, including termination. Seven youth were interviewed. All seven-
youth reported feeling safe in the program. None of the youth reported ever being denied the
opportunity to call the Florida Abuse Hotline since being at the program. All seven-youth
reported being aware of where to locate the Florida Abuse Hotline telephone number in the
program. Three of the seven youth reported staff are respectful when talking with youth. Two of
the youth reported some staff will call youth derogatory names. Two youth reported hearing the
curse word slip from another staff mouth; however, not at the youth. The interview findings were
shared with the program during the annual compliance review week. None of the youth reported
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 76 (Revised September 2022)
having exchanged emails, telephone numbers, or social media contact information with staff.
Seven staff were interviewed. All seven staff summarized the abuse reporting process, and
each stated they have never heard a coworker use profanity when speaking to a youth and
never observed a coworker telling a youth no to an abuse call. Each interviewed staff explained
the process for allowing staff and youth to call the Florida Abuse Hotline or the CCC to report
suspected abuse. All seven-staff reported knowing where the number is located throughout the
program. The facility administrator (FA) advised, the code of conduct includes how staff will
represent the Department and the program, along with how staff will protect individuals from the
misconduct of others. Conduct which interference with operations, discredits the company or is
offensive to employees, youth and their families is not tolerated. The program uses a
progressive corrective action system; however, does not tolerate offenses of physical abuse,
threats, or profanity towards youths.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program maintains a written policy and procedures regarding abuse reporting, which is
following the Department’s criteria for reporting abuse. The program’s practice is to initiate an
internal investigation regarding the complaint and remove the staff involved from contact with
youth, when necessary. The program had five allegations related to physical, psychological, or
emotional abuse involving a staff member or other youth since the last annual compliance
review, and all were reviewed. All five incidents documented management took immediate
action to address allegations. An interview with the facility administrator (FA) reported
management investigates all allegations of abuse or neglect and takes immediate actions to
address incidents through internal investigations.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program maintains a written policy and procedures regarding response to incidents in
accordance with Florida Administrative Code. The program had forty-three reportable incidents
since the last annual compliance review. A review of five incidents found each was reported to
the Department’s Central Communications Center (CCC) within two hours of the incident or staff
becoming aware of the incident. One of five incidents was not documented in the program’s
logbook. A review of the program’s internal incident reports found there were no incidents which
should have been reported to the Department’s CCC and were not. There was no comparison
during this annual compliance review regarding the program’s CCC incidents due to this
program’s contracted provider being new.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 76 (Revised September 2022)
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program maintains a written policy and procedures regarding the utilization of physical
intervention techniques in accordance with Florida Administrative Code. The program had
twenty-one Protective Action Response (PAR)/Right Interactions (RI) incidents during the
annual compliance review period. There was documentation to support a monthly summary of
PAR/RI Reports was submitted to the Department each month. A review of the seven PAR/RI
Reports found all involved staff completed appropriate statements prior to the end of their shift.
The PAR/RI Reports were reviewed by a PAR/RI-certified supervisor. The PAR/RI Reports were
reviewed and processed within seventy-two hours by all required parties. A copy of the PAR/RI
Report was placed in the program’s centralized file within forty-eight hours of approval by the
facility administrator (FA) or designee. The program’s PAR/RI training plan was approved by the
Department’s Office of Talent, Leadership, and Culture on January 9, 2023. None of the
reviewed reports documented the use of mechanical restraints. All seven reviewed PAR/RI
Reports did not result in injury to the youth or staff. Reviewed documentation indicated there
were no allegations of abuse by the youth during the PAR/RI incident. One of the reviewed post-
PAR/RI interviews indicated a need for a medical review. The program’s PAR/RI rate during the
annual compliance review period was 1.82, which is on the same level as the statewide
Residential PAR/RI rate of 1.82. An interview with the facility administrator, reported all use of
force incidents are to be communicated with supervisory and administrative staff immediately.
During times when an administrator is not on-site, PAR/RI Reports are scanned to
administrators prior to completion of the shift. All PAR/RI incidents and use of force incidents
are monitored daily in the morning meetings. The program keeps an internal monitoring process
to address all trends regarding PAR/RI and use of force. Seven staff were interviewed and all
seven staff were able to explain the program's PAR/RI process and procedures. Four of the
seven interviewed staff stated had never used PAR/RI and three staff reported using verbal
directives to de-escalate youth.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program maintains a written policy and procedures regarding a pre-service training plan for
all new staff. The pre-service training is provided through a combination of instructor-led and
web-based courses. Seven staff training records were reviewed for pre-service training. All
seven reviewed training records documented each staff completed the pre-service training
within 180 days of hire. All seven staff training records showed documentation to support each
staff exceeded the required 120 hours of pre-service training. Required trainings included
Protective Action Response (PAR)/Right Interactions (RI), first-aid, cardiopulmonary
resuscitation (CPR), automated external defibrillator (AED), professionalism and ethics, suicide
prevention, emergency procedures, child abuse reporting, facility operating procedures, and
Prison Rape Elimination Act (PREA), prior to having any contact with youth. In addition, staff
completed active shooter training, standards of conduct, adolescent development and behavior,
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 76 (Revised September 2022)
restorative justice, the Department’s Central Communication Center (CCC) reporting, civil rights,
communication, confidentiality/Health Insurance Portability and Accounting Act (HIPPA),
Department of Juvenile Justice Legacy, Equal Employment Opportunity, gang awareness,
human trafficking intervention, infection control, information security awareness, Juvenile
Justice Information System (JJIS), mental health and substance abuse, Motivational
Interviewing (MI), quality report writing, safety, security, and supervision of youth, sexual
harassment, effective and respectful treatment of youth, and trauma responsive practices.
Reviewed documentation confirmed staff were trained in the grievance process, behavior
management system (BMS), and the intended and safe use of tools. Shift supervisors, youth
care workers, and the recreation therapist are counted in the staff-to-youth ratio. All completed
training was documented in the Department’s Learning Management System (SkillPro) and was
delivered by qualified trainers. Additionally, the seven reviewed records documented staff were
trained in specialized youth services, as required.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program maintains a written policy and procedures regarding in-service training for all staff.
Seven staff training records were reviewed for in-service training which included two
supervisors. All seven reviewed staff training records documented each staff exceeded the
twenty-four hours of annual in-service training requirements. All seven staff had current
certifications in Protective Action Response (PAR)/Right Interactions (RI), first-aid, automated
external defibrillator (AED), and cardiopulmonary resuscitation (CPR). Each staff was trained in
six hours of suicide prevention, active shooter, human trafficking intervention, information
security awareness, mental health and substance abuse, Prison Rape Elimination Act (PREA),
professionalism, interpersonal communication and ethics, sexual harassment, and trauma
responsive practices. In addition, staff were trained in emergency drills, infection control, blood-
borne pathogens, and the Exposure Control Plan. Two supervisor records were reviewed, and
each supervisor completed the eight hours of management and supervisory training which
included coaching, leadership, and personal accountability. The program has a training calendar
which is updated as changes occur. All trainings were delivered by qualified trainers and were
documented in the Department’s Learning Management System (SkillPro). The program
maintains a written in-service training plan which was submitted to the Department’s regional
director on December 23, 2023.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program maintains a written policy and procedures regarding the grievance process.
According to the program’s policy, procedures are in place to confirm each youth’s right to
grieve and ensure all youth are treated fairly, respectfully, without discrimination, and their rights
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are protected. The program’s grievance procedures include informal, formal, and appeal
phases. Informal complaints are handled as soon as possible, but no later than twenty-four
hours from when the youth submitted the informal complaint, which excludes weekends and
holidays. The facility administrator (FA) investigates any formal grievances received and
resolves in writing with the youth within seventy-two hours of receiving the grievance. Youth are
also provided with the opportunity to file an alternative informal request by utilizing a conference
request form as a first opportunity to voice an objection and informally resolve a complaint.
Grievance and conference request forms were available to youth and were observed during the
program tour. A review of documentation verified the program maintains copies of grievances
for the past twelve months. Reviewed documentation found there were six grievances submitted
by youth since the last annual compliance review. A review of the six grievances revealed the
youth’s grievances were resolved at the formal phase. Each grievance was addressed within
the seventy-two-hour time frame. Seven youth were interviewed and five youth stated the forms
are placed throughout the program. Two stated there are time frames. All seven interviewed
youth reported being able to request assistance in completing a grievance form if needed.
Seven staff were interviewed and five staff stated forms are placed throughout the program.
Two stated youth can request assistance in completing the form. An interview with the FA
reported the AFA is the grievance officer and monitors the process. The phases include first
attempt to process with staff to learn pro-social communication skills. The second phase of the
grievance is if the incident or issue cannot be resolved. The supervisory on-site will attempt to
provide a resolution. The final phase is the meeting with the FA or director of operations to
conclude on the matter.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program maintains a written policy and procedures for the implementation of delinquency
intervention services and facilitator training requirements. A review of intervention group sign-in
sheets since the last annual compliance review indicated a total of five staff facilitated various
groups. The education and work experience of the five staff members were considered by the
program when determining which staff would deliver delinquency intervention services. Each
staff had training in the curricula for the groups facilitated. A review of the program contract
indicated the program is required to conduct Impact of Crime (IOC) and Thinking for a Change
(T4C) each of which was provided by trained case managers. The program’s activity schedule
reflects the program is providing structured and planned programming or activities at least sixty
percent of the youth’s awake hours. An interview with the facility administrator (FA) indicated all
youth participate in daily group sessions facilitated by a trained professional using evidence-
based curricula to include IOC and T4C. The designated mental health clinician authority
(DMHCA) was interviewed and indicated the program provides interventions to address the
youth needs through group therapy services, family services, and individual therapy services.
The trained mental health professionals provide each youth with evidence-based curricula which
aims to develop life skills and address the youth’s mental health needs. Seven youth were
interviewed and reported participation in groups and were able to list the different groups,
including mental health and substance abuse groups. All five youth were able to describe the
skills learned in the groups and stated they can practice the skills learned in the groups.
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1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a written policy and procedures to ensure provision of life and social
skills training to the youth. The program identifies youth in need of services by reviewing the risk
assessments and criminogenic needs. Each youth’s time is spent in structured, therapeutic
activities with a minimum of one hour of each day devoted to the delivery of treatment services
targeted to address identified risk factors, criminogenic behaviors, and treatment needs. The
program’s contract addresses life and social skills interventions through Life Skills Training
(LST), which is evidence-based, and Aggression Replacement Training, a promising practice.
Each group is provided by trained staff in accordance with the program’s contract. The program
provides life skills to helping youth to function more responsibly and successfully in everyday life
situations, including social skills specifically addressing interpersonal relationships and
interactions communication, non-violent conflict resolution, anger management, and critical
thinking, to include problem solving, and decision making. The program addresses the needs of
the program’s targeted gender groups to include health, hygiene, the physical environment, life
and social skills training, and leisure and recreational activities provided in a group setting. The
therapist conducts LST groups and coach counselors conduct positive skill development (PSD)
groups and positive organizational culture (POD) groups. A review of the program’s activity
schedule and sign-in sheets confirmed LST groups were provided to the youth once a week by
the therapist. An interview with seven youth revealed participation in groups. An interview with
the designated mental health clinician authority (DMHCA) confirmed youth are practicing the
skills in groups, when interacting with peers and staff, in school, during visitation, on the
recreation field, also in the dorms. The facility administrator reported youth participate in LST
group.
The interviewed designated mental health clinician authority (DMHCA) reported youth are able
to practice skills in groups, in interacting with peers and staff, in school, during visitation, and
during recreation.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s restorative justice programming includes Impact of Crime (IOC) groups which is
a stated they participated in community service projects baskets for families in need, and
participation in community service projects. Group sessions are held on Tuesdays and
Thursdays by staff trained to provide the service. A random review of seven youth performance
plans and group sign-in sheets coupled with the program’s activity schedule, verified the
restorative justice programming. Random video recordings of youth in IOC group were reviewed
and indicated the instructor delivered the curriculum as documented. The program had one
guest impact speaker during the annual compliance review period. The groups and activities are
designed to assist youth in accepting responsibility for harm they have caused by their past
criminal actions, challenging them to recognize and modify their irresponsible thinking such as
denying, minimizing, rationalizing, and blaming victims, and expose youth to victims’
perspectives through victim speakers. The interviewed facility administrator (FA) confirmed
youth participate in community service projects along with completing IOC groups. An interview
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with the clinical director confirmed IOC groups are conducted twice a week. Seven youth were
interviewed, two complete IOC group, two youth confirmed participation in IOC, two stated they
complete handouts, two confirmed participation in community service projects, and one youth
reported they have not started IOC yet. The interviewed designated mental health clinician
authority (DMHCA) confirmed restorative justice programming.
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 maintains a written policy and procedures requiring consistent and effective
notification and communication of youth on alert status for security or safety risks, and health-
related concerns. Program alerts include medical/sports restriction, security/safety, escape risk,
asthma, gang suspicion/affiliation, mental health, suicide risk, vulnerable to victimization,
medications, food, seasonal, and medication allergies. A review of case management, medical,
mental health, and safety alerts was conducted for seven youth records. The reviewed records
were applicable for twenty-six separate alerts. Each record reflected youth alert placement was
completed as required by the program’s written procedures. Each applicable alert was initiated
by the appropriate staff, documented in the logbook, the Department’s Juvenile Justice
Information System (JJIS), the program’s alert board, and the internal medical list. The
program’s alert board is wall-mounted in the main conference room and is accessible to all staff.
Alert lists were also located in the medical clinic, master control, and the kitchen. Reviewed JJIS
alerts correlated with the program’s internal alerts. The interviewed facility administrator (FA)
explained, the program meets daily with medical staff to discuss all medical issues pertaining to
youth. All discussions occur in the morning management meeting along with review of the
previous day’s documentation. The information discussed will include transports, follow-ups,
and all other concerns. Any changes in alerts or food allergies are discuss during each
management meeting and shift briefings daily. Interviewed nursing staff stated the registered
nurse (RN) is responsible for medical alerts. Seven interviewed staff each reported alert
information is shared during shift briefings, alert log located in master control and safety plan.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program has a written policy and procedures to ensure the management of all records are
consistent across operations and programs, consistent with company philosophy, goals and
objectives, and consistent with legal and contractual requirements. A review of seven youth
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healthcare, mental health/substance abuse, and case management records showed each was
marked “Confidential” and each record documented the youth’s name, Department identification
number (DJJID), the youth’s date of birth, county of youth’s residence, date of admission, and
committing offense. Individual case management records contained sections devoted to legal
information, demographics, chronological notes, correspondence, case management, and
treatment team activities. Observations during the annual compliance review confirmed all
individual healthcare records, mental health and substance abuse records, and case
management records were secured in a locked room, which was not accessible to youth.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a community advisory board which meets quarterly, and reviewed meeting
minutes, sign-in sheets, and agendas documented meetings took place in person on March 15,
2023, June 28,2023, September 21, 2023, and December 13, 2023. The advisory board
member roster currently consists of a law enforcement representative, two different interested
community partners, a community business member, a school district representative, a member
of the judiciary, a victim advocate agency, a representative of the lesbian, gay, bisexual,
transgender, queer, and intersex (LGBTQI) community, and a faith-based community member.
The advisory board also includes one member who are a parent/guardian of a child with
previous involvement in the juvenile justice system. The program-maintained documentation of
their email recruitment efforts. A review of community advisory board agendas and meeting
minutes documented the program provides the board members with information regarding
program updates, community updates, and restorative justice community service activities. A
telephone call was made during the annual compliance review to a local community partner who
serves as a board member. The board member confirmed the program’s board activities,
including regular invitations to events and meetings. The interviewed facility administrator (FA)
reported the program has an active community advisory board which meets once a quarter
generally at 11am on the 3rd Thursday of the designated month. This meeting includes
individuals from education, judiciary, law enforcement, faith based, victim advocate, business
owners, the Department, and state attorneys. The individuals assist in program planning of
activities and speakers along with providing mentor services to the youth. The community
advisory board members relay their recommendations during the quarterly meeting or by
contacting the FA or recreation therapist directly. The board assists in finding resources for our
youth in the program to include mentoring and vocational programming.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program maintains a policy and procedures to ensure requirements for evaluating staff
performance annually and upon completion of the first ninety-days of hire. The program
maintains a detailed position description for all staff and a written agreement outlining duties for
all contracted staff. A review of seven staff personnel records revealed newly hired staff
received ninety-day performance evaluations and each staff received an annual evaluation from
their direct supervisor on the anniversary of their hire date. A review of position descriptions
confirmed job duties are clearly outlined for each staff. Each staff was evaluated based on
established performance standards outlined in the position descriptions which were received
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and signed upon hire. An interview with the facility administrator (FA) revealed the program has
a morale committee to address the needs of the staff and to organize pro-social activities. The
program utilized retention plans through staff recognition, staff of the month, luncheons, and
birthday celebrations, which included monetary gifts and/or prizes. Staff are coached using the
staff development sessions monthly and evaluations are completed annually. Seven staff were
interviewed regarding performance evaluations. Two stated evaluations are conducted yearly,
one stated every six months, one stated have not receive one yet, one transferred and the
evaluation was not yet due, and two reported every ninety days. Seven staff were interviewed
regarding communication at the program. Two reported communication was very good, three
rated communications as good, and two reported communication was fair.
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, twenty amendments, and Memorandum of Negotiation were reviewed
for special contract provisions and/or items not captured within reviewed indicators, and
considered contract specific requirements, which may exceed the minimum requirements
outlined in Florida Administrative Code. Contract specific requirements within this category
include opportunities to create positive changes, the use of trained volunteers/mentors, and the
provision of regular faith-based opportunities. The program has a policy regarding affording
youth the opportunity to participate in community service. Reviewed documentation and on-site
interviews verified the youth participate in community service and community relationship
building through restorative justice programming. Seven interviewed youth attested having the
opportunity to complete community service hours at the program. The program utilized a local
faith-based mentor service which encourages youth on a journey which demonstrates love and
forgiveness. The local ministry requires no religious affiliation to be a participant. The program
involves a structure model which includes the weekend experience followed by a long-term
mentoring process which encourages youth in making better life choices, support, and prayer.
Their mission is to engage youth reasoning skills in seeking balance for their lives. The
interviewed facility administrator confirmed the mentoring activities and reported the program,
also provides vocational certification.
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1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
The program shall implement all career and technical education (CTE) services negotiated or
outlined in the contract which are considered Contract Specific Conditions or listed within the
Scope of Services Attachment. These may be referenced as the Memorandum of Negotiation
(MON), Summary of Negotiated Points, Summary of Supplemental Response Request (SSRR),
Best and Final Offer (BAFO), Special Conditions, or older contracts may not have them clearly
identified as a special condition. Career and technical education service instruction shall be
provided so the interests, aptitudes, and skills of the youth are developed, while building upon
their existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may exceed
the minimum requirements outlined in Florida Statutes and Florida Administrative Code. The
program offers Florida Ready to Work - Soft Skills, the Occupational Safety and Health
Administration (OSHA) ten-hour course (10), cardiopulmonary resuscitation (CPR)/first-aid and
an industry certification from the master credential list. Additional services include job skills, food
handler certification, and Microsoft Office. The program industry certification focus is on
Entrepreneurship and Small Business. At the time of the annual compliance review, reviewed
documentation confirmed fifty-five youth were enrolled and working towards Entrepreneurship
and Small Business certification. Twenty-two youth were enrolled in OSHA-10. Twenty youth
were enrolled in ServSafe certification or the food handler certification program. Fifty-five youth
were engaged in a career interest inventory, and fifty-five youth were enrolled in CPR/first-aid.
A total of fifteen youth completed certification in first-aid and CPR, ten youth completed
ServSafe, and twelve youth completed OSHA-10. CTE services are offered Monday through
Friday for sixty minutes during the regularly scheduled class periods. Reviewed documentation
confirmed four vocational educators with degrees in business administration and/or business
education provide CTE services. No observations of vocational activities were observed while
the annual compliance review team was on-site. Seven youth were interviewed, and all were
aware of CTE services provided. Most students received those services everyday which was
consistent with the schedule. An interview with the facility administrator confirmed CTE services
are being offered.
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1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program maintains a policy and procedures for reviewing and analyzing data trends to
utilize in decision-making practices. The program has a policy and procedures which ensures
they share data trends with administration, staff, and stakeholders in order to make changes to
policy, practices, and programming. A review of meeting agendas confirmed the program
shared the key performance indicator reports, and site operations summaries during advisory
board meetings, through emails, during daily management meetings, and during all staff
meetings.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program maintains a written policy and procedures regarding initial contacts to
parent/guardian and court notification. Seven youth case management records were reviewed,
each record contained documentation of youth’s chronological sheet, telephone call log, and
youth’s handbook. Review of the telephone call verification log confirmed the program notified
the youth’s parent/guardian within twenty-four hours of the youth’s admission to the program. All
seven youth case management records established the youth’s parent/guardian were notified in
writing within forty-eight hours of the youth’s admission to the program and written notification
was provided to the committing judge and juvenile probation officer (JPO) within five working
days of the youth’s admission. Each record contained a signed form indicating the youth
received a copy of the youth handbook.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program maintains a written policy and procedures delineating youth orientation. A review
of seven youth case management records found the program provided an orientation to each
youth on the day of admission. Each applicable record included documentation demonstrating
the youth completed the orientation process to include the program rules, expectations, goals of
the program, and services applicable to youth. Each record contained a signed
acknowledgement and orientation checklist form signed by the youth and residential case
manager documenting the orientation process which included all required elements. The
program did not have any youth admissions during the annual compliance review week;
therefore, an admission was not observed. Seven interviewed youth indicated the program
orientation was completed within twenty-four hours of admission and each was able to explain
the orientation process.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program maintains a written policy and procedures outlining consent for youth eighteen
years of age or older. Three applicable youth case management records were reviewed, and all
three applicable records contained a consent form signed by the youth to allow the program to
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share, or prevent sharing, information related to the youth’s physical or mental health
screenings, assessments, or treatment with the parent/guardian.
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 maintains a written policy and procedures outlining the classification process for
youth upon admission to the program and completion of reassessments. Seven youth case
management records were reviewed for classification factors, procedures, and reassessment
for activities. All seven-youth record indicated an admission classification form was completed
on the day of admission and prior to assigning newly admitted youth to a living unit and sleeping
room. The initial classification form included a pre-classification management briefing, factors
included, at a minimum, current and or past psychotropic medication, suicide risk, victim
notification required, sexually violent predator status, DNA testing, current or prior history of
sexual misconduct, sexual aggression, sexual offenses, predatory behavior, sexual victimization
status, vulnerable to victimization, runaway risk, escape risk, arson risk, the youth’s physical
characteristics, gender, height, weight, and general physical stature, age, maturity level,
identified special needs, including medical, mental health, development or intellectual and
physical disabilities, history of violence, gang affiliation, and criminal behavior. Two of the seven
youth’s admission classification forms reviewed did not identified an open medical alert and a
security alert within the Department’s Juvenile Justice Information System (JJIS) prior to youth’s
admission to the program. The program’s practice is to complete reassessments for each youth
prior to considering an increase in privileges or freedom of movement, participation in work
projects or other activities involving tools. An interview with the facility administrator (FA),
indicated the program’s admission classification is used prior to assigning each youth to a living
unit to determine the best placement for the youth, and to ensure their safety and the well-being.
A review of JJIS confirmed a new Victimization and Sexually Aggressive Behavior (VSAB)
screening was completed for each youth. Five out of the seven VSAB screenings were
completed and entered in JJIS prior to each youth’s room assignment and two were entered
one day after admission.
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2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program maintains a written policy and procedures outlining gang identification and
notification to law enforcement. Seven youth case management records were reviewed, and
three were applicable for notification to law enforcement and the assigned juvenile probation
officer (JPO), education staff, and the youth’s applicable post-residential services counselor.
Reviewed documentation reflected gang status was shared as required for each youth. A review
of the Department’s Juvenile Justice Information System (JJIS) indicated the gang alerts were
identified.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program maintains a written policy and procedures to address youth’s participation in gang
prevention and/or intervention activities. The program utilizes a prevention and intervention
activities for youth identified with gang affiliation, which is inclusive of providing youth with
assistance and guidance in formulating a plan to disassociate from their respective gang
affiliation. The program implements the Gang Resistance and Drug Education (GRADE)
curricula to the all-gang affiliated youth. A review of seven youth case management records was
conducted, and three were applicable for being identified as a gang member, suspected gang
member, or being gang affiliated. The GRADE group sign-in sheets were reviewed and
validated all three youth participated in gang prevention and intervention strategies. Each
youth’s performance plan included relevant goals and objectives related to gang intervention
strategies for the youth to complete prior to being released from the program. An interview with
the facility administrator (FA) confirmed the program provides each youth with resources to
disaffiliate from a criminal street gang and assists in developing a plan to dis-affiliate from a
criminal street gang.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program maintains a written policy and procedures to ensure a Residential Assessment for
Youth (RAY) is completed for each youth within thirty days of admission. Seven initial RAYs
were reviewed, and each was completed within the required timeframe. A review of the
Department’s Juvenile Justice Information System (JJIS) validated each initial RAY was
maintained in JJIS for all seven-youth case management records. Seven youth case
management records were review and five were applicable for RAY Re-Assessments at least
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every ninety-days. A total of twelve RAY-Reassessment were reviewed and two RAY Re-
Assessments were completed six days and forty-four days late. All initial RAYs and
reassessments were in the youths’ case management records.
2.08 Youth Needs Assessment Summary (YNAS) Limited Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
The program maintains a written policy and procedures regarding the completion of the Youth
Needs Assessment Summary (YNAS). Seven youth case management records were reviewed,
and each contained a completed YNAS. Four YNASs were not completed within thirty days of
youth’s admission. Two were completed six days late, one was seven days late, and the fourth
was twelve days late. Each YNAS was documented in the Department’s Juvenile Justice
Information System (JJIS) and a copy was maintained in each youth’s case management
record.
2.09 Performance Plan Development, Goals, and Transmittal
Limited Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program maintains a written policy and procedures outlining performance plan
development, goals, and transmittal. Seven youth case management records were reviewed.
Each reviewed Individualized Performance Plan (IPP) was developed after the initial Residential
Assessment for Youth (RAY)/ Youth Needs Assessment Summary (YNAS) and signed by the
treatment team leader, youth, administrative representatives, treatment staff, living unit
representatives, and education staff. Reviewed documentation for each youth case
management record demonstrated each IPP was mailed to the parent/guardian. Five youth
records documented IPPs were not developed within thirty days of the youth’s admission. One
was developed four days late, one was seven days late, one was nine days late, the fourth was
ten days, and the final IPP was fourteen days late. A review of seven youth case management
records found the IPPs were mailed to the youth’s parent/guardian, committing court, and
juvenile probation officer (JPO) within ten days of completion. Each reviewed IPP included
individualized goals based upon the prioritized needs identified during the initial assessment.
Six of seven IPPs addressed the youth’s three top criminogenic needs, specific delinquency
interventions based on RAY results, court-ordered sanctions, and transition activities targeted
for the last sixty-days of the youth’s anticipated stay. One did not address one of the top three
criminogenic needs. Each IPP outlined program staff responsibilities and target dates for goal
completion. Seven interviewed youth reported they participated in the development of their IPP.
Each youth knew goals within their IPP. Six youth reported they had a copy of their plan, and
one youth reported they did not.
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2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
The program maintains a written policy and procedures in place regarding revisions to a youth’s
Individualized Performance Plan (IPP). Four youth case management records were applicable
for and documented revisions to the performance plans based on the Residential Assessment
for Youth (RAY) reassessment, newly acquired information, transition status, and demonstrated
progress, or lack of progress, towards goal completion. The IPPs documented they were
reviewed during formal treatment team meetings with all the multidisciplinary team members.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program maintains a written policy and procedures outlining the completion of Performance
Summaries and transmittals letters. Seven youth records were applicable for a total of nine
youth Performance Summaries. Six were completed within the required timeframe and three
were completed late. One summary was seven days late, the second was thirty-seven days
late, and the third was fifteen days late. All the Performance Summaries included the youth’s
status on each performance plan goal, overall treatment progress, academic status, behavior,
and level of motivation/readiness to change. Each summary was reviewed and signed by all
treatment team members. The Performance Summaries were mailed to the committing court,
juvenile probation officer (JPO), and parent/guardian. Three closed youth case management
records were reviewed for release summaries. All three release summaries were completed
within the required timeframe. Each record contained the original summary which included
reason of release from the program. All three closed case management records documented a
Performance Summary and Pre-Release Notification (PRN) was submitted at least forty-five
days prior to the tentative release date. Each closed case management record documented
notification to the youth’s parent/guardian of the youth’s release date once the program obtained
the approved PRN from the youth’s committing court. Each youth’s case management record
contained a Residential Assessment for Youth (RAY) exit assessment. There were no youth
applicable for the sexually violent predator program or victim notification.
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2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program maintains a written policy and procedures outlining the process to encourage
parent/guardian involvement in case management services. A review of seven youth case
management records confirmed each demonstrated the parents/guardians were informed of the
youth’s treatment team meetings. Reviewed documentation found each youth’s case
management record reflected the program encouraged and facilitated involvement of youth’s
parents/guardian in case management activities, to include the assessment process,
development of the youth’s performance plan, and monthly progress reviews. Documentation
supported the program provided notice of formal treatment team meetings and transition
planning. An interview with the facility administrator, noted monthly calls are made to update
parents/guardians on the youth’s progress or lack thereof and any upcoming events or
meetings. The program also conducts family days. The program offers bus passes and hotel
stays for parents/guardians to be able to participate in youth meetings. Seven interviewed youth
reported their parents/guardians were involved in case management activities.
2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
The program maintains a written policy and procedures regarding the referencing and/or
incorporating of other treatment plans into the youth’s Individualized Performance Plans (IPPs).
Each of the seven-reviewed youth case management records had separate performance plans,
education plans, and treatment plans. Each reviewed IPP referenced and/or incorporated
education and treatment plans. The incorporation of the education, mental health, and
performance plans are reviewed during formal treatment team meetings with the
multidisciplinary team.
2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
The program maintains a written policy and procedures outlining the required treatment team
members. The director of case management and the youth’s assigned case manager oversee
the coordination of the treatment team and are responsible for leading the treatment team
meetings. A review of seven active youth case management records found each youth
participated in a formal and informal treatment team meetings. Each record confirmed each of
the required treatment team members, to include the youth, an administrative representative,
treatment staff, the assigned juvenile probation officer (JPO), parent/guardian, and educational
staff participated in treatment teams. The youth’s parent/guardian and JPO were invited to
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participate in treatment team meetings through correspondence mailed prior to the meetings.
Documentation verified the treatment team staff provided a brief synopsis of the youth’s
progress in the program by reviewing and discussing the youth’s performance plan. Each record
documented that youth was provided an opportunity to demonstrate skills acquired in the
program and comment on progress. All seven youth case management records contained
monthly formal treatment team and informal treatment team meeting documentation occurring
within the required timeframes and containing all required elements. The program did not have
treatment team the week of the annual compliance review; therefore, an observation of
treatment team was not possible. Seven youth were interviewed regarding performance
reviews. Six reported staff reviewed performance and goal progress and one youth reported
staff did not. Six youth reported they are able to practice skills learned in the program and one
reported they are not.
2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program maintains a written policy and procedures to ensure the intervention and treatment
team is planning for each youth’s successful transition to the community upon release from the
program. The policy outlines the process for transition planning, conferences, and Community
Re-Entry Team (CRT) meetings. A review of three closed youth case management records
documented each youth had a transition conference at least sixty days prior to the youth’s
targeted release date. Transition conference documentation reflected the youth, treatment team
leader, facility administrator, or designee, and other applicable team members were in
attendance. Notification documentation supported the youth’s juvenile probation officer (JPO)
and parent/guardian, were encouraged to participate. Transition documents supported the
conference included a review of transition activities, necessary performance plan revisions,
additional transition activities, target completion dates, and persons responsible for transition
activities. Transition conference documentation contained acknowledgement of transition goals
and responsibilities of members through signatures of participants. A copy of each transition
plan was sent to the assigned JPO and any members sharing responsibility of plan completion.
Three close case management records were reviewed, each had documentation a CRT
invitation was sent, and a meeting was held prior to the youth’s release.
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2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program maintains a written policy and procedures regarding the assembly of an exit
portfolio for each youth to assist the youth with transitioning back into the community. A review
of three closed youth case management record demonstrated the exit portfolio was discussed
during the exit transition meeting. Each youth’s record contained an exit portfolio which
contained at least an attempt from the program to obtain a copy of the birth certificate, social
security card, and Florida identification card. One record contained a Florida identification card,
and two did not. Each contained a copy of the youth’s transition plan, exit transition plan, a
calendar with all the dates, times, and locations of upcoming community appointments,
educational/vocational certificates earned at the program, educational records/documents,
school transcripts, a sample employment application, and a résumé. Reviewed documentation
supported an exit portfolio was provided to each youth upon release and forwarded to the
assigned juvenile probation officer.
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program maintains a written policy and procedures for the review and finalization of
transition conference items and release plans by way of the exit conference. A review of three
closed youth case management records was completed. Each reviewed case management
record documented an exit conference was held after the program notified the assigned juvenile
probation officer (JPO) of the youth’s release and at least fourteen days prior to release.
Documentation included a summary of pending transition goals and the dated signatures of
attendees. Attendees included the team leader, parent/guardian, education representative, JPO,
youth, and other pertinent parties. Documentation supported the exit conference was held
separately from the transition conference and Community Re-Entry Team (CRT) meeting for
each youth. A review of the Department’s Juvenile Justice Information System (JJIS) admission
and release dates corresponded with each youth’s record.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program maintains a written policy and procedures to address written provisions for youth
input. The program utilizes town hall meetings to promote a formal process for youth to have
constructive input regarding the program. The program uses “request to speak” forms,
grievance forms, student surveys, and conducts daily positive organizational culture (POC)
meetings. This provides youth with the opportunity to communicate with staff about any issues
or concerns. Seven youth were interviewed and validated the program’s current practice. The
interviewed facility administrator reported youth could provide input during treatment team
meetings, can submit a “request to speak” form to provide input, as well as participate in town
hall meetings.
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2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program maintains a written policy and procedures to ensures the instruction of a career
education curriculum which provide students program content and an orientation to the broad
scope of career choices, based upon personal abilities, aptitudes, and interests. The program of
study, which is conducted and directly supervised by the Palm Beach County School District, is
identified as a Type 3 career/vocational education program. The course programming includes
instruction of interpersonal communication skills, personal accountability, and behavior skills
leading to appropriate work habits for employment and living standards. Additionally, the course
provides content and an orientation to the broad scope of career choices based upon personal
abilities, aptitudes, and interests. The practice was confirmed with the facility administrator and
the lead educator. A review of three closed case management records confirmed each included
a résumé, and one completed employment application. All three contained a post-release
calendar identified as a “plan for success” which contained the youth’s immediate post release
appointments as well as the location and contact information of the Career Source office in
proximity to the address which the youth will be residing following their release from the
program. One record had a valid state driver’s license, two did not; however, there was
documentation the program requested documentation from the parents/guardians. Each record
contained documented evidence the youth’s parents/guardians, assigned juvenile probation
officer, and case manager were aware of the youth’s post release educational or vocational plan
as well as any other related post-release planning.
2.20 Educational Access (Critical) Limited Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program’s education component is directly supervised and managed by the Palm Beach
County School District. Reviewed documentation, and an interview with the lead educator
indicated the school districts accepted academic calendar for the education programming
provided 250 days of instruction distributed over twelve months and included up to ten days of
teacher planning or training. Seven interviewed youth reported classes were being held with
minimal disruption. A review of the program’s video and logbooks showed there were
inconsistencies of the youth arriving to class at the scheduled times. Three days of reviewed
video found fifteen classes were observed and only one teacher started with the youth in the
classroom on time. Video review indicated classes began between three and thirty minutes late
for fourteen out of the fifteen start times. Furthermore, three logbook entries indicated youth
were eighteen to twenty minutes late for class.
2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program maintains a policy and procedures providing for an individual transition plan (ITP)
to be developed upon admission. A review of three closed youth case management records
evidenced each youth had an ITP in place at the time of their release from the program. Each
plan addressed key services and monitoring responsibilities by individuals essential to the plan’s
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creation. The identified services addressed the youth’s reintegration back to their home
community, the recommended academic placement upon the youth’s release, specific
responsibilities of individuals, and the provision of support services for the youth upon return to
their home community. Each plan was signed by the key individuals directly related to the
transition plan’s creation, and included the youth, the parent/guardian, the youth’s juvenile
probation officer (JPO), a representative for the program’s education department, a transitional
representative, as well as a representative of the youth’s home school district. Seven were
interviewed, and each reported being involved in the development of their ITP. The interviewed
lead teacher stated education staff give assistance and support to the youth in the development
of the ITP and the student’s assessed needs addressed in each plan.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program maintains a written policy and procedures requiring a designated mental health
clinician authority (DMHCA) to work as a full-time staff who is on-site at least forty hours each
week. In addition, the program’s contract requires two additional full-time licensed mental health
professionals to be on-site. The DMHCA is responsible for the coordination and implementation
of mental health and substance abuse services in the program. As part of the assigned
responsibilities, the DMHCA ensures consistent and appropriate mental health and substance
abuse services in addition to being on call twenty-four hours each day for emergency
consultation. The DMHCA is a licensed mental health counselor (LMHC) with a free and clear
license in the State of Florida with an expiration date of March 31, 2025. The DMHCA’s license
was displayed within the program, as required. The interviewed DMHCA verified the program
provides Substance Abuse Treatment Overlay Services (SAOS), and Mental Health Overlay
Services (MHOS). Reviewed documentation and an interview with the DMHCA verified the
DMHCA was on-site weekly to ensure appropriate coordination and implementation of mental
health and substance abuse services provided to the youth, as required by the contract. The
program is licensed under Chapter 397 through the Department of Children and Families to
provide substance abuse services to adolescents. The reviewed license confirmed it was valid
with an expiration date of March 23, 2024. In an informal interview, the regional compliance
manager stated the licensed clinical social worker (LCSW) serves as the back-up DMHCA. The
back-up DMHCA is a LCSW in the State of Florida with a free and clear license which expires
on March 31, 2025. The interviewed DMHCA stated the program provides mental health
referrals and “one to one” forms to youth when need to address mental health staff. Clinical staff
complete Assessments of Suicide Risk for crisis interventions, provide individual therapy once a
month, family therapy once a month, and group therapy four times a week. Additionally, the
program provides group therapy which includes Impact of Crime (IOC), and Aggression
Replacement Training (ART) curriculums.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program’s
licensed designated mental health clinician authority (DMHCA) serves as the program’s
supervisor for all on-site clinical staff. The DMHCA ensures licensed clinical staff are performing
services and are qualified to provide based on education, training, and experience in
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accordance with the job descriptions, and an informal interview with the regional compliance
manager verified the practice. A review of the program’s contract requires two additional full-
time licensed mental health professionals to be on-site. The program has one licensed clinical
social worker (LCSW), and one licensed therapeutic manager position which has been vacant
since September 14, 2023. On January 10, 2024, a licensed mental health professional verbally
accepted the offer; however, had to decline due to a family emergency. A licensed mental
health counselor from another program is assisting while the position is vacant. Copies of all
licenses were available and displayed on-site. The program is licensed under Chapter 397 by
the Department of Children and Families to provide substance abuse services to adolescents.
The Chapter 397 license was posted in the lobby of the program and expires on March 23,
2024.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The interviewed
designated mental health clinician authority (DMHCA) confirmed their responsibility for ensuring
non-licensed clinical staff are working under their supervision and performing services are
qualified based on education, training, and experience. The program practice is to complete
weekly face-to-face individual clinical supervision for the one non-licensed clinician. A review of
clinical supervision logs since the last annual compliance review verified clinical supervision was
documented on the program’s supervision logs and included all elements on the Department’s
Licensed Mental Health Professionals and Licensed/Certified Substance Abuse Professionals
Direct Supervision Log form. Documentation verified the non-licensed clinical staff received
clinical supervision for one hour for each week services were provided. The program is licensed
under Chapter 397 through the Department of Children and Families to provide substance
abuse services to adolescents. A review of the license reflected it was displayed in the lobby
with the program’s physical address listed. The reviewed license expires on March 23, 2024.
The program’s contract requires one DMHCA, two licensed assistant therapeutic managers, one
recreation therapist, and three non-licensed therapeutic managers. The program had two non-
licensed therapeutic manager positions vacant since September 7, 2023, and November 21,
2023. One non-licensed therapist accepted an offer and is pending a background screening, the
second non licensed therapist is pending acceptance of an offer for employment. A review of
therapist caseloads verified they were within the contractual requirements despite the program’s
vacancies. A review of the one non-licensed staff’s education documentation reflected the
clinical staff held a master’s level degree from an accredited university or college in the field of
counseling, social work, psychology, or a related human services field. The non-licensed staff
providing clinical services was employed by a service provider which was licensed under
Chapter 397. The non-licensed clinical staff received training in the administration of the
Assessment of Suicide Risk (ASR) and/or Crisis Assessments conducted on-site in the physical
presence of the licensed mental health professional. All training was documented on the
Department’s Non-Licensed Mental Health Clinical Staff Person’s Training in Assessment of
Suicide Risk form.
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3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program maintains a written policy and procedures which establishes the system for
gathering important treatment and emergent needs information prior to each youth’s entry into
the general population. The program’s policy requires the staff to administer a mental health and
substance abuse screening, including a suicide risk screening, upon a youth’s admission to the
program. When indicated, referrals are made for further evaluation, assessment, and clinical
services. The program utilizes the Massachusetts Youth Screening Instrument - Second Version
(MAYSI-2) for initial screening. The policy dictates the screening shall be completed by the
clinical staff in a confidential manner with the youth on the day of admission. A review of seven
youth records reflected each youth was administered a MAYSI-2 on the day of admission. The
clinical staff completing the screening documented the review of available information to include
the commitment packet, and other pertinent documents for existing mental health or substance
abuse problems, and/or history of human trafficking. Reviewed documentation verified each
staff who completed the MAYSI-2 was trained, and the MAYSI-2 was completed in the
Department’s Juvenile Justice Information System (JJIS). A review of seven youth records
verified each completed MAYSI-2 included the date, name of staff completing the MAYSI-2, was
completed on the day of admission, and was conducted in a confidential manner. Six youth
MAYSI-2s indicated a need for further assessment and one was overridden by the staff
conducting the MAYSI-2 leading to a determination for further assessment; however, it is the
program’s practice to refer all youth for additional assessments regardless of the screening
results. None of the reviewed MAYSI-2s documented the need for a crisis intervention, or
emergency services. None of the reviewed MAYSI-2’s indicated an assessment was needed
due to the “suicide ideation” category; however, it is the program’s practice to complete an
Assessment of Suicide Risk (ASR) for all youth upon admission to the program. All seven youth
records verified each youth was referred for an ASR, comprehensive evaluation, and each
included the reason for the referrals. In addition to the MAYSI-2 and ASR, the program utilizes
the Substance Abuse Subtle Screening Inventories (SASSI-2), the How I Think (HIT)
questionnaire, Trauma Symptom Checklist for Children (TSCC), Adverse Childhood
Experiences (ACE) Questionnaire, and a comprehensive evaluation in-depth assessment to
evaluate youth. The program’s facility administrator (FA) is responsible for the implementation of
the standardized admission/intake mental health and substance abuse screening process. The
reviewed policy confirmed the process includes a review of commitment packet information,
reports and records, administration of the MAYSI-2 in JJIS by a qualified professional, and a
referral of youth identified by screenings as in need of further evaluation or immediate attention.
The policy outlines administration staff training and a standardized process for youth requiring
immediate attention and transfer to a Baker Act or Marchman Act receiving unit. The
interviewed FA reported the clinical staff utilize a comprehensive assessment, the MAYSI-2, and
ASR to identify youth for mental health and substance abuse problems and suicidal ideation.
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3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a written policy and procedures to establish an assessment and
evaluation process to guide the development of each youth’s individualized treatment plan. The
program ensures the mental health and substance abuse needs of the youth are identified
through a comprehensive mental health and substance abuse evaluation process. Each youth
receives an in-depth assessment within the first thirty days of residential placement. All
assessments are to be completed by a licensed mental health professional or mental health
clinical staff working under the direct supervision of the licensed mental health professional. The
program practice is to incorporate the findings of the Massachusetts Youth Screening
Instrument - Second Version (MAYSI-2) and intake packet into each assessment. A review of
seven youth records verified each youth received a new mental health evaluation within thirty
calendar days of admission. The mental health evaluation included youth demographics, reason
for the evaluation, relevant background information, behavioral observations, Mental Status
Examination, procedures administered, discussions of findings, diagnostic impressions including
the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, and
recommendations. A review of seven youth records verified each youth received a new
substance abuse assessment within thirty days of admission. Clinical staff obtained consent for
substance abuse services for all seven reviewed youth records. Each youth record included the
reason for the substance abuse assessment, all relevant background information, behavioral
observations, methods of assessment, patterns of alcohol and substance abuse, impact of
alcohol and substance abuse on major life areas, risk factors, clinical impression including the
DSM-5 diagnosis, and recommendations. All seven reviewed youth records indicated the mental
health/substance abuse assessment addressed the original referral reasons. In a formal
interview, the designated mental health clinician authority (DMHCA) stated documents are
obtained from the Department’s Juvenile Justice Information System (JJIS) and assessments
such as the MAYSI-2, Substance Abuse Subtle Screening Inventories (SASSI-2), Beck
Depression Inventory (BDI), Adverse Childhood Experiences (ACE) questionnaire, and the How
I Think (HIT) questionnaire are used to obtain comprehensive mental health information. An
Assessment of Suicide Risk is also completed, and additional information is obtained by
interviewing youth and their parent/guardian.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a written policy and procedures to establish an individualized treatment
planning process to guide service delivery. The program’s treatment planning focuses on the
provision of mental health and substance abuse interventions and treatment to reduce or
alleviate youth’s symptoms of mental disorder and/or substance abuse impairment. The
assigned intervention and treatment team shall assist in developing, reviewing, and updating
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each youth’s initial and individualized plan. A review of seven youth records reflected an initial
treatment plan was developed within seven days of admission. Each reviewed initial plan was
documented on the program’s form and included all elements of the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. Each initial plan was completed by a licensed
clinical staff and signed by the licensed designated mental health clinician authority (DMHCA)
within ten days of completion. Additionally, each initial plan was signed by all treatment team
members who participated in the development of the plan. Each plan was signed by the youth
and documented juvenile probation officer (JPO) and parent/guardian participation by
telephone. Each initial plan included the need for a psychiatric evaluation. The program practice
is to refer all youth for a new psychiatric evaluation regardless of medication status. One of the
reviewed records indicated the youth was on psychotropic medications at the time of the initial
plan creation and the medication details were included in the plan. The program completed an
individualized treatment plan for each of the six youth within thirty days of admission. One plan
was not due at the time of the annual compliance review. Each applicable individualized plan
was documented on the program’s form and included all elements of the Department’s
Individualized Mental Health/Substance Abuse Treatment Plan form. Each applicable
individualized plan was completed by a licensed clinical staff and signed by the DMHCA within
ten days of completion. Each of the six plans were signed by all treatment team members who
participated in the development of the plan. Each individualized plan documented the
participation of the assigned JPO and the parent/guardian by telephone. One youth was
applicable for being on medication at the time of the individualized plan development and the
plan clearly listed the medication details and monitoring frequency. Seven records were
reviewed, and four were applicable for individualized treatment plan reviews, three were not in
the program long enough for individualized treatment plan reviews. Each applicable record
verified the treatment plan reviews were conducted in thirty-day intervals. All treatment plan
reviews were documented on the program’s form which contained all elements on the
Department’s Individualized Mental Health/ Substance Abuse Treatment Plan Review form.
Prescribed services included individual and group therapy for all six youth, family therapy for
five youth, psychiatric services as needed for five youth, and medication management for one
youth. The treatment plan goals and objectives were individualized for each youth. A review of
the programs contract confirmed the program was providing groups as required. The program’s
primary service group is Anger Replacement Training (ART). The program is also currently
providing LifeSkills Training (LST), Coping with Stress, Skillstreaming the Adolescent, Seeking
Safety, and Living in Balance. A review of video for three randomly chosen groups verified the
sign-in sheets coincided with the video. A review of sign-in sheets confirmed the program was
providing groups as outlined in the daily schedule. The program provides groups four to seven
days each week, based on individual youth needs as outlined in contract. The interviewed
DMHCA stated sign-in sheets are utilized for individual, group, and family sessions. The
DMHCA stated there is formal treatment team every thirty days which includes the youth's
juvenile probation officer (JPO), parents/guardians, clinicians, medical team, education, and
case management. Special treatment team meetings are held to address any behaviors or
concerns with the youth. The clinical staff meet with the facility administrator daily in the morning
management meeting and the program has weekly one on one meetings.
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3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program maintains a written policy and procedures regarding discharge and transition
planning requirements for mental health and substance abuse treatment services. Discharge
and transition planning is a continual and perpetual process which culminates into the
development of a final mental health and substance abuse treatment summary. A review of
seven youth records reflected each youth was assigned to a treatment team on the day of
arrival to the program. Reviewed treatment plan documentation and the treatment team
assignment form for each reviewed record confirmed the treatment teams were comprised of
the youth, program administration, residential living unit, education, medical staff, mental health
and substance abuse staff, and applicable parents/guardians. A review of the seven youth
records reflected each was applicable for a substance abuse diagnosis and treatment. The
program is licensed through the Department of Children and Families under Chapter 397 to
provide substance abuse services to adolescents. Each record contained an executed Authority
for Evaluation and Treatment (AET) form. Additionally, each youth record contained a signed
Youth Consent for Substance Abuse Treatment, and Youth Consent for Substance Abuse
Treatment Records form. All reviewed mental health or substance abuse treatment notes were
documented on the program’s form and included all the information on the Department’s
Counseling/Therapy Progress Notes form. Reviewed progress notes confirmed treatment
services included individual psychotherapy and psychosocial skills training. A review of
treatment plans in comparison with progress notes confirmed each youth received services as
stipulated on their treatment plan. A review of three closed records was conducted for discharge
summaries. A review of three youth discharge summaries indicated each was completed on the
Department’s Mental Health/ Substance Abuse Treatment Discharge Summary form. None of
the reviewed closed records were applicable for the youth being released while on suicide
alert/precautions. Each of the three reviewed summaries documented the services needed for
daily maintenance of the positive improvement in behavioral, emotional, and social skills made
by the youth during treatment. Each reviewed discharge summary documented the telephone
participation of the assigned juvenile probation officer (JPO) and parent/guardian. Reviewed
documentation verified the program emailed a copy of the summary to each assigned JPO and
provided a copy to the youth and parent/guardian upon release. The designated mental health
clinician authority (DMHCA) stated the process used for individualized mental health treatment
planning includes meetings with the youth and the parents/guardian to determine treatment
needs. Clinical staff use the How I Think (HIT) questionnaire, Trauma Symptom Checklist for
Children (TSCC), Adverse Childhood Experiences (ACE) questionnaire, comprehensive
evaluation in-depth assessment, and other assessments to evaluate youth.
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3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program maintains a written policy and procedures to establish a delivery protocol for
Substance Abuse Treatment Overlay Services (SAOS), and Mental Health Overlay Services
(MHOS). The focus of substance abuse and mental health treatment is to target and
reduce/alleviate the youth’s symptoms of substance related disorder and/or mental disorder to
improve youth functioning within the program and ultimately the community. The program
provides substance abuse and mental health services through group therapy, individual therapy,
family therapy, and psychiatric services. A review of the program’s contract and an interview
with the designated mental health clinician authority (DMHCA) confirmed the program was
providing groups as required. The program’s primary service clinical group is Anger
Replacement Training (ART). The program is also currently providing substance abuse groups
which include Life Skills Training (LST), Seeking Safety, and Living in Balance. The program is
providing mental health groups which include Coping with Stress, Adolescent Coping with
Depression, and Skillstreaming the Adolescent. Seven interviewed youth reported participating
in individual, family therapy services, and participating in groups at the program. Seven
interviewed staff stated direct care staff do not facilitate any mental health or substance abuse
groups. The program provides substance abuse treatment services, which includes urinalysis
drug testing. Any positive tests are referred for an appropriate clinical intervention and
sanctions. A review of youth records, youth interviews, group sign-in sheets, and an interview
with the DMHCA verified individual, group, and family therapy are part of each youth’s treatment
plan. Documentation provided indicated therapeutic services are held at least five times a week.
A review of group sign-in sheets verified group therapy is limited to no more than fifteen
participants for substance abuse, and no more than ten youth for mental health. The program
has a Chapter 397 license through the Department of Children and Families to provide
substance abuse treatment services to adolescents. All metal health clinicians working at the
program were qualified to provide substance abuse treatment and education services. The
program has an agreement with a psychiatrist for the completion of psychiatric evaluations and
medication management needs. A review of the clinical staff schedules verified clinical staff
were scheduled to be on-site seven days each week, as required. A review of counselor
caseloads verified the caseloads are limited to no more than twelve youth for MHOS and to no
more than sixteen youth for SAOS. An interview with the facility administrator (FA) verified the
program provides MHOS and SAOS services for youth. An interview with the DMHCA verified
clinical staff use various assessment tools to identify specialized treatment service needs.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
The program maintains a written policy and procedures for the provision of psychiatric services.
The program’s contracted psychiatrist is responsible for psychiatric evaluations, consultation,
medication management, and medical supportive counseling. The program maintains an
agreement with a medical doctor for psychiatric services. The reviewed license showed it was
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free and clear in the State of Florida with an expiration date of January 31, 2026. Reviewed
documentation confirmed the completion of psychiatric evaluations, medication reviews, and
treatment team participation. The program does not utilize a psychiatric advanced practice
registered nurse (APRN). The program did not utilize a back-up psychiatrist since the last
annual compliance review. The psychiatrist agreement and contract require weekly services and
a review of sign-in sheets and medication management documentation for the past twelve
months reflected the psychiatrist provided on-site services as required. The program does not
utilize telepsychiatry services. An interview with the psychiatrist verified psychiatric services are
provided weekly. The psychiatrist provides initial evaluations, medication management and
conducts all necessary follow-ups with the youth. An interview with the designated mental health
clinician authority (DMHCA) and the psychiatrist confirmed meetings are held weekly. The
psychiatrist stated meetings are held with healthcare staff to review important medical issues
pertaining to youth receiving psychiatric services during treatment team weekly in person or
telephonically. The psychiatrist conducts weekly face-to-face or telephonic communication with
the treatment team. It is the program’s practice for all youth admitted to the program to be
referred for a psychiatric interview. A review of seven youth records found each youth was
referred for a psychiatric interview and one youth was applicable for entering the program on
psychotropic medication. The youth admitted to the program with psychotropic medication
received a psychiatric interview within fourteen days of admission. Each diagnostic psychiatric
interview included the youth’s medical, mental health, and substance abuse history, a mental
health status examination, and the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) diagnosis. A review of seven youth treatment plans verified the plan was
consistent with the DSM-5 diagnosis and included applicable psychiatric treatment
recommendations. A review of seven youth records found three were applicable for being
prescribed psychotropic medication, which was related to the youth’s diagnosis. Each diagnostic
interview included target symptoms, initial treatment goals, potential side effects, risk, and
benefits of taking the medication, and the frequency of medication management. Each initial
diagnostic psychiatric interview was documented on the Department’s Clinical Psychotropic
Progress Note (CPPN) and was clearly identified. One youth was admitted into the program
with psychotropic medication, one youth started taking psychotropic medication after the initial
psychiatric diagnostic interview, and one youth started taking psychotropic medication after
several months at the program. Two of the three applicable youth records documented youth
were seen for medication reviews by the psychiatrist at least once every thirty days, and one
youth had not been at the program for thirty days. The psychiatric evaluations were documented
on the Department’s CPPN form for each youth. The Department’s CPPN included the youth’s
identifying data, diagnosis, target symptoms of each medication, effect of prescribed
psychotropic medication on target symptoms, side effects of the medication, and the youth’s
adherence to the medication regime. In addition, each of the reviewed CPPN’s included the
youth’s height, weight, and blood pressure. The psychiatrist signed and dated each of the three
reviewed CPPNs. Two of the three reviewed youth records were applicable for the monitoring of
Tardive Dyskinesia monthly as indicated in the CPPN. Documentation verified the psychiatrist
was monitoring for Tardive Dyskinesia monthly. The program’s policy and contract does not
allow the use of tele-psychiatry.
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3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program maintains a policy and procedures regarding the implementation of a Suicide
Prevention Plan. The plan shall provide guidelines for the identification, management, and
assessment of potentially suicidal youth. The program maintains a Suicide Prevention Plan
which was last signed and reviewed by the facility administrator on December 21, 2023. A
review of the plan reflected it included identification, assessment, staff training, suicide
precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, and a review process. The review process for suicide attempts and
mortality review included circumstances surrounding the event, procedures relevant to the
incident, relevant training received by involved staff, pertinent medical and mental health
services involving the victim, possible precipitating factors, and recommendations.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
The program maintains a Suicide Prevention Plan which outlines the methods used for suicide
precautions which include observing, monitoring, and housing youth identified as a suicide risk.
It is the program’s practice to complete an Assessment of Suicide Risk (ASR) for all youth
admitted to the program. A review of seven youth records found each received an ASR upon
admission to the program. Each reviewed ASR included the precautionary observation date,
ASR referral date, and was completed on the Department’s Assessment of Suicide Risk form.
All seven records included the level of supervision. Six of the seven youth were placed on
standard supervision after completion of the ASR. One youth was identified as a suicide risk
and placed on precautionary observation several times after admission to the program. Two
separate instances of the same youth were reviewed, and the youth was placed one-to-one
supervision one time, and constant supervision the second time. One additional youth record
applicable for suicide risk was reviewed and documentation showed the youth was placed on
precautionary observation one-on-one supervision. Each of the three youth were identified as a
suicide risk through staff observations. All three applicable youth were placed on precautionary
observation status and assessed the same day. Each ASR was completed on the Department’s
ASR form by the licensed designated mental health clinician authority (DMHCA).
Documentation verified the parent/guardian and assigned juvenile probation officer (JPO) were
notified of the youth’s potential suicide risk. All three-youth records indicated a Follow-up ASR
was completed on the Department’s Follow-up ASR form. Upon the completion of a Follow-up
ASR, suicide precautions could be discontinued for the applicable youth, and the youth were
stepped to close supervision. The discontinuation of suicide precautions was the result of a
documented conference with the facility administrator, and mental health clinician in each
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applicable record. All three youth records verified youth were maintained on close supervision
until it was determined appropriate to step the youth to standard supervision. A review of the
Department’s Juvenile Justice Information System reflected accurate alerts were initiated and
updated as required. A review of the program’s logbooks and assessments supported the
administration staff provided instructions regarding suicide precaution decisions. Logbooks
documented the placement and removal of precautionary observation and close supervision.
Documentation supported youth on suicide precautions were able to participate in activities with
other program youth in the specified safe housing areas. None of the three reviewed records
indicated youth were placed in secure observation. The program has not utilized secure
observation since the last annual compliance review. The program’s video is stored for thirty
days. Only one youth during three different instances was placed on precautionary observation
within the last thirty days and could be observed by video. Video observation of one youth
during three different times and dates verified staff were maintaining constant supervision and
one-on-one supervision as documented on the Department’s Suicide Precautions-Observation
Log.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a Suicide Prevention Plan which outlines levels of supervision and the
process for recording observations of youth on suicide precautions. A review of seven youth
records reflected one youth was applicable for suicide risk on two separate occasions. A review
of one additional youth record was conducted. Each youth record contained documentation
where The Department’s Suicide Precautions-Observation Log was maintained for the duration
the youth was on precautions. Youth behaviors were documented in real time and not
exceeding thirty-minute intervals for each youth. Each youth was applicable for warning sign
observations, and notification to the mental health clinician was clearly documented. Each of the
reviewed logs were reviewed and signed by the shift supervisor and mental health staff.
Additionally, each log documented safe housing requirements.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a Suicide Prevention Plan which requires all staff with direct day-to-day
contact with youth to participate in suicide training. A review of seven pre-service and seven in-
service training records documented program staff completed the required six hours of suicide
training. The program has a total of three suicide kits which are in master control, medical, and
administration. The suicide kits are co-located with the program’s first-aid kits. The program is
required to complete one mock suicide drill for each shift at least quarterly. A review of suicide
drill documentation for the past twelve months reflected the program conducted a quarterly drill
on each shift as required. Reviewed drills consistently included the use of lifesaving measures
to include the use of cardiopulmonary resuscitation (CPR), suicide kits, first-aid kits, and an
automated external defibrillator (AED). The program’s practice is to review the drills during the
monthly all staff meetings. The interviewed facility administrator (FA) reported staff are trained
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through suicide drills monthly. Seven staff were asked what direct care staff are responsible for
if a youth expresses suicidal thoughts. Seven staff stated they would be responsible for notifying
their supervisor. Six stated for conducting constant sight and sound supervision. Five staff
stated for notifying mental health staff. Four staff stated they are responsible for documenting
supervision, and three stated they would search the youth and room for sharp objects. Seven
staff were interviewed on the location of the suicide response kits. Five staff stated a kit was in
master control, four staff stated in sub control, three staff stated in medical, and two reported
they were not sure.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a policy and procedures to outline operation procedures for crisis
intervention. The program’s Crisis Intervention Plan addresses mental health crisis intervention
services and Crisis Assessments. The Crisis Intervention Plan was signed and reviewed by the
facility administrator (FA) on January 10, 2023. A review of the plan verified it included
notification and alert systems, means of referrals, Crisis Assessments, follow-up,
communication, supervision, documentation, mental health supportive services, and review. The
plan states it shall be the responsibility of all staff to ensure crisis plans are implemented
immediately to afford youth with a maximum amount of safety and security.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program’s Crisis Intervention Plan addresses mental health crisis intervention services and
Crisis Assessments. A review of seven youth records found none were applicable for a Crisis
Assessment. There was only one youth applicable for a Crisis Assessment during the annual
compliance review period. The reviewed youth record had a Crisis Assessment conducted
based on the needs of the youth. The Crisis Assessment included the reason for the
assessment, Mental Status Examination and interview, determination of danger to self and/or
others, initial clinical impressions, supervision recommendations, treatment recommendations,
recommendations for further evaluation, and notification to the parent/guardian. The Crisis
Assessment was conducted by a licensed mental health professional. The results of the Crisis
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Assessment did not require a mental health alert to be entered in the Department’s Juvenile
Justice Information System (JJIS). The reviewed Crisis Assessment indicated the youth did not
require a Follow-up Crisis Assessment to be completed. There were no applicable youth
involved in an alleged Prison Rape Elimination Act (PREA) incident during the annual
compliance review period. The Crisis Assessment results did not require the youth to be placed
on precautionary observation.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written policy and procedures outlining the mental health and
substance abuse procedures for youth who are believed to be in imminent danger to
themselves or others because of mental illness or substance abuse impairment. The
Emergency Response Plan for Mental Health and Substance Abuse Emergencies requires
youth to receive the highest quality of care, safety, and management. The program’s
Emergency Response Plan was last signed and dated by the facility administrator (FA) on
January 10, 2023. A review of the plan validated it included immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health and substance abuse services, transport for emergency Baker Act, transport for
emergency Marchman Act, documentation, training, and review.
3.17 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program maintains a written policy and procedures regarding Baker and Marchman Acts. A
review of seven youth records found none were applicable for a Baker or Marchman Act. There
was only one youth applicable for a Baker Act placement during the annual compliance review
period. The one reviewed record indicated staff observations determined the need for
emergency care. The reviewed record indicated staff submitted a mental health referral
summary to clinical staff. The youth was placed on one-on-one supervision and the mental
health staff were involved. The youth was transported to an off-site emergency room by
program staff, which was authorized by the DMHCA, and was admitted under Baker Act
proceedings after a medical procedure. Upon return to the program from the Baker Act, the
youth was placed on constant supervision. The youth received a mental health referral
indicating a Mental Status Examination (MSE) was to be conducted. A Crisis Assessment was
completed for the youth by the DMHCA. The youth was maintained on constant supervision until
an assessment was completed by the DMHCA, which lowered the youth’s supervision level. An
interview with the DMHCA verified there was only one youth which required a Baker Act during
the annual compliance review period.
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3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a written policy and procedures to establish a planning process
designed to identify areas which affect the youth and incorporate trauma responsive practices.
Within fourteen days of admission, the intervention and treatment team meet with each youth to
develop a Safety Plan. Safety planning is designed to identify stimuli which have positive and
negative effects on the youth. A review of seven youth records confirmed each contained a
Safety Plan. Each plan included warning signs, youth baseline behaviors, crisis recognition,
jointly developed coping strategies, youth preferred intervention strategies, and a debriefing
process. Each plan was completed within fourteen days of admission and incorporated
recommendations from clinical assessments. Each plan was reviewed and updated at least
every thirty days and after significant behavioral or mental health events. According to the
program’s policy, the safety plans are reviewed during the monthly all staff meetings. Safety
plans are accessible to all staff and are located in master control and in each youth’s mental
health record. The interviewed facility administrator (FA) reported Safety Plans are updated
monthly or as needed. Seven interviewed youth confirmed participating in the development of
their Safety Plan. Seven interviewed staff were asked where the youth Safety Plans are located.
Five staff stated the plan is located in master control, two staff were not sure where the Safety
Plans were located. Seven staff were interviewed regarding the process for reviewing Safety
Plans. Two staff stated during shift briefing, one staff stated after speaking to the supervisor,
two staff stated reviewing the Safety Plans daily, and two did not know the location of the Safety
Plans. Seven staff were asked when they last reviewed youth Safety Plans. Two staff stated
daily during shift briefing, one staff worked in master control and did not interact with youth, one
staff stated once during an intake, one staff just finished training and saw a sample, one staff
stated sometimes the plan is reviewed, and one staff did not see a Safety Plan but heard case
management talk about 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 maintains a written policy and procedures regarding the designated health
authority (DHA). The program’s DHA is accountable for ensuring the delivery of administrative,
managerial, and medical oversight of the program’s health care system. The program has as
agreement with a licensed osteopathic physician to serve as the DHA. A review of the DHA’s
license reflected it was free and clear in the State of Florida with an expiration date of March 31,
2024. The DHA has a specialty in family medicine. A review of the Florida Department of Health
website reflected the DHA had no disciplinary cases/public complaints on record. The program
does not utilize a physician assistant (PA) or an advanced practice registered nurse (APRN). An
interview with the statewide director of nursing explained the program has not utilized a back-up
DHA in the past twelve months; however, if the need arose the program could utilize a DHA
from another program. The back-up DHA license was reviewed and reflected they held equal
licensure which was free and clear in the State of Florida with an expiration date of January 31,
2026. A review of the DHA agreement reflected it was executed December 5, 2022, and
identifies the DHA as clinically responsible for the medical care of all youth at program. A review
of DHA sign-in logs for the review period indicated the DHA was on-site, at a minimum, two
hours weekly. The program does not utilize tele-medicine/tele-health. A formal interview with the
DHA confirmed their role in the completion of Comprehensive Physical Assessments (CPA),
periodic evaluations, chronic condition evaluations, sick calls, policy and procedure
development, review of off-site care findings, and medication renewals. The DHA verified being
on-site weekly and regularly communicating with the program staff by telephone or in-person.
The interviewed DHA indicated they were on call twenty-four hours each day.
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’s contract requires three registered nurses (RN) to provide on-site nursing
coverage at the program. One RN serves as the health services administrator (HSA). The
program does not utilize licensed practical nurses (LPN). At the time of the annual compliance
review the program had one RN vacancy; however, duties were being covered by the regional
nurse, and statewide nursing director. The contract requires 100 hours of weekly nursing
coverage between the three positions. A review of the schedules verified the program was
providing the required coverage. A review of licenses of current nursing staff, coverage staff,
and staff previously providing services to youth in the past twelve months was completed. A
review of the six licenses showed each was an RN in the State of Florida with a free and clear
license. Licenses expired April 30, 2025, for three, and on July 31, 2024 for the remaining three.
Additionally, each RN held a current certification in cardiopulmonary resuscitation (CPR).
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program maintains a written policy and procedures regarding health care facility operating
procedures (FOPs). The program has FOPs for all health-related procedures and protocols. The
designated health authority (DHA) shall review and approve treatment protocols for the on-site
licensed nursing staff and non-licensed staff to utilize when administering care in response to
commonly encountered complaints. All newly employed health care staff shall receive clinical
orientation to the Department’s health care policies and procedures, given by a registered nurse
or designated licensed healthcare professional. The program maintains site-specific FOPs
which were last signed by the DHA, psychiatrist, and health services administrator (HSA) on
January 2, 2024, and the facility administrator (FA) on January 7, 2024. Each individual FOP
was signed and dated by the PD and DHA. The FOPs binder contains a cover page where
nursing staff sign indicating an annual review and/or acknowledgement of updated FOPs. The
reviewed FOPs were signed by the program’s nursing staff on January 2, 6, and 9, 2024,
December 1, 2023, November 29, 2023, July 13, 2023, March 23, 2023, and January 23, 2023.
A review of newly hired health care training records indicated each new registered nurse (RN)
received a comprehensive clinical orientation to the Department’s health care policies and
procedures by an RN as required.
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 maintains a written policy and procedures regarding informed consent. The
program ensures the completion of the Department’s Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth. The AET is signed by the parent/guardian and
witnessed by a Department representative. The AET shall serve as informed consent for non-
invasive medical procedures or for minor ailments which require over-the-counter medications,
or which can be treated by a nurse. The signed AET form is valid until the parent/guardian
revokes or modifies it, or for as long as the youth is under any type of Department supervision.
A separate, specific consent for treatment is required for invasive procedures.
Parents/guardians shall be notified of any significant changes in a youth’s condition and or when
new medications are prescribed. Youth eighteen years of age or older may provide their own
consent. For those youth in the care of Department of Children and Families (DCF), where there
has been a termination of parental rights, the court must authorize all treatment and procedures.
A review of seven Individual Healthcare Records (IHCRs) reflected three contained an AET, one
contained a court order, and three youth were over the age of eighteen. Each of the three youth
records applicable for an AET, contained a valid legible copy and the word “copy” was stamped
on the document. Each AET was signed by the youth’s parent/guardian and a Department
representative. One youth was applicable for being in the custody of DCF and a court order was
within the record authorizing care and treatment. The three remaining records contained an
“eighteen-year-old authorization for consent of treatment/release and request of information”
form which was signed by the youth. The interviewed nurse reported when a new AET is
needed the program practice is to contact the assigned juvenile probation officer to obtain a new
AET. The nurse reported youth over the age of eighteen sign a consent authorizing what
information is shared and with whom.
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4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program maintains a written policy and procedures regarding obtaining consents.
Parents/Guardians shall be notified of any significant changes in a youth’s condition
and/or when new medications are prescribed. Telephone contact and/or attempted
contact by the prescribing healthcare provider is documented in the progress notes of
the Individual Healthcare Record (IHCR) for each encounter in which the medication
regimen or medical condition changes. Written parental notification is documented using
Departmental standardized forms. Each form is to be completed each time a new
medication or treatment is prescribed and mailed to parents/guardians. A copy of the
completed form is mailed to the parent/guardian and is maintained in the Individual
Healthcare Record (IHCR), behind the Authority for Evaluation and Treatment (AET), in
reverse chronological order. Except in emergency situations, in the clinical judgment, or
when the medication must be started immediately, all new non-psychotropic medications
and changes in the medication regimen should be started only after the
parents/guardians have been notified. Parental consent and notification is required for
all hospitalizations, surgery, dental services other than evaluations, any procedure or
service of an invasive nature, any procedure where the benefit to the child is uncertain,
and any procedure or service which the parent/guardian has previously prohibited. A
copy of the Department’s Parental Notification of Health-Related Care form which was
sent to the parents/guardian and the returned form with the parent’s/guardian’s
signature must be filed in the IHCR in the section reserved for parental notices. A review
of seven IHCRs indicated four were applicable for notifications/consents beyond those
covered in the scope of the Department’s AET. Three youth were over the age of
eighteen. Two youth were applicable for notification for over-the-counter (OTC)
medications beyond those covered in the AET and notifications were completed. One
youth was in the care of the Department of Children and Families (DCF). The record
contained a court order authorizing treatment; however, the program continued to send
treatment notifications to the assigned case worker. The final youth record documented
parent/guardian consent was obtained. Four youth were applicable for medication being
ordered and progress notes documented contact and/or attempted contact with the
parent/guardian. Each of the four records contained documentation the program sent
the required Parental Notification of Health-Related Care form. One youth was
applicable for taking psychotropic medications and the notification/consent was
documented on page three of the Department’s Clinical Psychotropic Progress Note
(CPPN) form. Additionally, the CPPN documented staff witnessed a telephone call
between the parent/guardian and the psychiatrist regarding the prescribed medication.
Each of the seven reviewed IHCRs documented the nurse verified vaccinations within
thirty days of admission. Two youth were applicable for obtaining additional
vaccinations and consent was obtained utilizing the Department’s Parental Notification
of Health-Related Care Vaccinations/Immunizations form prior to administration. No
youth were applicable for a religious exemption. An interview with the program nurse
explained parental notification/consent needs to be obtained for any medical treatment
beyond the AET and consent is obtained within twenty-four hours. The nurse explained
when emergency care is needed the parent/guardian is to be contacted within two
hours. The nurse reported when youth are prescribed psychotropic medications the
parent/guardian is contacted while the psychiatrist is present and medical staff will
follow-up when parents/guardians are unavailable. Additionally, page three of the CPPN
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documents the contact and a copy of the form is mailed to the parent/guardian. The
program verifies all vaccinations through the Florida Shots website within thirty days,
and when a parent/guardian requests an exemption, the form is obtained from the
parent’s/guardian’s local health department.
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 maintains a written policy regarding admission screening and rescreening.
The program utilizes the Department’s Facility Entry Physical Health Screening (FEPHS)
form to document a review of a youth’s general health condition at the time of admission to
ensure the youth can be placed in the general population and the youth is not in need of
immediate medical attention. A review of seven Individual Healthcare Records (IHCRs)
indicated each record contained a FEPHS form completed on the date of admission by a
registered nurse (RN). One youth was applicable for a change in physical custody and the
program nurse completed a FEPHS rescreening on the day the youth returned. The
interviewed nurse confirmed all youth are seen by medical staff on the day of admission
and an admission screening is completed. Additionally, a rescreening is completed when
there is a change in physical custody.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program maintains a written policy and procedures outlining the process of orienting youth
to the health care services. The policy required the program’s medical staff to orient each youth
upon admission. Topics outlined in policy include access to medical care, sick call, what
constitutes an emergency and when to notify staff, how medications are administered,
notification of staff immediately if having side effects from medication, notification of staff about
allergies and or medical alert issues, notification to staff of any chest pain, extreme shortness of
breath, faintness while exercising, the right to refuse care and how it is documented, what to do
in the case of sexual assault or attempted sexual assault, the non-disciplinary role of the health
care providers, situations in which the health care staff shall notify security, and a review of the
list of health care contacts. A review of seven youth records indicated orientation was completed
on the day of admission and included orientation to medical, eye and dental care,
immunizations, over-the-counter (OTC) medications, sick call, athletes foot, personal items,
infection control, universal precautions, hand washing, zika virus, blood borne pathogens,
medication administration, medical alerts, emergency treatment, the right to refuse, abuse and
sexual exploitation, safety, alcohol and substance abuse, prevention of sexually transmitted
diseases, human immunodeficiency virus (HIV), basic nutrition, self- examinations, smoking
cessation, dental hygiene, cardiovascular health, respiratory infections, quarantine, and the non-
disciplinary role of healthcare staff. Each of the seven reviewed Individual Healthcare Records
(IHCRs) contained an orientation sheet signed by the youth.
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4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program maintains a written policy and procedures which contains the requirements for
admission notifications. The program’s designated health authority (DHA) shall be notified when
a youth is admitted with an emergency or medications. Notification will be completed by
telephone or electronically and documented in the Individual Health Care Record (IHCR). The
DHA shall be notified immediately when an admitted youth requires emergency care. The
program’s practice is to notify the DHA and psychiatrist of all youth admissions regardless of
medication and health status. A review of seven youth IHCRs verified this practice. Each record
contained an admission note which documented the notifications completed on the day of
admission. No youth were identified as in-need of emergency care upon admission. One youth
was applicable for admission on psychotropic medications and the psychiatrist was contacted
as required. A formal interview with the program nurse revealed the program process is to notify
the DHA on the day of admission of all youth, and this notification is documented on the
admission progress note.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program maintains a written policy and procedures regarding the completion of the
Department’s Health Related History (HRH) form. The HRH is a standardized, comprehensive
medical and health-related history, which is similar to the history a patient is often asked to
complete the first time they visit a new health care provider. A review of seven Individual Health
Care Records (IHCRs) indicated each contained an HRH form completed within seven days of
admission by a registered nurse (RN). Each HRH was completed prior to the youth’s
Comprehensive Physical Assessment (CPA) as evidenced by signature and date. The DHA
documented their review of each HRH on the HRH form and by checking a box on the CPA
verifying review. The interviewed nurse explained the program practice is to complete the HRH
on the date of admission.
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 maintains a written policy and procedures regarding the completion of the
Department’s Comprehensive Physical Assessments (CPA). The CPA is a standardized
physical assessment of a youth conducted by the designated health authority (DHA) to facilitate
identification, treatment, and functional medical and dental problems, while promoting growth,
development, prevention of communicable disease, and provision of health education. A review
of seven Individual Health Care Records (IHCRs) indicated each contained a CPA completed
on the Department’s form. Each record contained a new CPA completed within seven calendar
days of admission. Each was completed by the licensed DHA documenting the Medical Grade.
Each CPA was completed in full and where a youth refused part of the exam, the youth signed
both the CPA and a refusal form. The program’s Problem List was updated, as required, based
on CPA findings, and each record contained at least one verified Tuberculosis Skin Test (TST)
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within the last year. Each TST result was also documented on the Department’s Communicable
Disease form. The interviewed nurse reported the CPA and Tuberculosis screenings are
completed upon admission and annually.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program maintains a written policy and procedures to ensure all program youth are
evaluated and, when necessary, treated for sexually transmitted infections (STIs). Additionally,
the program shall routinely offer counseling, testing and referrals for medical treatment to all
youth at risk for human immunodeficiency virus (HIV) infection. Confidential HIV testing shall be
conducted for all youth recommended for testing based upon clinician assessment, risk
assessment, or upon youth request. A review of seven Individual Health Care Records (IHCRs)
indicated each youth was clinically screened and evaluated for STIs upon admission. Each
youth was applicable for further evaluation and subsequently referred to the designated health
authority (DHA) utilizing the Department’s STI form. Testing was ordered by the DHA for three
youth. The three applicable records documented the testing was performed and screening and
testing results were documented on the Department’s Infectious and Communicable Disease
(ICD) form. No youth were applicable for requiring a rescreening. Three youth were referred for
HIV testing and the IHCRs documented consent was obtained, and testing was received. Each
record contained the HIV results in a sealed envelope marked “confidential.” Each envelope
was signed by the DHA documenting review of the results. The DHA provided pre and post-test
counseling which was also documented within the IHCRs. A review of the program’s alerts
indicated each youths’ confidentially was protected and alerts did not include STI/HIV status.
The program’s policy clearly stated HIV results are only disclosed to the youth’s legally
authorized representative, health care providers during the course of consultation, diagnosis, or
treatment of the individual, the Department of Health for purposes of reporting and control of
spread of disease, health facility staff committees conducting program monitoring, evaluation,
and service reviews, medical personnel who have been subject to a significant exposure, and
health care facility personnel or agents for the healthcare provider who have a need to know in
the course of patient care activities or administrative operations. Seven interviewed youth
reported they can request an HIV test at the program. The interviewed nurse reported all youth
are screened for STIs and if screening indicates a need for further evaluation an order is
obtained from the DHA. The DHA provides all pre- and post-counseling. HIV results are kept in
a sealed envelope in the IHCR and when youth have been out of custody for more than thirty
days, and/or symptoms present, youth are rescreened. Additionally, all STI testing information is
documented on the ICD form.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program maintains a written policy and procedures regarding sick call. Program youth are
able to make sick call requests and have their complaints treated appropriately through the sick
call system. Sick call care, including dental complaints, shall be available to all youth two times
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a day, seven days each week. Sick call care shall be provided by licensed health care
professionals, pursuant to their scope of practice and according to protocols approved by the
Designated Health Authority (DHA). When a licensed health care professional is not on-site, the
shift supervisor shall review all sick call requests as soon as possible, within two hours after the
request is submitted. Any complaint of severe pain, including dental pain, shall be treated as an
emergency with immediate referral to the health care staff or DHA. Emergency dental care
services shall be provided by a licensed dentist. A review of seven Individual Health Care
Records (IHCRs) reflected three youth were applicable for a total of seven sick call encounters.
No youth were applicable for presenting with a similar sick call complaint three or more times
within a two-week period. Each sick call event documented the youth submitted a Sick Call
Request form, which was then completed by a registered nurse (RN). Each sick call form was
filed in reverse chronological order in the IHCRs. There were no youth applicable for restricted
housing of any kind. Each sick call form was documented in accordance with Florida
Administrative Code. All reviewed sick calls were also documented on the Sick Call Index and
the program’s Sick Call Referral Log. A review of the program’s schedule and postings verified
sick call was conducted daily at 7:00 a.m. and 5:00 p.m. Seven interviewed staff reported the
nurse responds to and conducts sick calls. Six interviewed youth reported they can see a nurse
within one day of submitting a sick call and one reported they can be seen immediately. The
interviewed nurse verified the sick call times and reported sick call care is provided in
accordance with approved treatment protocols. An observation of one sick call event was made
during the annual compliance review. The youth was escorted to the medical clinic by a direct
care staff. The direct care staff stood by the entrance to allow for privacy. The program’s RN
identified themselves and reiterated the sick call request. The youth was evaluated using an
exam table and privacy curtain.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program maintains a policy and procedures to ensure twenty-four-hour emergency medical,
mental health, substance abuse, and dental care shall be available to youth. The designated
health authority (DHA), in consultation with the registered nurse (RN), shall contract with
appropriate local health care providers to ensure the provision of emergency care. The name,
addresses, and telephone numbers of contracted emergency health care providers, on-call
health care providers, and the Poison Control Center to be used in cases of emergency shall be
posted and accessible throughout the program. All staff who have direct contact with or provide
supervision of youth shall be trained emergency complaints and proper emergency on-site
emergency notification procedures and care, to include transfer procedures in order to facilitate
the immediate transfer of youth who require emergency medical, mental health, and dental care
services. The facility administrator (FA) shall ensure all phones within the program have access
to outside lines to ensure unimpeded access to the emergency use of 9-1-1. A review of seven
Individual Health Care Records (IHCRs) reflected two youth were applicable for a total of seven
episodic/first-aid care encounters. Each care event was facilitated by an RN. The program has
seven first-aid kits which are located in master control, phase one, phase two, and the kitchen.
The three kits used for the program’s transport vehicles and are maintained in master control.
The program’s practice is to check the kits at least monthly to verify contents are stored in
accordance with established guidelines and to prevent expiration of items. A review of the
monthly check logs for the past twelve months verified this practice. Three first-aid kits were
checked for approved contents during the annual compliance review week. Each kit was
fastened closed with a plastic snap lock and were fully stocked with approved contents. The
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program has two automated external defibrillators (AEDs) located in the medical clinic and
master control. The AED instructions are located with the AEDs in addition to verbal instructions
provided by the device when activated. The program’s registered nurse (RN) checks the AEDs
at least monthly to ensure they are operational. A review of AED check forms verified this
practice. The program’s RN conducted a self-test in the presence of the annual review team
with no noted issues. The program’s AED batteries expire in March 2031 and December 2032.
The batteries were last changed in September and December 2022. The AED pads expire in
August 2024 and July 2027. It was not known when the pads were last changed. A review of
staff training and drills indicated the program conducts at least one drill including the use of
immediate first-aid and cardiopulmonary resuscitation (CPR) on a quarterly basis. All program
staff have the opportunity to participate in at least one emergency drill annually. A review of
program drills for the past twelve months verified the program’s RN facilitated at least one
unannounced drill on each shift quarterly. Observations made during the program tour validated
emergency numbers were posted in master control and the medical clinic, accessible to staff,
and inaccessible to youth. The program trains all supervisors on the administration of the
epinephrine auto-injector. The reviewed training verified training is facilitated annually by the
program’s RN. A review of seven in-service and seven pre-service training records validated all
staff completed the required CPR/AED, first-aid, and emergency care training. The program did
not have any episodic care events during the annual review week; therefore, an observation
was not possible. The program maintains a policy and procedures for the use of NARCAN®.
The program practice is to train all staff on the administration and reviewed sign-in sheets
verified this practice. Additionally, the program facilitates emergency response drills where the
appropriate response includes the use of NARCAN®. The program stores NARCAN® in master
control and the medical clinic and reviewed inventories validated the RN conducts a perpetual
and weekly inventory. Six of seven interviewed staff stated they were personally allowed to call
9-1-1 if a youth had a medical emergency and one staff said they were not sure. Seven
interviewed youth reported they could see a doctor or a dentist at the program if needed. The
interviewed nurse verified the locations of the first-aid kits, documentation requirements for
episodic care, AED locations, AED inspection practices, emergency drill practices, and
emergency response practices.
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 maintains a written policy and procedures for off-site care and referrals. When
program youth receive off-site care the health care staff shall review all new paperwork from the
health care facility and physicians for pertinent orders. The designated health authority (DHA)
shall be contacted to review and implement orders and all reports and orders shall be signed by
the DHA. Off-site care shall be documented on the Department’s Summary of Off-site Care
form. A review of seven Individual Health Care Records (IHCRs) reflected three youth were
applicable for a total of five off-site care events. Each event was documented on the
Department’s Summary of Off-site Care form. One youth was applicable for off-site emergency
care, and the care was documented on the Episodic Care Log. Each event documented
parental notification and the discharge documents were filed within the IHCRs. Each IHCR
documented the DHA reviewed and signed the off-site care information. One youth was
applicable for follow-up testing and appointments and the record contained documentation
indicating each of the five follow-up appointments occurred. The interviewed nurse reported the
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program tracks follow-up appointments on the chronic conditions roster. Additionally, all follow-
up orders are transcribed by the medical staff and flagged for the DHA to review and sign.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program maintains a policy and procedures for chronic illnesses and periodic evaluations.
Program youth identified with chronic medical conditions shall have treatment plans and
physician progress notes specifying a youth’s particular course of therapy, identifying the role of
qualified health professionals in carrying it out, and updates as indicated. The program shall
ensure youth who have chronic illnesses receive regularly scheduled evaluations and necessary
follow-up. A review of seven Individual Health Care Records (IHCRs) reflected four were
applicable for being identified with a chronic condition on the Facility Entry Physical Health
Screening (FEPHS) form. No youth were applicable for having a communicable disease. Two
youth were applicable for taking medications on an ongoing basis and two youth were
prescribed pro re nata (PRN) medication. Each applicable youth was identified with a chronic
health condition and undergoing treatment. Each youth was classified with a Medical Grade two
through four. Each youth was placed on the program’s chronic conditions list and received
periodic evaluations at least every ninety-days. Reviewed progress notes verified periodic
evaluations were documented in the IHCRs. No youth were applicable for taking anti-
Tuberculosis medications. One youth was applicable for off-site evaluations and the visits were
documented on the Department’s Summary of Off-site Care form as required. Each off-site
care form was reviewed and signed by the designated health authority (DHA). There were no
missed periodic evaluations noted and each IHCR contained the Department’s Problem List,
which was updated as needed. The facility administrator (FA) and registered nurse (RN)
reported the medical staff meets with administration during morning management meetings and
as needed. The interviewed FA reported items discussed included transports, follow-ups, and
any other applicable concerns. The interviewed DHA verified periodic evaluations are completed
at least every ninety days and the program’s RN keeps track of needed appointments on the
chronic conditions roster. The interviewed RN verified the use of a roster to track appointments.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program maintains a written policy and procedures for medication management. A youth’s
medication regimen shall be ascertained upon admission. To ensure there is no lapse in the
youth’s medication regimen, all prescriptions for youth shall be immediately processed, if the
medication needs to be immediately initiated. All other prescriptions shall be expeditiously
purchased and procured in a timely manner. Parental notification shall be made, except in
emergency situations. Prescribed medications shall never be delayed or withheld for funding
reasons. All prescribed medications shall be obtained from a licensed pharmacy. A review of
seven Individual Health Care Records (IHCRs) reflected five youth were prescribed medications
upon admission. Each record contained documentation the registered nurse (RN) verified the
medications and included the verification in the chronological progress notes. Each record
documented the designated health authority (DHA) was contacted, and an order was obtained
to resume the medications. Each IHCR documented the medications had a current, valid order,
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and were administered as prescribed. One youth was applicable for being prescribed new
medications after admission. Each of the six applicable records contained a Practitioner Order
Form listing the medications. No youth were applicable for being in restricted housing at
medication administration times. One youth was applicable for over-the-counter medications
not listed on the Authority for Evaluation and treatment and the medication was administered
according to approved protocols. The program uses a pharmacy printed Medication
Administration Record (MAR) which contains all elements of the standard Department
Medication Administration Record (MAR) to document all medication orders. There were four
youth applicable for trained non-healthcare staff assisting in the delivery of medications when
healthcare staff were not on-site. The program maintains a list of trained staff within the medical
clinic and training logs verified the training was facilitated by a registered nurse (RN). Each staff
initialed the daily administration of medication and there were no observed lapses or errors
regarding medication administration in the six IHCRs. The medical staff documented side-effect
monitoring at least weekly as required. Four youth were applicable for the refusal of medication
and the MARs clearly documented the refusal and a Refusal of Treatment form was completed
for each refusal. Each MAR within the six applicable IHCRs documented the youth’s name,
Department identification number, date of birth, allergies, precautions, Medical Grade, and
medical alerts. The program maintains a youth photograph of each youth within the MAR binder
alongside each MAR. The program’s practice is to have youth initial each provided medication
entry and reviewed MARs verified this practice. No youth were applicable for parenteral
medications. One youth was applicable for being admitted with prescribed psychotropic
medications. The one applicable record documented the psychiatrist was notified of the
prescribed medications and the psychiatrist completed an Initial Diagnostic Psychiatric Interview
within fourteen days of admission. Additionally, the psychiatrist completed medication
monitoring every thirty days, as required. The program had no standing orders for psychotropic
medications, emergency orders for psychotropic medications, or pro re nata (PRN) orders for
psychotropic medications. Medication administration is the sole responsibility of the nurse
during administration and a separate staff are responsible for supervising the youth.
Observations of one medication administration was completed during the annual compliance
review week. The youth was escorted to the medical clinic by direct care staff. The youth
approached the RN individually, the RN identified themselves and asked the youth to state their
name, medication, allergies, and side effects. The medication was not pre-poured. Staff verified
the medication was swallowed and the RN who prepared the medication also administered it.
The Six Rights of Medication Delivery were verified during the observation. Six interviewed
youth reported they do not take medication and one youth reported the staff administers the
medication at the program. One youth reported he uses a cream provided by the nurse and a
second youth reported their medication is administered by a specialist off-site. Seven
interviewed staff reported the nurse dispenses medication at the program and one staff stated
the trained supervisor may also dispense medication. The interviewed nurse verified the
process for verifying and documenting medication administration. The nurse reported non-
healthcare staff trained to administer medication are trained annually and a list is kept on the
medical clinic wall and in the MAR book. The nurse reported medications are administered three
times each day and all medications are procured from a local pharmacy.
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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 maintains a written policy and procedures regarding the security of medical tools
and supplies. The program nurse shall be responsible for ensuring all tools, equipment, surgical
materials, chemical products, and medicines assigned to the medical department are
inventoried, securely maintained, and in proper order. Observations of the medical clinic during
the annual compliance review week verified all medical equipment classified as sharps,
medications, and controlled substances were securely stored and inventoried. Observations of
the medication cart showed it was clean and organized with different medications separated and
stock items separate from youth medications. Medications were stored in the locked medical
clinic, behind a locked cabinet, or in a separate locked medication room. The medication cart
was locked and contained a separate lock for controlled medications. The refrigerator used to
store medications was exclusively used for medication and was observed locked. The
temperature logs verified the temperature was checked daily. The nurse reported unused
medication is returned to the pharmacy or destroyed with the pharmacy consultant using a
chemical agent designed for the destruction of medication. Perpetual and weekly inventories
were observed for all sharps and medications. Shift to shift counts were observed for three
controlled medications. The program has six supervisors trained in the self-administration of
medication and the list was observed within the medication room. Each staff was trained by the
program’s registered nurse (RN) as verified by sign-in sheets. A review of three randomly
selected over-the counter (OTC) medications, sharps, and controlled medications were
compared to Medication Administration Records (MAR) and/or inventories and counts were
accurate. The policy and RN reported if a count is inaccurate the health services administrator is
notified, searches are conducted, and the Department’s Central Communications Center is
contacted. The interviewed nurse reported controlled medications are kept behind two locks on
the medication cart. The program has a current agreement with a consultant pharmacist who
comes on-site monthly to review MARs, review controlled and non-control medication count
sheets, counts medication, ensures items are securely stored, and reviews refrigerator
temperature logs.
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 maintains a written policy and procedures for infection control. Additionally, the
program maintains an Exposure Control Plan. The exposure and infection control program shall
follow guidelines and recommendations of the Center for Disease Control and Prevention
(CDC), Occupational Safety and Health Administration (OSHA) and state and federal standards
related to infection control. The procedures in place included prevention, containment,
treatment, and reporting requirements related to infectious diseases. The reviewed plan was in
accordance with OSHA federal regulations and CDC guidelines. The plan was reviewed by the
designated health authority (DHA) on December 21, 2023, and the facility administrator (FA)
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and registered nurse (RN) on January 17, 2024. The reviewed infection control procedures
included common, infectious diseases of childhood, self-limiting, episodic contagious illnesses,
viral or bacterial infectious diseases, Tuberculosis, Hepatitis A, B, and C, human
immunodeficiency virus (HIV), infectious diseases caused by blood-borne pathogens, outbreaks
or epidemics caused by any other infectious agent, outbreaks of pediculosis and/or scabies,
Methicillin-Resistant Staphylococcus Aureus (MRSA) and other emerging antibiotic-resistant
micro-organisms, food-borne illnesses, bio-terrorist agents, and chemical exposures in the
workplace, The program makes Hepatitis B immunizations available to all staff and staff have
access to protective equipment. The program had no instances of infectious disease requiring
contact with the local county health department or the Department’s Central Communications
Center during the annual compliance review period. The program has a separate record
maintained for youth and/or staff who have experienced an occupational exposure. The
interviewed statewide director of nursing reported there were no instances of exposure for the
annual review period. The Exposure Control Plan is available to all staff and is maintained in
the maintenance and medical offices. The program screens for infectious and communicable
diseases at admission. Additionally, a laboratory profile is conducted to ascertain blood work
which may be indicative of an infectious or communicable disease, if applicable. Through a sick
call format, the health care staff shall provide assessment of youth’s medical needs, and if a
youth should present with symptomology associated with infectious and/or communicable
diseases, the steps taken are outlined in policy. The program’s process for needle stick
exposure is to document, identify, test, follow medically indicated guidelines, evaluate reported
illness, and provide information to the staff exposed. The interviewed FA verified the locations of
the Exposure Control Plans. The interviewed RN verified the nursing staff provides annual
infection control training.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a written policy and procedures to address youth supervision and
requiring all program staff to promote safety and security by maintaining active supervision of
youth to include interacting positively with youth, engaging youth in a full schedule of
constructive activities, closely observing behavior of youth, and consistently applying the
program’s behavior management system (BMS). The program’s daily activity schedule was
posted and available to youth. The program’s contract requires a staff-to-youth ratio of one-to-
twelve during sleep hours, one-to-five for off-site activities, and one-to-eight during awake
hours. The program staff are required to account for the whereabouts of youth under their
supervision and ensure staff-to-youth ratios are in compliance with contract requirements.
Observations of staff supervision during the annual compliance review week included classroom
activities, line movement, youth searches, school breaks, youth head counts, transportation,
groups, outdoor/indoor recreation, and leisure activities. Activities observed during the annual
compliance review consisted of supervision of youth during school hours, youth in the dining
area, recreational activities, and youth movement through the program. Staff were observed to
be positioned to ensure proper supervision and to ensure there were no physical obstructions in
their view of the youth. Informal interviews with three staff while providing supervision were
conducted, staff were asked how many youth they were actively supervising, and each staff was
immediately able to report the accurate number of youth which were assigned to supervise.
Observed staff and youth were appropriately attired. Youth and staff interactions were observed
to be positive and consistent with the program’s BMS. A review of the program’s logbooks
validated head counts, movements, perimeter checks, and room checks were conducted, as
required since the last annual compliance review. An interview with seven staff, indicated each
staff was knowledgeable of the program’s procedure for when youth counts cannot be
reconciled.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program maintains a written policy and procedures addressing the implementation and
training of the program’s behavior management system (BMS). The program’s policy outlines
the implementation of the BMS, which is designed to maintain order and security, promote
safety, respect fairness, protection of rights within the program, foster compliance with the
program rules, and teach youth alternative social methods of dealing with problems, and to
provide positive reinforcement and recognition for accomplishments. The program maintains a
BMS staff manual and a youth handbook outlining program expectations and norms. The youth
are provided a copy of the youth handbook during intake. The youth handbook includes details
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of the BMS to include the rules governing positive and negative consequences. The program
utilizes the “Measurable Achievement Plan” (MAP) behavior management system. It is an
incentive-based, multi-level point system which allows youth to know their status and able to
receive incentives for all achievements made on a daily basis. The BMS is designed to enhance
youth treatment, to increase healthy pro-social behavior using positive reinforcement, and to
decrease unhealthy behaviors through natural consequences. Observations made confirmed
the BMS was posted throughout the program. The program maintains a weekly/monthly
incentive calendar of BMS activities and rewards. Each youth begins the program at the
orientation level and earn points to be progressively promoted to each of the higher levels.
Positive and negative behaviors are identified throughout each day and incentives are in place
to encourage youth to improve their behavioral choices. Special treatment team meetings are
conducted when serious infractions of the BMS occur. The program’s policy and procedures
were revised and signed by the facility administrator (FA) on August 25, 2023. The program has
an agreement with the Palm Beach County School District related to the BMS and
documentation provided indicated the teachers were trained, by the FA and/or the designee, on
December 13, 2023. The BMS training is provided to staff during pre-service training. A review
of seven staff pre-service training records confirmed each was trained on the BMS. A review of
the program’s parent/guardian handbook reflected an overview of the BMS was included. The
program’s written BMS included details regarding maintaining order and security, promoting and
protecting youth rights, positive and negative consequences, constructive disciplinary actions,
opportunities for positive reinforcement, recognition of accomplishments and positive behaviors,
promoting socially acceptable means for youth to meet their needs, process for explaining to
youth the reasons for any sanctions imposed, youth having the opportunity to explain their
behavior, opportunities for staff and youth to discuss the impact of behaviors on others,
reasonable reparations for harm caused to others, discussion of alternative behaviors,
promoting positive dialogue and peaceful conflict resolution, minimizing the separation of youth
from the population, coordination of any individual behavior plans, and consistent
implementation and treatment through oversight. A review of seven youth case management
records confirmed the youth’s orientation included a review of the program’s BMS. A review of
seven youth case management records supported the program was utilizing individual behavior
plans as outlined in the BMS. The program’s BMS did not include increased length of stay,
denial of youth basic rights, promotion of group punishment, punishment of youth by other
youth, and/or disciplinary confinement. Observations made during the annual compliance review
confirmed program staff adhered to the implementation of the BMS when interacting with youth
throughout each day. An interview with the FA indicated the program utilizes the MAP/BMS,
consisting of five levels, which allow the youth to track their status on a daily basis and youth
are provided incentives for achievements made. Additionally, the FA indicated, the recreation
manager is responsible for monitoring and tracking of all consequences and rewards, to ensure
consistency and fair treatment of all youth. Six of seven interviewed staff reported receiving
training on the BMS, and one staff reported not yet having received the BMS training. Six of
seven staff reported the program utilizes a point and level system with rewards and
consequences and one staff indicated the BMS is included in the youth’s handbook and
orientation process. Additionally, four staff indicated the BMS is posted throughout the program.
Five of seven interviewed staff reported things cannot be taken away from youth as a
consequence and two staff reported levels and/or transition, or privileges can be taken away.
Staff reported rewards provided as part of the BMS include shopping at the canteen store,
receiving snacks, food, and/or other special activities. Seven youth were interviewed and
explained the consequences used in the program include level freezes, special treatment team
meetings, and incentive privilege suspension. Seven youth were interviewed, and each reported
youth are rewarded with incentives on a weekly or daily basis, with canteen, snacks, meal
incentives, gaming systems, or other activities. Seven of the interviewed youth were
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knowledgeable and able to explain the difference between each level and how to move level to
level. All interviewed youth denied being able to punish other youth. Each of the seven
Interviewed youth reported staff are consistent with rewards and consequences; however, one
youth indicated some staff tend to give some youth more attention than others, and two youth
indicated staff treat all youth the same. Three of the seven interviewed youth felt the behavior
management system was fair, two youth indicated it was good, and two indicated it was very
good.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program’s policy, procedures, and practice confirm the program does not use room
restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program maintains a written policy and procedures in place to conduct and document ten-
minute checks during sleep hours or at other times, such as during an illness. The program has
a total of one-hundred and two video surveillance cameras from which video recordings are
maintained for at least thirty days. During the annual compliance review week, all cameras were
operational except for one camera. Staff are required to conduct room checks every ten-minutes
and document the time of the check on the ten-minute check log when youth are sleeping.
Checks are documented on the program’s ten-minute check logs with the time of each check
noted in real time along with the initials of the staff conducting each check. A review of nine
separate video footage samples of ten-minute checks and ten-minute check logs, documented
by staff, reflected there were no discrepancies. An interview with the facility administrator (FA)
and observations confirmed all the cameras, except for one, were functional during the week of
the annual compliance review. Five of seven interviewed staff indicated room checks are
completed every ten-minutes, and the remaining staff indicated room checks are conducted
every eight to ten minutes.
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5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program maintains a written policy and procedures to ensure youth are always accounted
for through a system of physically counting youth at various times throughout each day. The
program’s policy indicates headcounts will occur and shall be documented conducted minimally
at the beginning of each shift and during any emergency at regular intervals. The program
utilizes the logbook to document the youth counts and movements conducted throughout the
day. Counts are conducted at the beginning of each shift, after outdoor activities, and in
emergency situations. The program also documents and tracks youth intakes, releases, and all
movements outside of the program. The program utilizes an alert board located in the program’s
conference room for tracking of the daily counts of all youth in and out of the program.
Observations conducted during the annual compliance review week and a review of program
logbooks for the last twelve months confirmed the youth daily census counts, head counts, and
youth movements were documented at the beginning of each shift, and after each outdoor
activity. In addition, the program logbooks included documentation of new admissions, releases,
transfers, and youth temporarily away from the program. Observations conducted during the
annual compliance week confirmed staff were aware of all youth whereabouts and were able to
provide the proper counts to the annual compliance review team. Seven staff were interviewed,
and each staff was able to explain when counts and emergency counts are conducted.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a written policy and procedures requiring a chronological record of
routine events, incidents, activities, and emergency situations in a logbook in accordance with
Florida Administrative Code. A review of the program logbooks confirmed the program’s
logbooks were bound with pre-printed numbered pages. Observations and a review of logbooks
for the annual compliance review period, found logbook entries were documented in ink with no
erasures or white-out areas. Errors were typically 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 names of
the staff and youth involved, a brief description of the event, and the name and signature of the
staff making the entry. The program utilizes shift reports to summarize the events, incidents,
and activities documented in the program’s logbook and to brief all incoming staff. An
observation of a shift briefing was not possible during the annual compliance revie week. A
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review of the logbooks and shift reports demonstrated staff documented the required events,
incidents, and activities. The logbook included documentation of incidents, counts, perimeter
checks, youth transports, emergency situations, admissions, releases, movements, education,
recreation, and calls to the Florida Abuse Hotline and the Department’s Central
Communications Center (CCC).
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program maintains a written policy and procedures for key control and security which
includes the assignment, inventory, tracking, storage, replacement of damaged keys and
accountability of all keys used in the program. All facility keys are maintained within the master
control area, which is located at the entrance of the program. All restricted keys are housed
within a central key cabinet, which remains locked when not in use. All key rings are tagged to
record the ring number, keys assigned, and number of keys on the ring. A review of the
inventory matched the key rings in use. Each set of keys has an assigned key hook and tracking
number. To provide strict accountability of facility keys, master control operators, supervisors, or
designees are responsible for the inventory, issuance, inspection, return, and documentation of
active keys. The keys are assigned to staff according to their department and position at the
program. Key control logs documented the issuance and return of keys on a consistent basis.
Staff sign-out the facility keys at the start of the shift and sign-in the facility keys at the end of
their shift. The program maintains all restricted keys, and visitor keys separate from each other.
The program has a list of staff who are assigned permanent keys. Permanent keys are issued,
and staff sign an acknowledgment form indicating a key identification number and the number of
keys issued. Permanent issued keys are assigned to the facility administrator (FA), director of
group living, director of student services, human resource generalist, clinical director, and to the
maintenance manager. Observations made throughout the annual compliance review week
found all staff and visitor surrendered their personal keys upon entering the program and keys
were stored within the master control office. A review of three staff and their assigned keys
during the annual compliance review week verified keys matched the key log. All observations
during the annual compliance review found personal keys were secured and staff were aware of
the function of each program key in their possession. A review of Department’s Central
Communications Center (CCC) reports verified there were no instances of a staff losing their
program keys during the annual compliance review period. An informal interview with the master
control operator confirmed each set of keys has an assigned key hook and tracking number and
indicated to provide accountability of facility keys, only supervisors, master control, FA, or
designee are responsible for the inventory, issuance, inspection, return and documentation of
active keys. Additionally, the master control staff indicated permanent keys are assigned to
staff according to their department and position at the program. An informal interview with the
maintenance manager validated the program’s process for reporting and replacement of keys.
Seven interviewed staff confirmed having knowledge of key control policies and procedures.
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5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a written policy and procedures to ensure the safety and security of
youth, staff, the program, and the public through effective search practices which include
detection and removal of contraband. The program’s policy specifies items and materials
defined as contraband and unauthorized items, which are also detailed in the program’s youth
handbook, which are never allowed to be in a youth’s possession. The policy states any staff
who is found in possession of contraband in a program will be subject to disciplinary action up
to, and including, dismissal, as well as procedures regarding notification of law enforcement for
items considered illegal as defined in Florida Administrative Code. A review of the policy and the
youth handbook confirmed prohibited items included 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 any keys not issued by the program. The program’s policy also includes a list and
quantity of approved youth items. The policy dictates all illegal contraband will be surrendered to
law enforcement, and unlawful activity will be reported to law enforcement. The policy and
handbook outline the consequences for youth found with contraband, which is also outlined in
the behavior management system. Additionally, reviewed documentation included the
procedures for searching incoming and outgoing mail. Contraband items are disposed, returned
to sender, mailed to the youth’s home, or returned to the youth upon release. Additionally, a
contraband notice is posted at the entrance of the program and states law enforcement will be
contacted for anyone bringing in contraband and a criminal report will be filed. The policy
outlines the program’s responsibilities, standards for searches of youth, and program searches.
Program searches include youth rooms, common areas, and the program perimeter. A review of
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the contraband logs found contraband searches were conducted on a weekly basis on each
shift during the annual compliance review period. Unannounced random youth searches are
conducted, as well as searches of common areas prior to and after use by youth. The program’s
perimeter security is checked on each shift. Searches and search findings are documented in
the program’s logbook. Observations of daily youth searches during the annual compliance
review week, included searches of youth moving to and from educational classes, meals,
breaks, transports, and other movements within the program validated the program’s practices.
A review of the Department’s Central Communications Center (CCC) incidents related to
contraband, indicated there was nine contraband incidents reported during the annual
compliance review period. An informal interview with the compliance manager indicated any
unauthorized items/illegal contraband is documented on the contraband log, reported, and
disposed of properly, if applicable. Any findings of illegal contraband are reported to law
enforcement and to the CCC. Seven staff were interviewed, and all were knowledgeable and
able to explain the programs process for youth room searches. An interview with the facility
administrator (FA) indicated contraband items are confiscated and provided to the shift
supervisor for storage or disposal. Additionally, if a visitor is in the possession of contraband,
they will be asked to return the item to their vehicle, or leave the program. In the event illegal
contraband is confiscated, the program will contact law enforcement and will wait until law
enforcement arrives to the program for further investigation.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a written policy and procedures to ensure searches are conducted
according to Florida Administrative Code at the time of admission, after off-campus activities,
and visitation to enhance safety within the program and control the introduction of contraband.
Parents/guardians are notified of searches during visitation by way of the parent/guardian intake
letter, which is sent at the time of each youth’s admission. Youth are searched before all
movement, during a new admission, readmission, returning from visitation, returning from off-
campus activities and/or appointments, when suspected of contraband, or determined to be a
security risk. The program practice is to search youth after school, group, outdoor recreation,
visitation, work detail, transports, and meals. Full body visual searches are conducted only for
new admissions and re-admissions. There were observations of searches made for a transport
and a re-admission during the annual compliance review week with no noted issues. During the
annual compliance review week, the program did not have any visitations or off-site activities
available for observation; therefore, no observations of searches were conducted during any of
these events. Youth search and full body visual search forms were reviewed and confirmed the
program conducts full body visual searches at the time of admission and other off-site
appointments. Observation during the annual compliance review week included searches of
youth conducted before and after line movements, youth traveling to and from educational
classes, after meals, and following hygiene breaks, which validated the program’s practice.
Observations made throughout the annual compliance review week validated youth are
provided instructions regarding the search, searches were conducted by staff of the same
gender as the youth, were conducted in a manner as not to degrade the youth and were based
on the Protective Action Response (PAR)/Right Interactions (RI) training manual. Seven staff
were interviewed, and each staff were knowledgeable of the program’s policy regarding the
search procedures. Seven interviewed youth reported youth searches occur when returning
from off-campus, after outdoor activities, after visitation, after meals, when items are missing,
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and after work detail. Additionally, the youth indicated searches are conducted at every
movement.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a written policy and procedures requiring the program vehicles to be
properly maintained, to contain safety and emergency equipment, and to be operated in a safe
manner. 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. At the
time of the annual compliance review, the program had two operable vans to transport youth.
Each vehicles had a completed inspection during the annual compliance review period and
were conducted on March 23, 2023, and December 12, 2023. Both transportation vans did not
have installed a safety screen; however, the regional director of residential services has been
made aware, and the program provided documentation showing all efforts to add a safety
screen in both transportation vehicles. Each vehicle was equipped with a fully charged fire
extinguisher, seatbelt cutters, a window punch, and operable seatbelts for each passenger. The
vehicle first-aid kits are stored in the master control office and are checked out each time a
vehicle is in use. The program maintains a transportation vehicle inspection log which contains
the documentation of the completed weekly vehicle inspections. The results of the weekly
inspections are documented and stored in the program’s vehicle maintenance log/binder. A
review of the weekly inspections for the annual compliance review period, showed all weekly
inspections were completed, as required. A random check of nine personal vehicles and the
program’s transportation vehicles was conducted during the annual compliance review week
and each vehicle was found to be locked when not in use. There was a transportation available
for observation during the annual compliance review week, and observations confirmed the
program’s practice was in accordance with policy. Six of seven interviewed youth indicated,
during transports, youth are secured within the vehicle with seatbelts, handcuffs, and shackles.
One youth stated they have not utilized or been transported in the program’s vehicles. Six of
seven interviewed staff indicated, during transports, youth are secured within the vehicle with
seatbelts, handcuffs, and shackles. One staff stated they have not participated in any
transports.
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5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a written policy and procedures to ensure the safety and security of
youth and the community during transportation of youth, and to ensure the appropriate staff-to-
youth ratio is maintained while youth are transported off program grounds. The program has an
approved transport list which is updated monthly to ensure staff driver’s licenses are valid. The
approved driver’s list is located within the administration office. The program’s human resources
manager conducts monthly driver’s license checks to determine ongoing driver eligibility.
Reviewed documentation validated the program’s practice. The program provides secure
transportation for high-risk youth, determined to be at greater risk. The program’s transport ratio
is one staff to five youth, not including the driver. Observation was conducted of the vehicles
during the annual compliance review and each appeared to be maintained and in working order.
The transportation vehicles are not equipped with a safety screen which separates the driver
from the passenger’s compartment. The program has documented efforts for the installation of
the safety screens to both transportations. Observations of a transport was conducted during
the week of the annual compliance review and confirmed the staff rode in the back with the
youth, the staff-to-youth ratio was within the contract requirements, youth were secured, were
wearing seatbelts, and staff had all required equipment including a program issued telephone.
Seven youth were interviewed, and all stated they felt safe while being transported and have not
seen any staff place contraband in a transport vehicle. Seven staff were interviewed, and six
staff indicated utilizing the program’s cellular telephone or communication device when
transporting youth, and one staff stated have not transported any youth. Seven staff were
interviewed and three indicated the safety equipment in the transport vehicles consists of a first-
aid kit, fire extinguisher, and a window punch. Four staff were unsure of what the safety
equipment was, and two stated they have not transported youth. Seven staff were asked if the
transport vehicles have a safety screen and if not does staff sit in the back of the vehicle with
the youth during a transportation. Five staff indicated staff sit in the back with the youth, and two
staff were not sure, as they had not conducted any transportations. All staff reported transport
vehicles are searched for contraband prior to and after each use and staff are not allowed to
use personal vehicles to transport youth. Six of seven staff indicated the emergency response
process during transports consists of notifying the program, the facility administrator (FA), or the
assistant facility administrator (AFA), and four staff indicated calling emergency services or law
enforcement, and one staff indicated not having to transport any youth. Five of seven staff were
knowledgeable of the program’s transportation ratio policies, and two staff indicated they had
not conducted any transports. An interview with the FA confirmed the program’s policy is for
staff to sit in the back with the youth, due to the vehicle not having a safety screen.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a written policy and procedures requiring the maintenance of a safe and
secure physical plant, grounds, and perimeter. The facility manager (FA) shall ensure weekly
safety and security audits are conducted, reviewed, submitted to the Department, and ensure
verification of all deficiency, corrections and implementations are in compliance. The weekly
safety and security audits include the inspection of the facility cameras, radios/communication,
keys, locks and doors, vehicles, and living areas to include youth rooms and bathrooms. The
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program maintains the weekly safety audits in a binder. A review of the program’s Preventive
Maintenance Checklist and Safety Inspection Logs for the past twelve months confirmed the FA
conducts weekly safety/security inspections. Findings are documented on the Weekly Safety
Inspection Reports. All deficiencies are tracked, and efforts are made to correct any deficiencies
noted. During the annual compliance review period, there were no inspections missing or any
discrepancies noted. The forms documented safety and maintenance repairs needed and the
date and time the repairs were completed, or due to be completed. All inspection forms were
reviewed and signed by the FA. The program has documentation of on-going efforts for any
repairs. An interview with the FA indicated all safety and security deficiencies are identified and
tracked through weekly safety, security, and perimeter checks.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a written policy and procedures to address the proper identification,
control, and management of tools to ensure youth do not use tools or equipment as weapons or
security breaches. The reviewed policy addresses the issuance, inventory, and control of
equipment and tools. The policy prohibits specific tools including machetes, bowie knives, and
long blade knives. The program has a policy and procedures for missing/lost tools and for tools
requiring disposal. The program has identified the maintenance manager as the program’s tool
control manager. The policy classifies tools into two categories, Class A tools and Class B tools.
Class A tools are hazardous with sharp edges or points with a high potential to be used as a
weapon to inflict serious bodily harm such as knives, hammers, screw drivers, and electric drills.
Class B tools do not have sharp edges or points, such as brooms, mops, and scrub brushes. A
review of inventory logs and the tool storage room verified tools are securely stored when not in
use, easily marked for identification, inventoried prior to, and following work activities. Class A
tools are secured in the maintenance office and are inventoried daily when in use. Observations
found the maintenance office to be organized, and clean. All tools were observed to be
maintained in a secured location. All Class A tools were stored on the maintenance office walls
with a photo of the tool and a number to identify the tool was stored in the proper place. A
review of fourteen randomly selected class A tools showed each tool was labeled and securely
stored and in the correct location. All Class A tools were in good repair and accounted for. All
Class A tools are inventoried daily by the maintenance manager except on days when tools are
not utilized. The program has a sign-in and sign-out log for Class A and Class B tools. An
informal interview with the maintenance manager confirmed all tools are signed in and out when
used. Class B tools, including mops, brooms, and buckets are maintained in a locked closet
which is inaccessible to the youth. Class B tools are inventoried daily by program staff. A review
of Class B storage reflected inventories were accurate and tools were secured when not in use.
A review of the inventory sheets validated the program’s practices. All tools were properly
identified and inventoried during the annual compliance review period. A review of fourteen
randomly selected separate tools coincided with the inventories. In an informal interview, the
program’s maintenance manager was aware of the proper procedures to follow if tools are
missing or damaged. The maintenance manager reported there were no instances of missing or
lost tools during the annual compliance review period. Additionally, they indicated if a tool is
missing, staff notify administration and master control, the program will lockdown the facility,
and the program will stop all youth movement to conduct a search of the program until the tool
is located. The maintenance manager reported there were no instances of broken tools which
required disposal or replacement during the annual compliance review period. A review of
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seven pre-service training records indicated all staff were trained on the safe use of tools. A
review of the Department’s Central Communications Center (CCC) reports verified there were
no instances of missing/lost tools since the last annual compliance review.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries to themselves, other youth, and staff. The program’s
policy and procedures included supervision requirements, issuing tools to youth and staff, and
activities involving tools. Class B tools which include mops, brooms, toilet brushes, and scrub
brushes are inventoried daily by staff to ensure each tool is accounted for. A review of the Class
B tool inventory log sheets confirmed the program’s practice. A risk assessment of each youth’s
risk to self and others is required to determine their eligibility to use Class B tools. Use of Class
B tools and participation in work projects is based upon each youth’s level within the program’s
behavior management system (BMS). Seven youth case management records were reviewed,
and all indicated youth had been trained on the proper usage of tools. A signed
acknowledgement form was filed in each youth’s case management record. The program staff-
to-youth ratio during Class B tool use if one staff to five youth. The interviewed regional
compliance manager confirmed the youth are allowed to use Class B tools, and indicated youth
are only allowed to use them during weekend chores and on some occasions in the evenings.
During the annual compliance review week, there were no cleaning, chores, or work projects
which involved youth and the use of tools; therefore, no youth were observed handling tools.
Seven youth interviews confirmed youth are allowed to use a scrub brush, mop, and broom.
Seven staff were interviewed, and each confirmed youth are allowed to use a mop, broom,
and/or a scrub brush. One staff indicated youth are allowed to use a dustpan.
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 maintains a written policy and procedures establishing guidelines for outside
contractors who come on-site to complete repairs. Contractors are required to sign the visitor
log upon entry and are provided a contract agreement form which indicates a list of
unauthorized items. The maintenance manager or designee inspects all tools upon the arrival of
outside contractors and is responsible for providing approval if tools are required. The program’s
guidelines for external workers includes checking of tools upon arrival and departure, searching
of all vendors prior to entering the program, tool restriction while in the program, missing tool
follow-up, and restriction of youth from the work area. The outside contractor completes the
program’s outside contractor form upon entrance to the program, listing what tools are needed
to complete the work order. Maintenance will review the form and sign once the tools are
inventoried and approved. If any unauthorized items are needed by the contractor while in the
program, approval is obtained by the facility administrator (FA) or designee. Upon exiting the
program, the outside contractor form is reviewed, all tools are verified, then the form is signed.
Any tools required to be used within the program are inventoried and recorded on the
contractor’s agreement form before and after the repair is completed. A review of the sign-in
sheet, the contractor’s agreement forms, and three randomly chosen work invoices verified the
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contractors were on-site on the same date the documents were signed. An informal interview
with the maintenance manager indicated when contractors are on-site, youth are not allowed
near the work area, a maintenance staff is assigned to supervise and escort the contractor to
ensure the work is being completed, and all tools are secured.
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 maintains a written policy and procedures to ensure fire safety and evacuation
drills are conducted, and youth and staff are prepared for immediate implementation or
mobilization in the event of an emergency or disaster. The program has a written Continuity of
Operations Plan (COOP) which was approved by the Department on February 22, 2023. The
COOP requires the program to conduct unannounced fire drills once every month for each shift.
A tour of the program during the annual compliance review, found fire evacuation routes and
egress plans were posted throughout. The program has a total of one-hundred twenty-six fire
extinguishers and reviewed documentation confirmed the annual inspection was completed in
January 2024. A review of drill documentation for the annual compliance review period indicated
the program conducted one monthly fire and a COOP drill, as required, on each shift. The
program conducted monthly COOP drills which included emergency drills, riot, disturbances,
escapes, bomb threats, chemical spills, medical situations, and severe weather scenarios.
Reviewed documentation for all drills contained the type of drill, date and time, participants, brief
scenario, findings, and recommendations. The program reviews each drill and debriefs staff on
how well drills were conducted during the monthly all staff meetings. An interview with the
facility administrator (FA) indicated COOP drills and fire drills are conducted monthly on each
shift. Seven interviewed youth reported participating in fire drills and having been instructed on
what to do in the case of a fire. Each youth indicated drills are conducted at least once a month.
Seven staff were interviewed indicating participation in at least one COOP and/or mental health
drill which included either a weather, major disturbance, chemical spill, escape, and/or bomb
threat, and fire drills. One staff indicated not participated in any drill due to being a new
employee.
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 written policy and procedures requiring the development of a
Continuity of Operations Plan (COOP) which is updated as necessary and maintained for the
continuity of mission essential functions of the provider in the event an emergency prevents
occupancy of the primary program location, in compliance with state law and the Department’s
policy. The COOP addresses phases of a disaster plan as well as emergency management
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including preparedness, response, and recovery. The COOP addressed emergencies including
fire prevention and evacuation, severe weather, major disturbances, bomb threats, hostage
situations, chemical spills, flooding, terrorist threats or acts, staff roles and responsibilities, any
equipment and supplies needed, information about youth which may be needed, alternative
housing arrangements, provisions for continuity of care and custody of youth, and provisions for
public protection. The COOP details alternative housing plans in case the program is required to
vacate due to an emergency or disaster. A review of the COOP validated the plan was
submitted and approved by the Department on February 22, 2023, and provides for the basic
care and custody of youth in the event of an emergency or disaster. An interview with the
program’s facility administrator (FA) indicated the staff has access to the program’s COOP Plan
and the plan is located in the FA’s office, the office of the director of group living, and in master
control. The program has the necessary supplies readily available in case of an emergency
evacuation in an office. The program maintains an administrative hard copy for each youth
record in case of an emergency. The program’s hard copy records are easily accessible and
mobile in the event of an emergency resulting in the program relocating quickly or in the event
needed information cannot be accessed electronically for all youth in the program. A review of
seven youth case management records confirmed each contained the youth’s name, a
photograph, Department identification number, admission date, date of birth, gender, race,
overall health status, address, and parent/guardian contact information which included name,
address, telephone number of the person with whom the youth resides, their relationship to the
youth, and person(s) to notify in case of an emergency. In addition, the records contained the
youth’s assigned juvenile probation officer (JPO), committing judge, state attorney, public
defender, and victim notification contact information.
5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program maintains a written policy and procedures addressing storage and inventory, to
ensure all youth and staff are safe from the effects of the unauthorized use of flammable,
poisonous, toxic, and caustic materials. The program’s maintenance manager maintains a
monitoring system to ensure compliance with flammable, poisonous, and toxic item
requirements. The program’s flammable, poisonous, and toxic materials are stored in a flame-
resistant locked cabinet within the locked maintenance office. A review of five flammable,
poisonous, and the toxic items verified the items were securely stored and inventories were
accurate. A copy of each current Safety Data Sheet (SDS) was maintained in the maintenance
office for each substance. A complete chemical inventory is completed daily and documented
on the monthly chemical inventory sheet. A tour of the program and observations found the
program stores all toxic items and poisonous materials in the cabinets within the maintenance
office and other cleaning agents are stored within a secure locked cabinet in the kitchen office
area, inaccessible to youth. A review of five separate cleaning chemicals was completed and all
inventories were accurate. All inventory forms, sign-in and sign-out forms, and SDSs coincided
with the chemicals maintained. The program also stores cleaning supplies in a locked storage
closet, along with the Class B tools. The storage room is always locked and can only be
accessed by the maintenance manager, supervisors, and administration or authorized
personnel. The items maintained in the storage room are inventoried and have an
accompanying SDS located in the binder, as well as a perpetual inventory for staff to sign-in and
sign-out items with each use. The informally interviewed maintenance manager indicated the
program has an approved list which identifies shift supervisors, maintenance staff, direct care
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workers, the facility administrator (FA), and the assistant facility administrator (AFA) as staff
authorized to handle flammable, poisonous, and toxic items. Additionally, the maintenance
manager reported the program does not keep any gas, or any antifreeze.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a written policy and procedures prohibiting youth from handling any
flammable, poisonous, and/or toxic items or materials. Program youth are strictly prohibited to
use, handle or clean dangerous or hazardous chemicals, respond to chemical spills or clean,
handle or dispose of any other person’s biohazardous material, bodily fluids, or human waste.
Observations confirmed all chemicals were maintained behind at least one locked door/cabinet
and youth do not have access to areas where items are being stored. Youth do not have access
to these items and are supervised by staff during any cleaning. During the annual compliance
review week, there were no observations of youth cleaning and/or using any chemicals. Seven
interviewed youth reported not using any chemicals/cleaning products. The informally
interviewed compliance manager indicated staff handle cleaning products, as youth are only
able to clean with a cloth and youth are not allowed to handle any chemicals.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program maintains a written policy and procedures for the disposal of flammable, toxic,
caustic, and poisonous items. The policy requires adherence to procedures in accordance with
Occupational Safety and Health Administration (OSHA) federal regulations. The policy prohibits
chemicals from being poured on the ground or being disposed of by any method other than
what is outlined by the biohazard guidelines. The program reported liquid waste, including dirty
mop water and unused beverages, are disposed of in the kitchen or mop storage plumbing
drains. The program’s maintenance manager, facility administrator (FA), assistant facility
administrator (AFA) and authorized staff, are the only staff authorized to handle flammable,
poisonous, and toxic items. Reviewed documents confirmed the program’s disposal procedures
of chemicals were created in accordance with Occupational Safety and Health Administration
(OSHA) standards. Used kitchen grease and waste is stored in a container outside the kitchen
area. The program has a contract with a vender to dispose of used kitchen grease and waste.
Reviewed invoices validated the program’s practice. The program maintains strict procedures
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regarding chemical spills. All spills are reported immediately to the shift supervisor and the
direct shut down of the air handler and ventilation system is performed. An evacuation of the
affected area is conducted, and a determination is made by the FA whether to contact outside
assistance to contain the spill. The maintenance manager reported the program has not had a
chemical spill during the annual compliance review period. The program’s maintenance
manager was interviewed regarding the proper procedures of disposing chemicals and stated all
items for disposal are collected by the local county waste disposal department. Additionally, the
maintenance manager indicated the program has not needed to dispose of any chemicals. A
review of the disposal logs confirmed the program did not have any chemicals disposed of
during the annual compliance review period. An interview with the FA validated the disposal
practices.
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
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5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a written policy and procedures to allow youth to have visitation and
communication with family members while in the program. The program assists youth and
families in maintaining connections in a visitation environment which provides monitoring,
control of movement and security practices to ensure visitor, youth, staff, and program safety.
The program’s policy provides each youth opportunities to promote communication and
engagement which fosters family reunification and community connections. The program also
maintains a list of approved visitors; however, attorneys, representatives of the court, juvenile
probation officers (JPO), other agency representatives, and clergy are authorized to visit at any
time. Searches of visitors will be conducted upon entry and all youth shall be searched following
visitation sessions. The program’s visitation policy indicated consideration for requests of
alternative visitation arrangements with parents/guardians, if needed. Youth are informed about
visitation upon their admission to the program during the orientation process. The visitation and
communication procedures are covered in the youth handbook, parent/guardian handbook, and
addressed on the orientation checklist. The visitation procedures are posted in the lobby.
Visitation is held on Sundays from 1:00 p.m. to 3:00 p.m. Youth are given opportunities to
communicate with their families in person, by telephone, and by mail. Youth are provided with
writing materials and stamped self-addressed envelopes to send letters to approved family
members. The program maintains a correspondence log for each youth which documents
incoming and outgoing mail, which is inspected by staff. The correspondence logs are
maintained in each youth’s case management record. Youth are permitted weekly telephone
calls. Each youth’s use of telephone is documented in each youth’s case management
chronological and telephone log. A review of the logbooks, visitation sign-in logs, and outgoing
and incoming mail logs verified the program allows visitation and mail for approved family
members. A review of the telephone logs verified youth have consistent telephone
communication with family members. It is the program’s practice for the assigned case manager
to follow-up with the JPO regarding human trafficking victims to determine whether the
parent/guardian should be permitted to communicate with the youth; however, there were no
youth applicable with a history of human trafficking for review. Seven youth were interviewed,
and each confirmed being able call and/or send letters to their parent(s)/guardian(s). Seven
youth were interviewed, and five youth indicated not knowing what services the program utilizes
for youth who do not speak English, and two youth indicated the program used a translation
system. An interview with the facility administrator (FA), indicated the program has an
agreement with a third-party language translation system for youth, if English is not their primary
language. Seven staff were interviewed and two indicated the program utilizes language
interpreter or would use a translator for youth, where English is not their primary language, and
five staff indicated they were not sure what was utilized.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a written policy and procedures to ensure each youth has a variety of
recreation and leisure activities. A review of the staff roster confirms the program has a
recreation therapist, who meets all requirements for the position. The program’s recreation
calendar designates an activity for the youth to participate in during outdoor recreation each
day, as well as a calendar of alternative activities if recreation is indoors. A review of the
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program’s schedule found large muscle activities are scheduled for at least one hour daily. All
activities promote social and cognitive skill development, creativity, teamwork, healthy
competition, mental stimulation, and physical fitness. The program takes precautionary
measures to prevent over-exertion, heat stress, dehydration, frostbite, hypothermia, and
exacerbation of existing illness or physical injury. The program’s activity schedule is posted
throughout the living units and common areas of the building. Youth are provided with at least
one hour of large muscle activity daily. Seven youth case management records were reviewed,
and recreational therapy was included in each youth’s Individualized Performance Plan (IPP). A
review of the logbook and daily activities schedule confirmed the program has a range of
supervised and structured indoor and outdoor recreation and leisure activities for the youth, for
at least one hour daily. Observations made throughout the annual compliance review week
validated youth are provided with at least one hour of indoor or outdoor recreation and leisure
time. Seven staff were interviewed regarding the type of recreation activities the program
provided and how long the activities and each staff indicated the program provides youth with at
least one hour each day. Each staff indicated the outdoor activities consist of basketball,
football, soccer, and/or other sports. The indoor activities consist of board games, indoor
games, card games and/or gaming systems. Seven youth were interviewed, and each youth
indicated the program allows youth the opportunity to exercise, play outside, or inside
depending on the weather, and four youth further indicated going to recreation for at least one
hour each day. Each youth reported participating in basketball, football, soccer, or exercise,
while outside and during indoor recreation, youth indicated they are given the opportunity to play
board games, cards, and/or can play on gaming systems.
5.24 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program maintains a written policy and procedures for the search and inspection of the
controlled observation room. The room used for controlled observation has a metal door with a
shatter-resistant window, with at least thirty-five unencumbered square feet, properly covered
vents and lighting, an approved fire-retardant mattress, and no electrical outlets. The program
had a total of five controlled observation reports completed during the annual compliance review
period. Each reviewed report found each staff documented an inspection of the room and a
search of the youth before the youth was placed in the room, as required.
5.25 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program maintains a written policy and procedures for controlled observation. The
program’s policy indicates a youth may be placed in a controlled observation room only in
emergency situations where there is imminent threat, or when there’s a safety and security risk.
The program had a total of five controlled observation reports completed during the annual
compliance review period. There were no applicable youth who exhibited behaviors indicative of
a mental health crisis or suicide. A review of all five controlled observation reports found each
contained documentation the supervisory or higher-level staff authorized placement. Each
incident documented the youth displayed active aggression, violent behavior, was physically
out-of-control, and staff advised the youth the reason of placement in controlled observation and
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expected behavior for removal. A healthcare professional or staff of the same gender as the
youth completed the Health Status Checklist in each instance. Three of the five youth had
complaints or injuries were observed and a healthcare assessment and/or treatment was
provided. There were no youth who required an approved extension, which is required if placed
for over the initial two hours.
5.26 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program maintains a written policy and procedures for controlled observation safety checks
and releases, including staff designations for controlled observation. To ensure the youth’s
safety while in the controlled observation room, staff shall conduct safety checks at least every
fifteen minutes and shall provide continuous sight and sound supervision. Staff shall document
all safety checks and observations of youth and their behavior while placed in controlled
observation on the Controlled Observation Safety Checks form. The program’s facility
administrator (FA) or designee with delegated authority shall approve a youth’s release from
controlled observation when it is determined, and based on the youth’s verbal and physical
behaviors, they are no longer an imminent threat of harm to self or others. The program had a
total of five controlled observation reports completed during the annual compliance review
period. A review of the five reports found each staff making the placement completed the first
page of the Controlled Observation Report and submitted it to a supervisor. Staff documented
safety checks at least once every fifteen minutes and observations of the youth’s behavior, as
required. Staff documented all safety checks and observations on the Controlled Observation
Safety Checks form. The FA or supervisor who has delegated authority, gave written approval
before each youth was released from controlled observation. The Controlled Observation
Report, Health Status Checklist, and Controlled Observation Safety Checks form were
maintained in an administrative record and in the youth’s case management record. The FA or
designee reviewed and approved each controlled observation report within fourteen days of the
youth’s release from controlled observation.
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report_type: QI Residential

program_name_raw: Palm Beach Youth Academy

rule: Indicator 2.08

excerpt: Youth Needs Assessment Summary (YNAS)

rating: Limited Compliance

rule: Indicator 2.09

rule: Indicator 2.20

excerpt: Educational Access (Critical)