summary: QI Residential - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Broward Youth Treatment Center
Youth Opportunity Investment, LLC
(Contract Provider)
8301 South Palm Drive, Building #2
Pembroke Pines, Florida 33025
Review Date(s): August 29 - September 1, 2023
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:
Ebony Evans, Office of Accountability and Program Support, Lead Reviewer ([Standard 1])
Rob Aguis, Career and Technical Education Deputy Director (Standard 1)
Christine Calvert, Office of Accountability and Program Support, South Region Supervisor
(Standard 3)
Tonya Gittens, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Interviews)
Peter Keelan, Office of Education, Education Coordinator, South Region (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Shakela Minns, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Broward Youth Treatment Center MQI Program Code: 1269
Provider Name: Youth Opportunity Investments, LLC Contract Number: 10533
Location: Broward County / Circuit 17 Number of Beds: 40
Review Date(s): August 29 - September 1, 2023 Lead Reviewer Code: 200
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
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 67 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
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 Youth Input Satisfactory
1.16 Advisory Board Satisfactory
1.17 Staff Performance Satisfactory
1.18 Recreation and Leisure Activities Satisfactory
1.19 Special Contract Conditions Satisfactory
1.20 Contract Specific Career and Technical Education Services Satisfactory
1.21 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 67 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
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 67 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * 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 67 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
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 67 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure 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 Non-Applicable
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
5.25 Controlled Observation Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 67 (Revised September 2022)
Program Overview
Broward Youth Treatment Center is a forty-bed program, for thirteen to eighteen-year-old males,
located in Pembroke Pines, Florida. The program is operated by Youth Opportunity
Investments, LLC, through a contract with the Department. The program provides Substance
Abuse Treatment Overlay Services (SAOS), including substance abuse assessments,
evaluations, individualized substance abuse treatment planning, daily substance abuse services
including individual, group, and family substance abuse counseling, crisis intervention therapy,
suicide prevention services, mental health and substance abuse treatment for youth with co-
occurring mental disorders, twenty-four-hour response capability, routine, and random
urinalysis, psychopharmacological therapy, and psychiatric and psychological services. In
addition, the program fosters each youth by providing weekly group therapy services to include
the Living in Balance substance abuse group, Men’s Trauma Recovery and Empowerment
Model, and Skillstreaming the Adolescent groups. The program has available Mindfulness for
Addiction, Stop the Chaos, and Trauma Focused Cognitive Behavioral Therapy to provide as
supplemental services based on identified needs. Program administration is comprised of a
facility administrator (FA), one assistant facility administrator (AFA), a clinical director, a human
resources/business manager, and two administrative assistants. Case management services
are provided by a director of case management, three case managers, and one transition
services manager. Mental health and substance abuse staff at the program include a
designated mental health clinician authority (DMHCA) who supervises three non-licensed
therapists. In addition, the program contracts with a licensed psychiatrist for the provision of
psychiatric services to all applicable youth. Medical services are offered seven days a week and
are provided by a licensed medical doctor who serves as the designated health authority (DHA),
one registered nurse (RN) who serves as the health service administrator (HSA), and two
additional RNs. Educational services, including vocational training courses, are provided by the
Broward County School District. The layout of the program includes one main building with
hallways on each wing of the facility. Youth rooms are located on the east wing and the west
wing; however, during the annual compliance review the west wing was non-operable due to
construction. Staff offices are in areas which are secured and inaccessible to youth. All meals
are prepared on-site. The program has sixty-one security cameras providing coverage with the
capability to store video for up to thirty-days. All cameras were operational at the time of the
annual compliance review. At the time of the annual compliance review, the program had nine
vacant positions including seven safety and security specialists, and two shift supervisors.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 67 (Revised September 2022)
Strengths and Innovative Approaches
The program continues to build and enrich youth therapeutically by adding a new component to
the recreational department. The program partnered with a private vendor to build a recording
studio equipped with state-of-the-art microphones, headphones, speakers, interface, and a
variety of recording and engineering software. The goal of the studio is to give youth an outlet to
speak their mind through poetry, writing, podcasting, and producing music.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 67 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program maintains a written policy and procedures to ensure all newly hired staff,
volunteers, and interns receive an initial background screening prior to unsupervised contact
with youth. The program had twenty-three 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 twenty-three 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 hiring. The program reported there were two new applicable volunteers
since the last annual compliance review, and initial background screenings were completed and
reviewed with no discrepancies. The Annual Affidavit of Compliance with Level 2 Screening
Standards was signed and submitted to the BSU on January 25, 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 24, 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 has a written policy and procedures to ensure all staff, volunteers, and interns
receive a background rescreening every five years from the initial hire date. The program’s
policy is to submit information to the Department’s Background Screening Unit
(BSU)/Clearinghouse at least ten days prior to the staff’s anniversary date. There were four staff
applicable for requiring a five-year background rescreening at the time of the annual compliance
review. All four staff five-year rescreenings/renewals were reviewed with no discrepancies
noted. There were no volunteers, interns, or contracted workers applicable for a rescreening
since the last annual compliance review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 67 (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 others 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 ethics. Staff are required to sign the manual acknowledgment form
indicating they reviewed the required information. Five reviewed staff personnel records
reflected each staff reviewed the program’s code of ethics and signed the acknowledgement
form. The program completed a Trauma Responsive and Caring Environment (TRACE) self-
assessment in April 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. A telephone located in the main hallway and cafeteria has been
designated for youth to contact the Florida Abuse Hotline or the CCC, if youth feel they have
been abused or neglected. 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
one abuse allegation since the last annual compliance review. The incident was still under
management review during the annual compliance review week. 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. Five youth were interviewed, and each stated they feel safe in the
program, have never been stopped from reporting abuse to the Florida Abuse Hotline or the
CCC, and staff are respectful when talking to them. Five staff were interviewed, and each stated
they have never heard a coworker use profanity when speaking to a youth and never observed
a coworker telling a youth they could not make 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. 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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 67 (Revised September 2022)
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 to ensure the program takes immediate
action to address incidents of physical, psychological, and emotional abuse. The program’s
administration manages youth and staff needs and provide directions to each on how to access
the Florida Abuse Hotline. The program had one incident report alleging non-physical abuse
toward a youth since the last annual compliance review, and the incident was still under
management review during the annual compliance review week. A review of the incident report
indicated the facility administrator (FA) took immediate action to address the concerns by
removing the staff from youth contact, until further notice. An interview with the FA indicated the
program’s management response to allegations of abuse is for all staff, volunteers, interns, or
contracted staff to immediately report any allegations, or suspicion of an incident of abuse, or
harassment, to the Florida Abuse Hotline and the Department’s Central Communications
Center, for youth eighteen years of age or older.
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 to ensure incidents are reported to the
Department’s Central Communications Center (CCC). The program had thirty-three incidents
reported to the CCC since the last annual compliance review. A review of five CCC reports
confirmed each incident had the incident date, time, and CCC number, with the time the
program became aware of the incident. Each incident was reported to the CCC within the
required two-hour time frame and documented in the program’s Incident Report Logbook and
shift reports, as required. There were no incidents which were reported late. A review of the
program’s internal incident reports and youth grievances reflected no additional incidents which
should have been reported to the CCC. An interview with the facility administrator (FA) indicated
the incident reporting process is to notify the CCC/Florida Abuse Hotline within two hours of the
reportable incident or learning of the incident. The FA maintains a separate file of all incidents
and utilized a tracking system. The program staff notifies the supervisor and completes an
internal incident form. A review of the incident is completed by the supervisor with staff during
debriefing. The incident is reviewed by management to assess if all protocols were followed or if
there is an additional investigation needed. All completed reports are forwarded to the FA for
storage. The FA stated if the allegations are false, the youth will meet with the behavioral
management review team. The program did experience a decrease in the number of reportable
incidents to the CCC in comparison to the previous annual compliance review period. The
program maintains a separate file of all incident reports and has a system in place for tracking
all incidents.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 67 (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 policy and procedures to ensure the proper use of Protective Action
Response (PAR)/Right Interactions (RI) techniques by staff. The program had twenty-four
PAR/RI incident reports since the last annual compliance review, of which ten were reviewed.
Documentation confirmed all ten reports were completed by the end of the staff’s workday and
written statements were provided by each staff involved. Mechanical restraints were not used in
any of the ten reviewed PAR/RI incidents. All required reviews were conducted and documented
by the supervisor on duty at the time of the incident and by a PAR/RI certified instructor staff
within the required time frames. All ten PAR/RI Reports were reviewed within seventy-two hours
of the incident by the facility administrator (FA) or designee. The program’s practice confirmed a
post-PAR/RI interview was conducted with each youth within thirty-minutes of the incident by
the FA or designee to assess the need for further medical review. None of the ten PAR/RI
Reports indicated the need for medical attention or abuse allegations. Reviewed documentation
validated the completion of monthly PAR/RI Reports. The program’s PAR/RI plan was submitted
to the Department’s Office of Talent Leadership and Culture on January 26, 2023. An interview
with the FA confirmed PAR/RI incidents are tracked utilizing the incident report tracker with
monthly PAR/RI Reports to determine if there are factors, such as scheduled activities, which
correlate with a rise of incidents, shifts, and staff patterns. Documents and an interview with
staff revealed the program’s practice confirmed a post-PAR/RI interview was conducted with
each youth within thirty-minutes of the incident by the FA or designee to assess the need for
further medical review. The number of PAR/RI incidents reported during the annual compliance
review period was twenty-four. Documentation supported the program had a total of eleven
PAR/RI incidents during the last annual compliance review. An interview with the regional
director revealed the reason for the increase in the PAR/RI rates, was due to new intakes
getting acclimated to the program. The program’s PAR/RI rate during the annual compliance
review period was 1.35, which is below the statewide Residential PAR/RI rate of 1.59.
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 has a policy and procedures to ensure pre-service training requirements for new
staff are completed during the initial 180-days of employment. An informal interview was
conducted with the assistant facility administrator (AFA) confirming all youth care workers are
Protective Action Response (PAR)/Right Interactions (RI) certified for the direct care of the
youth. These staff are included in the program’s staff-to-youth ratio. Each supervisor, AFA, case
management staff, kitchen staff, nursing staff, maintenance staff, and mental health staff are
PAR/RI certified and qualified to supervise all youth in special circumstances. Pre-service
training is provided through a combination of instructor-led, web-based courses, and on-the-job
training. Five staff training records were reviewed for pre-service training. A review of five staff
pre-service training records verified all five staff exceeded the required pre-service training
requirements within 180-days of employment to include cardiopulmonary resuscitation (CPR),
first-aid, automated external defibrillator (AED), PAR/RI, ethics, suicide prevention, facility
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 67 (Revised September 2022)
operating procedures, emergency procedures, child abuse reporting, Prison Rape Elimination
Act (PREA), human trafficking, active shooter preparedness, adolescent development and
behavior, balanced approach to restorative justice, the Department’s Central Communications
Center incident reporting, civil rights, communication, confidentiality/health insurance portability
and accountability act (HIPAA), diversity, the Department of Juvenile Justice (DJJ) history, as
well as individualized job specific training. Additional trainings include Equal Employment
Opportunity, gang awareness, human trafficking, infection control/bloodborne pathogens,
information security awareness, the Department’s Juvenile Justice Information Systems, mental
health and substance abuse, Motivational Interviewing (MI), quality report writing, safety,
security, and supervision of youth, sexual harassment, standards of conduct, trauma responsive
practices, DISC assessment, brain tactics for crisis, and addressing workplace dilemmas one on
one. Documentation confirmed all trainings were delivered by qualified trainers and documented
in the Department’s Learning Management System (SkillPro).
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a written in-service training plan which was approved and submitted to the
Department’s Office of Talent Leadership and Culture on November 20, 2022. According to the
program’s contractual requirements, specific training is required for each position classification
to include direct care staff, case managers, management, and mental health. An informal
interview with the assistant facility administrator (AFA) reported all youth care workers are
Protective Action Response (PAR)/Right Interactions (RI) certified and included in the program’s
staff-to-youth ratio. Each supervisor, mental health staff, maintenance staff, the AFA, kitchen
staff, nursing staff, and case management staff are PAR/RI certified and qualified to supervise
all youth in special circumstances; however, are not included in ratio. Five staff training records,
including two supervisor’s training records, were reviewed for in-service training. Each reviewed
staff training record documented staff exceeded the twenty-four hours of in-service training
requirements, which included active shooter preparedness, cardiopulmonary resuscitation
(CPR), first-aid, automated external defibrillator (AED), information security awareness, PAR/RI
certification update, professionalism, interpersonal communication, sexual harassment, trauma
responsive practices, and Prison Rape Elimination Act part one and two. Each staff had current
certifications in first-aid, CPR, AED, and PAR/RI. Each staff completed training in
professionalism and ethics, including standards of conduct, suicide prevention, and human
trafficking. Each reviewed record further verified completion of training in mental health and
substance abuse. A review of two supervisor training records confirmed completion of eight
hours of management and supervisory training inclusive of coaching, leadership, and personal
accountability. Documentation confirmed all training was delivered by qualified trainers and
documented in the Department’s Learning Management System (SkillPro). The list of in-service
trainings which included course names, descriptions, objectives, and training hours for any
instructor-led training based on the above topics was approved by the Department’s regional
director on November 30, 2022. The program has an annual in-service training calendar, which
is updated as changes occur.
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1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program maintains a policy and procedures to ensure the grievance process is outlined for
the youth to formally file complaints regarding conditions, treatment, services, and the actions of
program staff and other youth which are in violation of the youth’s rights. Staff are trained on the
grievance process as a part of the program’s pre-service training plan. A review of five staff pre-
service training records confirmed each completed grievance training. The policy ensures
complaints are reviewed in a fair and expeditious manner and are resolved in the best interest
of the youth, the program, and the Department. The program’s grievance process includes
informal, formal, and appeal phases for youth to submit a grievance. In the informal phase,
when the youth have concerns, they are encouraged to make all efforts to reach a resolution for
the complaint. The youth may present an informal grievance to any staff and all staff shall make
every reasonable effort to discuss the youth’s concerns or complaints and assist the youth in
resolving the issue. The program had no grievances filed since the last annual compliance
review. Five youth were interviewed and confirmed grievance forms are placed throughout the
program. Each youth stated they can request assistance to complete a grievance form. Five
staff were interviewed concerning the grievance process. Each staff stated forms are placed
throughout the program, youth can request assistance in completing the form, and a supervisor
reviews each grievance. The facility administrator (FA) was interviewed and was able to
summarize the informal, formal, and appeal grievance processes.
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 who’s regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program has a written policy and procedures to ensure delinquency interventions and
facilitator training. A review of the program’s contract required services identified the curriculum
Men’s Trauma Recovery and Empowerment Model as the group provided to youth in the
program. All remaining groups provided were either identified as primary services or clinical
groups. The program’s case managers are trained to facilitate gender-specific groups. A review
of training documentation found two staff facilitate and were trained to deliver the curriculum. A
review of the program’s activity schedule, the group sign-in sheets, and documentation,
supported groups were being conducted. An interview with the facility administrator (FA)
documented these services were conducted to address the needs of the youth, as identified
through screenings conducted during admission. An interview with the designated mental health
clinician authority (DMHCA) revealed the program provides implementation to interventions to
address the needs of the youth through trainings for groups being facilitated. Documentation
revealed all groups were provided as outlined in the contract table. The program’s Living in
Balance substance abuse group is a primary service. The program is also providing Men’s
Trauma Recovery and Empowerment Model and Skillstreaming the Adolescent groups. The
program has available Mindfulness for Addiction, Stop the Chaos, and Trauma Focused
Cognitive Behavioral Therapy to provide as supplemental services based on identified needs.
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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 skill training to
the youth. The program identifies youth in need of services by reviewing the risk and
criminogenic needs. Life skills training is provided utilizing Skillstreaming the Adolescent. 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, criminogenic
behaviors, and treatment needs. The program provided life and social skills intervention
services addressing communication, interpersonal relationships and interactions, non-verbal
conflict resolution, anger management, critical thinking; including 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 which are key components in providing a gender-specific program,
provided in a group setting. Additionally, life and social skills services/activities are provided to
youth. Reviewed documentation confirmed life services were held. An interview with five youth
revealed four of the five youth participated in daily life, social skills groups, and recreational
activities. One youth reported not participating in a gender-specific group. An interview with the
designated mental health clinician authority (DMHCA) confirmed youth life skills groups are
provided through Skillstreaming the Adolescent and youth are provided an opportunity to
practice these skills during groups and interactions with their peers. The program identifies
youth in need of services by reviewing the risk and criminogenic needs. A review of the
program’s activity schedule, handouts, and group sign-in sheets verified groups were held, as
required.
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 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 contract requires provision of the IOC
curriculum to the youth as a primary service. The Impact of Crime (IOC) curriculum is designed
to assist youth to accept responsibility for the harm caused by past criminal actions. The
restorative justice activities or instruction planned or designed to assist youth to accept
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 teach youth about the impact of crime on victims, their families, and their
communities. The restorative justice programming is designed to expose youth to victims’
perspectives through victim speakers, in person or on videotape or audiotape, or through victim
impact statements, and engage youth in follow-up activities to process their reactions to each
victim’s accounting of how crime affected the youth’s life. The programming is known to provide
opportunities for youth to plan and participate in reparation activities intended to restore victims
and communities, such as restitution activities and community service projects. An interview
with the facility administrator (FA) indicated youth who have been identified with high-risk
criminogenic factors are assigned to IOC and provided the opportunity to give back to the
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community by participating in IOC and community service projects. The program provides
opportunities for the youth to participate in activities intended to restore victims and communities
which include campus cleanup, gardening, holiday baskets and cards for youth with special
needs, food drives, and donating personal hygiene bags to a local homeless shelter. Based on
a review of documentation, restorative justice activities were conducted and planned, as
designed. Group sessions are held on Tuesdays and Thursdays by staff trained to provide the
service. A review of the program’s activity schedule verified the practice of restorative justice
programming. An interviewed with the designated mental health clinician authority (DMHCA)
confirmed the restorative justice practices. Five youth were interviewed, and they all reported
they participated in restorative justice groups/activities.
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 to ensure security, medical, and mental
health alerts, the use of an internal alert system, and entering alerts into the Department’s
Juvenile Justice Information System (JJIS) are all documented properly. The policy explained
how alerts are identified, documented, updated, and communicated to staff. The program’s
written policy and procedures are used to determine how new alerts are identified, documented,
updated, and communicated to staff. The program maintains a written policy for internal alerts.
The alerts help staff identify youth who pose a risk to security or safety including escape,
assaultive or violent behaviors, suicide risk, other mental health, as well as other concerns
including food allergies and special diets. A review of five youth case records revealed each
youth presented with alert risks and placed on the alert system, as specified in the program’s
written procedures. Alerts are identified at the time of admission either through an interview with
the youth and/or a review of supporting documentation within the admission packet. Alerts are
then entered in JJIS and added to the program’s internal alert system. The observed internal
alert lists were posted in the kitchen, medical, and the training/break room which identified
security and/or escape risks, mental health and applicable suicide risks, medical alerts, and
allergies. An interview with the facility administrator (FA) reported the program has an internal
alert system which reflects all safety and security alerts, in addition to all medical, dietary, and
mental health alerts. Alerts are addressed in the daily management meeting and updates are
provided to the staff in the daily shift briefing and logbook. The program utilizes a color-coded
process to identify each youth alert. The interviewed nursing staff confirmed the registered
nurse (RN) is responsible for updating the medical alert system. Five staff reported staff are
informed of all youth alerts during shift briefing meeting, the alert board in the training/break
room, kitchen, and there is a food allergy clip board in the meal preparation area. A review of
documentation and observations during the annual compliance review confirmed the alert board
and Medical Alert Log were discussed by the shift supervisor at each shift briefing for oncoming
staff. No discrepancies were identified when comparing the internal alert system with JJIS alerts
for the five applicable reviewed youth.
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1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains a written policy and procedures to ensure the maintenance and storage
of Individual Healthcare Records (IHCRs), mental health and substance abuse records, and
case management records for each youth at the program. A review of five IHCRs and individual
management records were labeled and contained the youth’s name, Department identification
number (DJJID), date of birth, county of residence, and committing offense. A review of five
youth mental health and substance abuse records confirmed they were secured in the
therapist’s office in a locked file cabinet not accessible to youth. Each case management record
was organized with tabs dividing information into specific sections for legal information,
correspondence, and documentation of case management activities and marked, “Confidential.”
A review of the five youth case management records confirmed the program’s practice is
following the tab requirements, records, and confidential information provisions pursuant to
Florida Statutes.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program established a community advisory board which meets at least every ninety to 120
days to serve as a support to the program and a link to the community. The program provided a
contact list for their twelve-member community advisory board. The advisory board consisted of
representatives of law enforcement agencies, judiciary, local community business, school board
member, faith-based member, a local victim advocacy agency, a former program resident, and
a parent/guardian of a youth formerly involved in the juvenile justice system. The facility
administrator (FA) solicits and maintains a collaborative partnership with the Department and
local stakeholders in the community. Partnerships consist of letters of support, community
service projects, participation in community board meetings, and public service events. The
program provided documentation reflecting correspondence soliciting active involvement of
other interested community partners. The program maintains a community advisory board
binder which was reviewed. Reviewed meeting agendas and minutes for the previous four
quarters reflected consistent attendance by members of the business community, school board,
and members of the faith community. The program provided copies of recruitment letters and
letters of invitation to interested community partners. A review of the community advisory board
agendas and sign-in-sheets validated the program hosted quarterly advisory board meetings.
An interview with the FA confirmed there is an active community advisory board. An interview
with one of the program’s board members reflected they are an active member on the
community advisory board and attend meetings regularly.
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1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program maintains a policy and procedures to ensure requirements for evaluating staff
performance annually and upon completion of the first ninety-days of hire. A review of five
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 and signed upon hire. An interview with the facility
administrator (FA) revealed systems are in place to address turnover and morale issues. The
program follows a monthly orientation plan for new hires to combat vacancies, and the
program’s overall vacancy rate is low. The program utilized retention plans through staff
recognition, staff of the month, lunch, and birthday celebrations, to include monetary or gift
prizes. Staff are coached using the staff development sessions monthly and evaluations are
completed annually. An interview with five staff revealed two stated evaluations are conducted
yearly, three stated monthly, and one stated every six months.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program shall implement all items or services either negotiated or outlined in the contract,
Memorandum of Negotiation, and applicable Award Letter. These items typically exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code. An
interview with the facility administrator (FA) revealed contracted negotiated items are offered at
the program. These items include the safety flagger online course and certification, food handler
training, forklift course, gardening, and agri-technology. Additional items include, ServSafe,
medical coding or similar medical technical training, first-aid, cardiopulmonary resuscitation
(CPR), and Microsoft Office. Five youth were interviewed, and each youth stated they receive
and actively participate in the contracted condition services which are being provided. The
contract also requires the director of compliance to be on-site at least quarterly. The reviewed
visitors log since the last annual compliance review reflected the director exceeded the
requirement. Additionally, the regional director is required to be on-site monthly to provide
corporate oversight. Reviewed documentation supported the regional director exceeded the
requirement since the last annual compliance review.
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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 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 offers vocational
certifications in safety flagger as an online course, food handler training course, forklift,
gardening, agri-technology, ServSafe, medical coding (phlebotomy, medical technician), first-
aid/cardiopulmonary resuscitation (CPR), and Microsoft Office. Reviewed documentation
confirmed participation. Three youth successfully completed the safety flagger online and
certification course. Twenty-nine youth successfully earned their food handler training course
certification. Nine youth completed the forklift operator course and certification. Eighteen youth
completed Urban Gardening for Beginners. Two youth elected agri-technology participation.
One youth completed agri-technology and one youth is in progress of completing agri-
technology. Twenty-five youth earned ServSafe certifications. Ten youth earned medical
training. Twenty-eight youth successfully completed the CPR/first-aid certification. Twenty-three
youth completed Microsoft Office.
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 Department’s 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, which is included in the program’s practice. The information
including incident reports, vacancies, physical interventions, vocational certifications, youth and
family surveys, and budget are shared with staff and administration monthly and the data shall
be integrated into the core practices. All department program areas and contract providers
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include discussions on data specific to their area in leadership and staff meetings. The
management team dedicates time to using data to inform and educate staff, providers, and
stakeholders on a minimum of quarterly basis. The program’s practice in sharing this
information with providers and stakeholders on a quarterly basis is carried out by the
management team conducting analysis of the available data and including the analysis in
monthly management meetings. The center implemented the collected data to improve their
processes by expecting the staff to exercise effective communication skills when interacting with
youth demonstrating treatment with respect and dignity. Staff shall ensure they are available
and accessible to youth demonstrating availability and openness. Staff shall place a high priority
on the active supervision of youth and effectively communicating expectations and providing
honest evaluation of the youth’s behavior. Regular youth meetings shall be facilitated with
participation by direct care, treatment and supervisory staff reinforcing expectations, youth
performance, and problem solving and skill development.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a written policy and procedures regarding initial contacts to parents/guardians
and court notification. A review of five youth case management record’s documentation showed
the program notified the parent/guardian by telephone within twenty-four hours of admission.
Each of the five reviewed records included documentation supporting the program notified the
parent/guardian in writing within forty-eight hours of the youth’s admission. All five records had
documentation indicating the juvenile probation officer (JPO), court, and applicable post-
residential counselor were notified in writing within five working days of the youth’s admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a written policy and procedures regarding youth orientation. A review of five
youth case management record’s documentation showed the program provided each youth an
orientation on the day of admission. Each reviewed record documented a signed receipt
acknowledging the youth received an orientation packet including a copy of the youth handbook.
The programs orientation included services available, daily schedule, expectations and
responsibilities of the youth, written information on the program’s behavior management system,
information on how to access medical and mental health services, access to the Florida Abuse
Hotline or the Department’s Central Communications Center if the youth is over eighteen years
of age, and items considered contraband. The youth orientation also included information on the
performance plan process, dress code and hygiene requirements, procedures regarding
visitation, mail, and use of the telephone, anticipated length of stay, community access,
grievance procedures, emergency drills, physical design of the facility, and assignment to a
living unit. Observation of a youth orientation was not conducted due to the program not having
an admission during the annual compliance review week. An interview with five youth was
conducted and each youth stated they received an orientation within twenty-four hours of their
admission. All five youth confirmed orientation to the program included program rules,
procedures, schedules, and other pertinent information.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a written policy and procedures which address obtaining written consent of
youth who are eighteen years of age or older. A review of five youth case management records
was completed and two youth were applicable for youth who are eighteen years of age or older.
The program provided one additional applicable youth record. A review of each youth’s record
found a consent form signed by each youth prior to any release of information related to the
youth’s physical or mental health screenings, assessments, or treatments.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a written policy and procedures outlining the classification process for youth
upon admission to the program and completion of reassessments as warranted. A review of the
program’s classification form confirmed the form included all required elements. A review of five
youth case management record’s documentation showed each record contained an admission
classification form including all required elements outlined by the Department’s policy. A review
of the Department’s Juvenile Justice Information System (JJIS) alerts and the programs internal
alerts confirmed there were no issues affecting each youth’s classification. Each youth was
classified for the purpose of assignment to a living area, sleeping room, and group. The
program maintains an alert board in the staff break room and master control, which are updated
as needed. All five youth case management records included documentation for reclassification
of youth prior to engaging in certain activities. A review of the program’s policy and procedures,
treatment team notes, and/or performance summaries showed each youth was reclassified
before engaging in increased privileges. The facility administrator (FA) stated within twenty-four
hours upon intake a classification meeting is held with a minimum of the FA, clinical director,
case manager, and parent/guardian. The program’s classification form is designed to gather the
information mentioned above, in addition to gang membership and youth's aggressiveness. The
information is used to determine the youth's living unit and room assignment. The FA added, on
some occasions, due to interpersonal conflicts, room assignments may change.
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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 has a written policy and procedures to address gang identification including
notification to law enforcement. A review of five youth case management records was
completed and one youth was applicable for notification to law enforcement of suspected gang
association. Two additional case management records were provided. Each applicable record
documented local law enforcement was notified of suspected gang activity prior to the
monitoring and quality improvement (MQI) seven-day notice. Documentation supported each
youth’s home county law enforcement program was notified of the youth’s gang affiliation.
Reviewed documentation reflected all gang alerts were maintained in the Department’s Juvenile
Justice Information System (JJIS) and updated as required. Each applicable record documented
gang information was shared with the educational staff at the program and the youth’s juvenile
probation officer (JPO). None of the three youth were applicable for having a post-residential
services counselor.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a written policy and procedures to address a youth’s participation in gang
prevention and/or intervention activities. The program’s policy addresses providing youth an
opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang. The
program utilizes the Project Renew curriculum and Impact of Crime (IOC) intervention groups as
part of the gang prevention and intervention curricula. A review of five youth case management
records was conducted. One youth was applicable for being identified as a gang member, or
affiliated. The program was able to provide two additional applicable youth. Documentation
supported all three youth participated in gang prevention and intervention strategies. Each
youth’s performance plan included goals and objectives related to gang intervention strategies
to be completed prior to release from the program. The program maintains sign-in sheets to
document youth participation in gang prevention and intervention activities. An interview with the
facility administrator confirmed the program’s gang intervention and prevention strategies.
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2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a written policy and procedures to ensure a Residential Assessment for Youth
(RAY) is completed for each youth within thirty days of admission. A review of five youth case
management record’s documentation showed each record contained a RAY which was
completed within thirty days of admission. Each initial RAY assessment was maintained in the
Department’s Juvenile Justice Information System (JJIS). Three youth were applicable for
reassessments. All three applicable records documented RAY Reassessments were completed,
at least every ninety-days. Each initial RAY and reassessments were maintained in the youth’s
case management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
The program has a written policy and procedures regarding the completion of the Youth Needs
Assessment Summary (YNAS). A review of five youth case management record’s
documentation supported each youth YNAS was completed within thirty days of the youth’s
admission. All five YNASs were documented in the Department’s Juvenile Justice Information
System (JJIS).
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a written policy and procedures outlining performance plan development,
goals, and transmittal. A review of five youth case management record’s documentation
supported each youth Individualized Performance Plan (IPP) was developed within thirty days of
the youth’s admission and developed after the initial Residential Assessment for Youth (RAY).
Each reviewed IPP was developed and signed by the treatment team leader, youth,
administrative representatives, living unit representatives, treatment staff, education staff, the
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Department of Children and Families (DCF) counselor, when applicable, and all parties who
have significant responsibility in goal completion. Documentation showed each of the five
completed IPPs were mailed to the youth’s parent/guardian requesting a signature; however,
none were returned to the program at the time of the annual compliance review. Each reviewed
IPP included the youth’s individualized goals based upon the prioritized needs identified during
the initial assessment. Each IPP addressed the youth’s three top criminogenic needs, specific
delinquency interventions based on RAY results, court-ordered sanctions, and transition
activities targeted for the last sixty-days of the youth’s anticipated stay. Each IPP outlined
program staff responsibilities and target dates for goal completion. Each of the five IPPs were
sent to each youth’s committing court judge, juvenile probation officer (JPO), parent/guardian,
and the DCF counselor, when applicable, within ten days of completion. Five interviewed youth
stated they participated in the development of their performance plan, and each youth was able
to state the goals they were working on. Four youth stated they have a copy of their
performance plan. One youth stated they did not have a copy of the plan.
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 has a written policy and procedures in place regarding revisions to a youth’s
performance plan. A review of five youth case management records was completed. Three
youth were applicable for Individualized Performance Plan (IPP) revisions. Each of the three
record’s revisions were completed based on the Residential Assessment for Youth (RAY)
Reassessment results. Two records were based on newly acquired/revealed information and all
three were based on youth demonstrating progress toward completing a goal. None of the three
records were applicable for youth demonstrating lack of progress toward completing a goal and
facilitating transition activities during the last sixty days of the youth’s stay.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety-day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a written policy and procedures outlining the completion of performance
summaries and transmittals. A review of five youth case management records was completed.
Three records were applicable for performance summaries. Two youth were still within their
ninety calendar days. All three youth’s records included performance summaries which were
completed within ninety days following the signing of the performance plan, or at shorter
intervals. None of the three youth were applicable for a performance summary prepared prior to
the youth’s release, discharge, or transfer from the program. Each performance summary
included all required elements. Each youth performance summary included documentation
which was signed confirming the youth read and was allowed to add comments to the
performance summaries. Each youth was provided a copy of the signed summary. Each
performance summary was signed and dated by the treatment team leader, staff preparing the
summary, facility administrator or designee, and the youth. Documentation showed each
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performance summary was sent to the youth’s committing court, juvenile probation officer
(JPO), youth, parent/guardian, and the Department of Children and Families (DCF), when
applicable, within ten working days. Three closed case management records were reviewed for
release summaries. Each record included a copy of the youth’s original summary, along with
justification for release, sent with the Pre-Release Notification (PRN) to the JPO at least forty-
five days prior to the youth’s planned release date. A signed copy was retained in each of the
youth’s case management records. None of the three youth were applicable for the court
objecting to the youth’s release. Documentation supported each of the youth’s
parents/guardians were provided written notification of the youths planned release. There was
documentation in all the records showing the program completed a Residential Assessment for
Youth (RAY) exit assessment. None of the youth were applicable for the sexually violent
predator program (SVPP) or notification to a victim.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a written policy and procedures to provide parental involvement in case
management services. Documentation supported the program makes efforts to include the
parent/guardian in the assessment process, participation in the development of the youth’s
performance plan, progress reviews, formal treatment team meetings, and transition planning. If
parents/guardians are unable to attend the meetings in person, they are afforded the
opportunity to participate by telephone or conference call or are able to provide verbal or written
input prior to the meeting. Observations of a treatment team meeting confirmed the program’s
practice to have the parent/guardian participate by telephone. The interviewed director of case
management (DCM) stated the program reaches out to the youth’s parent/guardian to facilitate
involvement by telephone calls or letters. A review of five youth case management record’s
documentation confirmed the program reached out to the parent/guardian by telephone or
letters. The interviewed facility administrator stated the program encourages parental
involvement through monthly invites to treatment team, weekly visitations, quarterly family
forums, and family days. Five interviewed youth stated their parent/guardian participates in
treatment team meetings, and one youth also stated family counseling sessions.
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 has a written policy and procedures for the intervention and treatment team to
reference or incorporate other treatment plans into each youth’s Individualized Performance
Plan (IPP). A review of five youth case management record’s documentation supported each
youth’s IPP incorporated the youth’s education plan, which was referenced in the performance
plans. Each youth record had separate mental health/substance abuse treatment plans, all of
which were referenced in the performance plans. Two youth were involved with the Department
of Children and Families (DCF) and both youth’s DCF plans were incorporated into the IPP.
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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 has a written policy and procedures regarding treatment team meeting. A review
of five youth case management records found formal treatment team meetings were held every
thirty days for each youth and informal meetings were held bi-weekly, as required.
Documentation for each of the formal and informal treatment team review meetings included the
youth’s name, date of review, required attendees, comments from treatment team members, a
brief synopsis of the youth’s progress, performance plan revisions, performance plan goals,
positive and negative behaviors, behaviors resulting in physical interventions, treatment
progress, and Residential Assessment for Youth (RAY) Reassessment results. Each youth’s
record reflected formal treatment team and informal treatment team documentation included all
required elements. All required parties were present either in person or by telephone during the
formal and informal treatment team meetings. Informal reviews were held bi-weekly each month
alternating formal treatment team meetings. Observations of a treatment team meeting were
conducted. All required program participants were in attendance or provided written input. The
youth commented about improvements in their Individual Performance Plan and areas they
would like to work on. The youth’s parent/guardian was available by phone and gave input on
the youth’s improvements. Five youth were interviewed, and each youth stated staff review
performance plans. All five youth stated they are given an opportunity during treatment team
meetings to demonstrate any skills learned in the program.
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 has a written policy and procedures addressing transition planning, conferences,
and Community Re-Entry Team (CRT) meetings. A review of three closed youth case
management records was completed. There was documentation the program held a transition
conference at least sixty-days prior to the youth’s anticipated release date in each record. Each
record documented the youth’s juvenile probation officer (JPO), parent/guardian, education
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staff, and any other additional pertinent parties were invited and encouraged to participate in the
youth’s transition conference. There was documentation the youth, treatment team leader,
facility administrator (FA) or designee, and other team members were in attendance. None of
the reviewed youth records required a human trafficking specific service provider. Documents
supported each transition 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. Each of the five closed records documented a CRT
invitation was sent, and a meeting was held prior to the youth’s release.
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 has a written policy and procedures outlining the requirements of the exit portfolio.
A review of three closed youth case management record’s documentation showed each youth’s
exit portfolio was discussed during the transition conference. Each exit portfolio contained a
state-issued identification card, a copy of the youth’s transition plan, a calendar of upcoming
appointments, a Social Security card, birth certificate, educational/vocational certificates earned
at the program, school transcripts, résumé, and a sample employment application.
Documentation supported each youth’s exit portfolio was verified during the exit conference,
and documentation indicated the exit portfolio was given to the youth upon release and
forwarded to the youth’s juvenile probation officer (JPO). The program’s contract did not include
any additional requirements for the exit portfolio.
2.17 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 has a written policy and procedures to address the requirements for each youth’s
exit conference. Three closed youth case management records were reviewed. There was
documentation each youth’s exit conference was conducted after the program notified the
youth’s juvenile probation officer (JPO) of the youth’s pending release at least fourteen days
prior to the youth’s release date. The conference documentation included a summary of pending
transition goals and the date. Each record had documentation to confirm the treatment team
leader, parent/guardian, education representative, therapist, JPO, youth, and other pertinent
parties participated during the exit conference. Each record had documentation reflecting the
status of transition activities and finalized plans for the youth’s release. The date of admission
and date of release correlated with the Department’s Juvenile Justice Information System (JJIS)
in each record. There was documentation in each youth record the exit conference was held
separately from the transition conference and Community Re-Entry Team (CRT) meeting.
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2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a written policy and procedures to address written provisions for youth input.
The program has a student council and utilizes town hall meetings to promote a formal process
for youth to have constructive input regarding the program. The program’s student council
meetings are held every other Tuesday. The student council consists of board members. Town
Hall meetings are held once a month and ensure all issues are addressed concerning the youth.
The town hall meetings are held for youth to communicate with a board member regarding a
concern and the board member would then submit the concern at the student council meeting to
be addressed. A review of the program’s sign-in sheets, agendas, and meeting minutes
confirmed the meetings are being held as required. An interview with the facility administrator
(FA) stated the program’s formal process to solicit input from youth is conducted through
student council meetings and town hall meetings. In addition, the program uses request to
speak forms, grievance forms, and monthly youth surveys. Five interviewed youth stated they
can provide input by speaking to staff, the FA, the therapist, and through student council.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures to provide for career education. The program of study
which is conducted and directly supervised by the Broward County School District, is identified
as a Type 2 career education program. The course programming includes instruction of
personal accountability skills and behaviors leading to appropriate work habits for employment
and living standards. Additionally, the program provides content and the orientation to the broad
scope of career choices based upon personal abilities, aptitudes, and interests, as well as
offering youth the opportunity to explore and gain knowledge of occupational options and the
level of preparation required to meet the qualifications of their chosen occupations. The program
utilized a career technician through the Broward County School District to support and motivate
the youth participating in vocational programing. A review of five closed records confirmed each
included a résumé, completed employment application, a calendar identifying an appointment
with the local Career Source Center, and documentation to support the youth’s parent/guardian
and juvenile probation officer were made aware of the youth’s vocational plan. Five closed
records were applicable for having the appropriate documentation necessary to gain
employment which included a copy of a State of Florida issued identification card, birth
certificate, and a Social Security card. An interview with the lead teacher and the facility
administrator (FA) reported career inventories, workforce credentialing, and virtual education
are utilized to prepare youth for work or college.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide for educational access. The program’s
education program is directly managed and supervised by the Broward County School District.
Reviewed documentation and input from the on-site lead teacher indicated the school board
academic calendar for the program provided 250 days of instruction which included ten days set
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aside for teacher planning or professional development during the calendar year. A review of
the daily academic calendar identified the start of classes was at 7:30 a.m. and the school day
concluded at 12:45 p.m. Each youth in the program was provided a minimum of twenty-five
hours of classroom education each week. A review of three randomly chosen days in the
program’s logbook reflected classes were held in accordance with the program’s schedule with
minimal interruptions. A review of three randomly selected school days of video along with the
corresponding days in the logbook was conducted and each showed school starting on time and
ending on time as required by the program’s academic calendar. Youth are able to receive
credits for the educational and training experience received at the program. Five interviewed
youth reported no interruptions during school hours. An interview was conducted with the
program’s lead educator confirming the daily schedule.
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 Individualized Educational
Transition Plan (IETP) to be developed upon admission. A review of five closed youth case
management records evidenced each youth had an IETP 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 creation. The identified services addressed the youth’s
reintegration back to their home community, the recommended academic placement upon the
youth’s release, as well as the specific monitoring responsibilities by individuals who were
assigned responsibilities for the coordination, 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 of the youth,
the youth’s juvenile probation officer (JPO), a representative for the program’s educational
component, a transitional representative, as well as a representative of the youth’s home school
district. Five youth were interviewed and reported they are involved in the development of their
IETP. The interviewed lead teacher confirmed the IETP process.
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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. The DMHCA is responsible for the coordination and implementation of mental health and
substance abuse services in the program. As part of the assigned responsibilities, the DMHCA
shall ensure consistent and appropriate mental health and substance abuse services in addition
to being on call twenty-four hours each day for emergency consultation. The program’s DMHCA
is a licensed mental health counselor. The reviewed license reflected it was free and clear 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 they were on-site for sufficient
time to ensure appropriate coordination and implementation of mental health and substance
abuse services. Documentation verified the DMHCA was on-site for a minimum of forty hours
each week. 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 April 1, 2024. The program’s regional clinical director serves
as the back-up DMHCA. The back-up DMHCA is a licensed mental health counselor in the
State of Florida. The reviewed license verified it was free and clear with an expiration date of
March 31, 2025. The interviewed DMHCA confirmed their role in ensuring clinical staff working
under their supervision are performing services they are qualified to provide based on their
education, training, and experience. The interviewed DMHCA reported completing intake
screenings and clinical assessments, in addition to communicating with program staff daily.
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. A review of the programs staff listing, and contractual
requirements verified there are no additional licensed staff requirements beyond the DMHCA;
however, the program’s regional clinical director is a licensed mental health counselor. The
regional clinical director’s license was free and clear in the State of Florida with an expiration
date of March 31, 2025. The regional clinical director provides support and supervisory services
to the DMHCA and clinical staff. The program is licensed under Chapter 397 by the Department
of Children and Families to provide substance abuse services to adolescents. The Chapter 397
license expires April 1, 2024. The program’s contract requires one DMHCA, one recreation
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therapist, and three non-licensed mental health clinicians. The program’s clinical staffing was in
accordance with the contract.
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 program’s
contract requires three non-licensed mental health clinicians and a recreation therapist. 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 they are qualified to, based on education, training, and experience. The program’s
practice is to complete group and/or individual clinical supervision for the three non-licensed
clinicians and the recreation therapist. A review of clinical supervision logs since the last annual
compliance review was conducted. The clinical supervision was documented on the program’s
form and included all elements on the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. Documentation
verified each non-licensed clinical staff received clinical supervision for each week they provided
services. The program is licensed under Chapter 397 through the Department of Children and
Families to provide substance abuse services to adolescents. A review of the license reflected it
was displayed in the lobby with the program’s physical address listed. The reviewed license
expires on April 1, 2024. The program’s contract requires a recreation therapist. The recreation
therapist credentials, schedule, and services were reviewed. Documentation supported
education and service requirements were in accordance with the contractual requirements. The
program had no clinical staff vacancies during the annual compliance review week. The
program had four non-licensed mental health clinicians providing therapeutic services since the
last annual compliance review. One staff was no longer working at the program. A review of the
four non-licensed staff’s education documentation reflected each held a master’s-level degree
from an accredited university or college in the field of counseling, social work, psychology, or a
related human services field. Each non-licensed staff providing clinical services was employed
by a service provider which was licensed under Chapter 397. Each of the four non-licensed
clinical staff received training in the administration of the Assessment of Suicide Risk or Crisis
Assessments conducted on-site in the physical presence of the licensed mental health
professional. All trainings were clearly documented on the Department’s Non-Licensed Mental
Health Clinical Staff Person’s Training in Assessment of Suicide Risk form. Reviewed
documentation verified the program’s clinical staffing was in accordance with contractual
requirements.
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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 establish 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 case
manager in a private/confidential manner with the youth on the day of admission. A review of
five youth records confirmed each youth was administered a MAYSI-2 on the day of admission.
The case manager 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, or history of human trafficking. Each reviewed MAYSI-2 was
completed by the director of case management (DCM). Reviewed documentation verified the
DCM received MAYSI-2 training. Each MAYSI-2 was completed in full in the Department’s
Juvenile Justice Information System (JJIS). The program’s practice is to refer all youth for
additional assessment regardless of the screening results, and each MAYSI-2 documented the
need for further assessment. None of the screenings indicated the youth was in crisis, requiring
immediate attention, or required a staff override. None of the reviewed MAYSI-2s indicated an
assessment was needed due to the “suicide ideation” category. Each record documented youth
were referred for a comprehensive assessment and the referrals clearly documented the reason
for each referral. 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 facility administrator reported a MAYSI-2 is completed upon intake to identify risks.
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 shall 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. Additionally,
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the program administers the Beck Depression Inventory, Substance Abuse Subtle Screening
Inventory (SASSI), and Suicide Probability Scale (SPS) for inclusion in the assessment. The
program completes a single biopsychosocial evaluation to determine the mental health and
substance abuse needs of all program youth. A review of five youth records reflected a new
biopsychosocial evaluation was completed within thirty days of admission. Each was completed
by a non-licensed clinical staff working under the direct supervision of the designated mental
health clinician authority (DMHCA). Documentation reflected the DMHCA reviewed and signed
each biopsychosocial evaluation within ten calendar days as required. Each reviewed
evaluation included identifying information, the reason for evaluation, relevant background
information, behavioral observations, a Mental Status Examination, a summary of procedures
administered, discussion of findings, a Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) diagnosis, and recommendations. Each biopsychosocial evaluation was
inclusive of mental health and substance abuse findings. A review of youth records confirmed
consents for substance abuse treatment services were obtained. Each substance abuse portion
of the reviewed evaluations documented the reason for assessment, relevant background
information, behavioral observations, methods of assessment, patterns of alcohol and other
drug use, impact of alcohol and other drugs on major life areas, risk factors of continued alcohol
and other drug use, a DSM-5 diagnosis, and recommendations. All five reviewed youth were
applicable for both mental health and substance abuse diagnoses and treatment.
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
each youth’s initial and individualized plan. A review of five 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 non-
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’s practice is to refer all youth for a new psychiatric evaluation regardless of medication
status. Two of the reviewed records indicated the youth were on psychotropic medications at
the time of the plan creation and the medication details were included in the plan. The program
completed an individualized treatment plan for each of the five youth within thirty days of
admission. Each 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 individualized plan was completed by a non-licensed clinical staff; therefore,
requiring the signature of the licensed DMHCA within ten days of completion. Two plans clearly
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documented the signature within ten days, the third was signed one day late, the fourth was
signed four days late, and the fifth plan was signed; however, was not dated by the DMHCA.
Each of the five 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. Four youth were applicable for being on medication
at the time of the individualized plan development and each plan clearly listed the medication
details and monitoring frequency. The five reviewed records were applicable for a total of
twenty-one treatment plan reviews occurring at 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. All reviews were
completed at least every thirty days as required. Prescribed services included individual and
group therapy for all five youth, family therapy for two youth, and psychiatric services for four
youth. Observed 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
Living in Balance substance abuse group is a primary service. The program is also providing
Men’s Trauma Recovery and Empowerment Model and Skillstreaming the Adolescent groups.
The program has available Mindfulness for Addiction, Stop the Chaos, and Trauma Focused
Cognitive Behavioral Therapy to provide as supplemental services based on identified needs. 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.
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 five
youth records reflected each youth was assigned a treatment team on the day of arrival to the
program. Reviewed treatment plan documentation and the treatment team assignment form for
each reviewed record confirmed the treatment teams were comprised of the youth, program
administration, residential living unit, education, medical staff, mental health and substance
abuse staff, and applicable parent/guardian. A review of the five youth records reflected each
was applicable for a substance abuse diagnosis and treatment. The program is licensed through
the Department of Children and Families under Chapter 397 to provide substance abuse
services to adolescents. Each record contained an executed Authority for Evaluation and
Treatment (AET) form or court order. Additionally, each youth record contained a signed Youth
Consent for Substance Abuse Treatment, and Youth Consent for Substance Abuse Treatment
Records form. All reviewed treatment notes were documented on the program’s form and
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included all of the information on the Department’s Counseling/Therapy Progress Notes form.
The program form included demographic information, service provided, target behavior, content
of sessions, clinical impressions, specific progress towards goals, plan, clinician signature, and
the date. Reviewed progress notes and sign-in sheets 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. One youth record did not document two months of family sessions were
completed; however, the therapist clearly documented several attempts. A review of five closed
youth records for discharge plans was completed. All discharge plans were 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 five 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. The
program’s practice is to email a copy of the summary to each assigned JPO and provide a copy
to the youth and parent/guardian upon release. Documentation supported this practice.
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 Overlay Services (SAOS) programming. Substance abuse and mental health
treatment are provided on-site through the provision of SAOS. 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 SAOS services through group therapy,
individual therapy, family therapy, and psychiatric services. Ancillary services shall be provided
directly or through referral in instances where the youth require certain services which may not
be provided by the program. The policy indicated therapy models utilized include Trauma
Focused Cognitive Behavioral Therapy, Men’s Trauma Recovery and Empowerment Model,
Living in Balance, Skillstreaming the Adolescent, Seeking Safety, Mindfulness for Addiction, and
Stop the Chaos: How to Get Control of Your Life by Beating Alcohol and Drugs. Five
interviewed youth reported participating in individual, group, and family therapy services at the
program. Five interviewed staff reported only mental health clinicians facilitate mental health
and substance abuse groups. The interviewed designated mental health clinician authority
confirmed services included SAOS, crisis intervention, suicide assessment, and intervention
services. The program provides group services four to seven times each week based on the
services prescribed to youth through their treatment plans. Program youth with co-occurring
disorders are provided both mental health and substance abuse treatment. Caseload sizes were
reviewed and reflected the average caseload for each program therapist was between eight and
ten youth, which is below the contractual maximum of sixteen youth. The reviewed sign-in
sheets verified mental health groups consisted of ten or fewer participants and substance abuse
groups consisted of fifteen or fewer participants. The program has a Chapter 397 license
through the Department of Children and Families to provide substance abuse treatment
services to adolescents. The license expires April 1, 2024. All mental 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
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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.
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
within the program. The program’s contracted psychiatrist shall be responsible for psychiatric
evaluations, consultation, medication management, and medical supportive counseling. The
program maintains an agreement with a medical doctor for psychiatric services. The reviewed
license showed it was free and clear in the State of Florida with an expiration date of January
31, 2024. The psychiatrist has an education specialty in adolescent psychiatry and has a
specialty certification through the American Board of Psychiatry and Neurology in
pediatric/child/adolescent psychiatry. An interview with the psychiatrist, a review of the policy
and procedures, and a review of the agreement confirmed the psychiatrist is on call twenty-four
hours a day, seven days a week for emergency consultation. Reviewed documentation
confirmed the completion of psychiatric evaluations, medication reviews, and treatment team
participation. The program does not utilize a psychiatric APRN. The program did not utilize a
back-up psychiatrist since the last annual compliance review. The psychiatrist agreement and
contract require bi-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. The interviewed psychiatrist
confirmed their responsibilities, regular communication with the team, time on-site, and
treatment team participation. The interviewed designated mental health clinician authority
(DMHCA) confirmed the psychiatrist conducts on-site visits bi-weekly. A review of five youth
records reflected each youth received a new psychiatric evaluation within two weeks of program
admission. The program’s practice is to complete an evaluation regardless of psychotropic
medication status. Each evaluation included the youth’s history, Mental Status Examination
results, a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis
which was consistent with the youth’s treatment plan, and treatment recommendations. Four
reviewed records were applicable for psychotropic medications at the time of the evaluation and
all four listed the applicable prescribed medications, explanation for the need for psychotropic
medications, target symptoms, initial treatment goals, potential side effects, risks and benefits to
taking medication, and frequency of medication management. Prescribed psychotropic
medications included the name, dosage, quantity of medication, dosage range, ordered dosage,
frequency and route of administration, and applicable reasons for change in medication or
dosage in each of the four applicable records. Each of the five completed evaluations were
completed on the Department’s Clinical Psychotropic Progress Note (CPPN). Four youth were
applicable for medications and page three of the CPPN was completed as required. Each
evaluation for youth prescribed medications documented the youth’s adherence to the
medication regime, height, weight, blood pressure, description of response to medication, most
recent laboratory findings, when appropriate, whether there was telephone contact with the
youth’s parent/guardian to discuss medication, date, and signature of the psychiatrist. The four
records were applicable for a total of twenty-three medication reviews to be completed at a
minimum of every thirty days. Reviewed documentation supported all medication reviews were
completed at least every thirty days and documented on the Department’s CPPN form. Three
youth were applicable for the monitoring of tardive dyskinesia on a monthly basis. The
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monitoring was documented on the CPPN, and each applicable record contained a psychiatric
medication monitoring form which was completed as indicated.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a policy and procedures 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 designated mental health clinician authority (DMHCA) and the
facility administrator on August 18, 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
screening, supervising, and assessing youth exhibiting suicide risk. A review of five youth
records reflected none were applicable for suicide risk. A review of three additional records was
completed. One youth was identified as a suicide risk during the admission screening, and two
were identified through staff observations. Each of the three applicable youth were placed on
precautionary observation status and assessed the same day. Each Assessment of Suicide
Risk (ASR) was completed on the Department’s ASR form by the licensed designated mental
health clinician authority (DMHCA). Each youth was maintained on constant supervision upon
completion of the ASR. Each ASR documented the parent/guardian and assigned juvenile
probation officer (JPO) were notified of the youth’s potential suicide risk. Each record
documented the youth was provided supportive services and a Follow-Up ASR was completed
prior to the removal of youth from precautionary observation. Each 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 all three youth, and each youth was 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 applicable record.
Each of the three 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
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review of the program’s logbooks and assessments supported the administration staff provided
instructions regarding suicide precaution decisions. Logbooks also 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. An interview with the facility administrator and a review of the
policy and procedures reflected the program does not utilize secure observation. The program’s
video recording system is capable of storing thirty-days of footage. There were no youth on
precautionary observation in the past thirty days; therefore, video observation of suicide risk
supervision was not possible. Five staff were interviewed and reported when a youth expresses
suicidal thoughts direct care staff are responsible for notifying mental health staff, searching the
youth and room for sharp objects, maintaining constant sight and sound supervision, and
documenting supervision. Additionally, two staff reported youth with suicide risks sleep in an
open area.
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 five youth
records reflected none were applicable for suicide risk. A review of three additional records was
completed. Each youth record contained documentation where a Suicide Precaution
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 five pre-service and five in-
service training records documented program staff completed the required six hours of suicide
training. The program has a total of four suicide kits which are located in the clinic and in the
master control areas of the program. 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). The
program’s practice is to review the drills during the monthly all staff meetings. The interviewed
facility administrator reported the program’s medical and mental health staff facilitate mock
suicide drills monthly. Four interviewed staff reported medical and mental health emergency
drills were conducted monthly, and one staff reported weekly.
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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 program’s Crisis Intervention Plan was last reviewed and
signed by the facility administrator and the designated mental health clinician authority
(DMHCA) on August 18, 2023. A review of the plan indicated it included notification and alert
system, referrals, communication, supervision, documentation, 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. The program’s designated mental health clinician authority (DMHCA)
reported there were only two youth requiring a Crisis Assessment since the last annual
compliance review. One youth had a Crisis Assessment administered after receiving bad news,
and the second was due to a Prison Rape Elimination Act (PREA) allegation. One Crisis
Assessment was completed immediately and the second was completed the next day. Both
assessments documented the reason for assessment, Mental Status Examination results, the
determination of danger to self and/or others, initial clinical impressions, supervision
recommendations, treatment recommendations, recommendations for follow-up or further
evaluation, and notification to parent/guardian of follow-up treatment. Both assessments were
completed by the DMHCA. None of the reviewed youth were applicable for an increase in
supervision or an alert in the Department’s Juvenile Justice Information System. One youth was
applicable for a Follow-Up Crisis Assessment, as a precautionary measure, and the follow-up
was completed by the licensed DMHCA. The submission of a referral was completed for the
youth identified as an alleged PREA victim, and the youth was offered ongoing mental health
treatment services. A review of the Department’s Central Communications Center PREA
incidents did not identify any additional youth requiring a Crisis Assessment since the last
annual compliance review.
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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 and
designated mental health clinician authority (DMHCA) on August 18, 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 did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
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 shall meet with each
youth to develop a Safety Plan. Safety planning shall be designed to identify stimuli which have
positive and negative effects on the youth. A review of five 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. The
five reviewed records were applicable for thirty-two reviews. Five interviewed staff reported
Safety Plans are accessible to staff and located in master control, the day room, and the break
room. Five interviewed staff reported youth Safety Plans are reviewed upon admission, when a
youth has a change in behavior, and monthly. Staff reported reviewing plans daily, weekly,
monthly, and as needed. The interviewed facility administrator reported Safety Plans were
updated monthly. Five interviewed youth confirmed they participated in the development of their
Safety Plan.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a written policy and procedures which require a contracted health authority to
provide on-site medical services to youth in the program. The program maintains a contract with
a State of Florida board-certified licensed medical doctor (MD) who serves as the designated
health authority (DHA). The DHA has a clear and active license in the State of Florida, expiring
on January 31, 2024, with specialty training in pediatrics. The DHA is a current member of the
American Board of Pediatrics. A review of the Florida Department of Health records supported
the DHA had no current disciplinary cases and/or public complaints on record. The program
does not utilize an advanced practice registered nurse (APRN) or physician’s assistant (PA).
The DHA is available twenty-four hours a day, seven days a week for acute medical concerns,
emergency care, and coordination of off-site care. The DHA is contracted to be on-site for a
minimum of two hours each week with no more than nine days passing between on-site visits. A
review of DHA sign-in sheets since the last annual compliance review found the DHA was on-
site for a minimum of two hours a week; however, reviewed documentation found on two
occasions more than nine days had passed. The DHA conducted a site visit on November 29,
2022, and the next visit was on December 9, 2022. On the second occasion the DHA conducted
a site visit on January 1, 2023, and the next visit was conducted on January 13, 2023. The
program has a back-up DHA who is a licensed physician with a clear and active license in the
State of Florida expiring on January 31, 2025; however, the back-up DHA was not utilized
during the annual compliance review period. A review of the program’s policy indicated it did not
have any conditional language included for either telemedicine or telehealth services. The DHA
reported their role in the program is to conduct Comprehensive Physical Assessments (CPAs)
of youth upon admission, conduct periodic evaluations every ninety days for youth on
medication or with chronic conditions, evaluate and approve nursing protocols, assess youth
with a sickness, and supervise the medical staff. The DHA confirmed being on-site two hours a
week and available by telephone twenty-four hours a day 365 days of the year.
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 with the Department outlines the requirements for a health service
administrator (HSA) and one additional full-time registered nurse (RN). The program has one
health service administrator (HSA) who is a RN, one full-time RN, and one part-time RN on-site.
A review of the nursing schedule found the HSA and full time RN are both on-site weekly for
forty hours. The schedule reflected the part-time RN is on-site weekly at a minimum of sixteen
hours. The program provides on-site nursing coverage seven days a week from 8:00 a.m. to
7:00 p.m. A review of licenses for the HSA and two current nursing staff providing services at
the program found each had a clear and active RN license in the State of Florida, which expire
July 31, 2024. The program does not utilize a licensed practical nurse (LPN). Reviewed
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documentation found all three RNs had current cardiopulmonary resuscitation (CPR)
certifications.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The designated health authority (DHA) is solely responsible for
an annual review of all health-related policies, procedures, and protocols. Reviewed policies
and procedures validated they were reviewed and signed by the DHA on August 18, 2023. The
DHA reviewed and signed all nursing protocols on July 28, 2023. The nursing staff signed a
cover page acknowledging review of all FOPs and treatment protocols on August 15, 2023. The
psychiatrist reviewed applicable FOPs on August 13, 2023. The facility administrator and
corporate staff signed on July 31, 2023. There were no noted applicable policy changes during
the annual compliance review period. The program staff reported no new hires since the last
annual compliance review. The program’s practice is to provide new hires a comprehensive
clinical orientation to healthcare services provided by the health services administrator (HSA).
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a written policy and procedures to ensure the completion of the Authorization
for Evaluation and Treatment (AET) for all youth admitted into the program. The program utilizes
a separate form for youth eighteen years of age or older providing consent for release of
specific information as noted on the Release of Information Authorization for Youth Eighteen
Years of Age and Older form and to whom the information can be released and shared. A
review of five youth Individual Healthcare Records (IHCRs) found four contained a valid and
legible copy of an AET and the word, “Copy” was clearly stamped on each AET. Two of the five
reviewed youth IHCRs were also applicable for the youth being eighteen years of age or older.
Documentation supported the youth signed a Release of Information Authorization Form for
Youth Eighteen Years of Age or Older. One youth was in the care of the Florida Department of
Children and Families (DCF) and the youth’s IHCR contained a valid court order authorizing
treatment at the program. The nurse reported if there is not a current AET on file, the juvenile
probation officer (JPO) will be contacted to obtain a current AET.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a written policy and procedures to inform the parent/guardian of significant
changes in the youth’s condition and obtain consent when new medications and treatments are
prescribed. Five youth Individual Healthcare Records (IHCRs) were reviewed for parental
notifications. Two youth were applicable for consent from the youth’s parent/guardian for all new
medications, over-the-counter medications beyond those covered by the Authority for
Evaluation and Treatment (AET), or new psychotropic medications prior to administration. One
additional record was requested to meet the sample size. Two of the three IHCRs documented
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the program received consent from the youth’s parent/guardian. One youth was eighteen years
of age or older and signed a Release of Information Authorization Form. Four of the five
reviewed IHCRs indicated the youth were taking prescribed psychotropic medications prior to
admission into the program. All four youth were continued on the same psychotropic medication
with no change in dosage. There was no documentation of a witness being present during
conversations about psychotropic medication. An informal interview with the registered nurse
(RN) confirmed youth remaining on the same medication case notes would not document a
witness being present. One youth was in the care of the Florida Department of Children and
Families (DCF) and a court order was found authorizing all medications and treatment and an
additional court order authorized the youth’s psychotropic medication prior to administration, as
required. Each of the five reviewed IHCRs documented the program received and verified the
youth’s vaccination records on the date of admission. None of the youth were applicable for
requiring new vaccinations or requesting religious exemption. During an informal interview, the
nurse confirmed the Florida Shots website is reviewed within the required time frame by the
nurse and designated health authority (DHA). The nurse also confirmed notifying
parents/guardians of medical treatment by telephone and in writing.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a written policy and procedures regarding healthcare screening for each youth
upon admission into the program. The program’s practice is to complete a rescreening and
complete the Department’s Facility Entry Physical Health Screening (FEPHS) form anytime a
youth is admitted into the program or each time the physical custody of the youth changes with
subsequent return or readmission to the program. Five youth Individual Healthcare Records
(IHCRs) were reviewed, and each contained a FEPHS form completed by a registered nurse
(RN) on the day of the youth’s admission. None of the FEPHS were completed by a direct care
staff. None of the youth were applicable for a change in custody. The nurse confirmed the
admission screening is completed by the nurse, and if there is a change in custody a new
FEPHS form is completed.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a written policy and procedures to ensure each youth admitted into the
program receives a healthcare orientation. Five youth Individual Healthcare Records (IHCRs)
were reviewed, and each contained documentation the youth was oriented to healthcare
services at the program upon admission. Each youth’s orientation included all required topics
and was documented on the Health Education form and an orientation sheet which listed all
reviewed topics and was signed and dated 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 has a written policy and procedures to notify the designated health authority (DHA)
by telephone, text message, or verbally, if on-site, of all youth admitted into the program
identified with chronic health conditions or youth in need of emergency care. Five youth
Individual Healthcare Records (IHCRs) were reviewed and four were applicable for a
documented chronic condition upon admission. One youth was non-applicable. Reviewed
documentation found the DHA and psychiatrist were notified upon admission for each of the five
youth regardless of the youth’s status. Notification of the required parties was documented in
each youth’s IHCR in the Chronological Progress Notes. The nurse confirmed the DHA is
notified the same day by the registered nurse (RN) and an admission progress note is
completed.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a written policy and procedures to address the completion of the Health-
Related History (HRH) form prior to the completion of the Comprehensive Physical Assessment
(CPA) upon each youth’s admission to the program. Five youth Individual Healthcare Records
(IHCRs) were reviewed, and each contained a HRH completed by a registered nurse (RN) on
the day of admission. Each reviewed HRH was completed prior to completion of the CPA as
evidenced by the date and signatures on both the HRH and CPA. Each HRH was reviewed by
the designated health authority (DHA) This was evidenced by a checkbox on the CPA,
indicating the HRH was reviewed. An interview with the nurse confirmed the practice of
completing the HRH upon admission. The nurse also indicated the program’s practice is for the
DHA to complete a CPA during admission if the CPA is outdated.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a written policy and procedures ensuring the completion of the Department’s
standardized Comprehensive Physical Assessment (CPA) form for all youth admitted into the
program. Five youth Individual Healthcare Records (IHCRs) were reviewed, and each contained
a new CPA completed by the designated health authority (DHA) within seven days of admission
on the Department’s form. Each youth received a new CPA upon admission. Each of the CPAs
documented the appropriate Medical Grade for the reviewed youth. There was no indication of
any missing or incomplete elements on any of the reviewed CPAs. All five youth refused the
genital examination, and each CPA documented the refusal and included the youth’s signature
by the applicable portion of the CPA examination. All sections of the CPA were completed in full
utilizing an “O” and/or applicable “X” markings except for sections numbered nineteen through
twenty-two, as those sections were not applicable to the male program. The results of each
youth’s Tuberculosis Skin Test (TST) were documented on the CPA, the Department’s
Infectious and Communicable Disease (ICD) form, and on the program’s Tuberculosis Skin
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Test/Purified Protein Derivative (PPD) form. Reviewed documentation confirmed the
Department’s Problem List was updated as needed. An interview with the program’s nurse
confirmed the CPA is completed by the DHA during admission and updated as needed.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a written policy and procedures ensuring all youth admitted shall be clinically
screened and medically evaluated for sexually transmitted infections (STIs) and human
immunodeficiency virus (HIV). The policy reflected HIV test results may only be disclosed to the
youth and entities approved by Florida Administrative Code. Five youth Individual Healthcare
Records (IHCRs) were reviewed, and each documented the youth was clinically screened for
STIs. Each of the youth were applicable for further evaluation and were referred to the DHA.
One of the five youth was referred to the designated health authority (DHA) for testing on the
required Department form; however, the youth refused the testing which was documented on a
refusal form maintained in the youth’s IHCR. The IHCRs for four youth, documented testing had
been ordered and performed. Testing, screening, clinical evaluations, and diagnoses were
documented accordingly on the Department’s Infectious and Communicable Diseases (ICD)
form, excluding HIV results, and filed within the lab section of the IHCR, for all five youth. There
were no applicable youth who were out of the Department’s custody for over thirty days and/or
requiring a rescreening due to presenting symptoms. The program maintains a written policy
and procedures ensuring all youth at risk for HIV infection are offered counseling, testing,
education, prevention counseling, and a referral for medical treatment. A review of five youth
IHCRs found each youth was offered the opportunity to receive counseling and testing for HIV.
Four youth consented to receive counseling and testing by signing the Department’s HIV
Antibody Test Youth Consent form. One youth checked the “I do not consent” box on the
Department’s HIV Antibody Test Youth Consent form. All applicable youth received pre-
counseling, testing, and post-counseling services. A review of each youth’s Health Education
form found each youth had pre-test and post-test counseling documented. All youth consenting
for testing are tracked on the program’s HIV Testing Tracking Log maintained by the nursing
staff. The health service administrator (HSA) reported the program utilizes the local health
department to provide pre- and post-test counseling. Reviewed documentation confirmed the
youth results were filed in a confidential manner in a sealed envelope marked, “Confidential”
and included a documented review by a practitioner on the sealed envelope. Five interviewed
youth reported they can request a HIV test if needed. The nurse reported youth are screened for
STIs when the DHA orders a test or the youth request. If a further evaluation is needed, the
DHA is notified when the results are received. The nurse also reported the program’s practice is
to document screenings, evaluations, referrals, and testing on the ICD form, practitioner’s order,
and progress notes.
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4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a written policy and procedures ensuring all youth shall be able to make sick
call requests and have their complaints treated appropriately through the sick call system. Sick
call care is provided by licensed healthcare professionals pursuant to their scope of practice and
according to protocols approved by the designated health authority (DHA). Observations made
during the tour found Sick Call Request forms located in the main hall where the youth are
housed with a corresponding locked box for them to submit their request. The program’s
practice is to check the boxes randomly throughout the day. Sick call is provided daily by the
registered nurse (RN) at 10:00 a.m. and 2:00 p.m. A review of the program’s contract and the
activity schedule found the program is following the sick call hours. The program also provides a
Non-Healthcare Medical and Emergency Protocol Guide for staff to utilize when nursing staff
are not on-site. The program has identified and trained staff on the sick call process. The DHA
is on-call seven days a week, twenty-four hours a day for consultation. All staff have access to
call 9-1-1 if they feel a youth requires emergency care. Five youth Individual Healthcare
Records (IHCRs) were reviewed, and none were applicable for sick call requests. Three
additional records were requested and reviewed to meet the sample size. None of the
applicable youth presented a similar sick call complaint three or more times within a two-week
period. A sick call request form was completed for each of the sick call requests reviewed. Each
of the sick call request forms reviewed were completed by a registered nurse (RN). The
program does not have a licensed practical nurse (LPN). All sick calls were documented on the
Department’s Sick Call Index, Sick Call Referral Log, and filed within the youth’s IHCR in
reverse chronological order. None of the youth reviewed were in restricted housing, as the
program does not utilize restricted housing. During the annual compliance review week there
was one sick call request made by a youth, requesting to be seen by the medical staff;
therefore, an observation of a sick call was able to be conducted. Observations validated the
program’s practice when conducting a sick call request. Five interviewed staff reported sick calls
are reviewed and conducted by the nurse. Five youth were interviewed regarding the sick call
process. Two youth reported being seen immediately after requesting a sick call. One youth
reported being seen within a day. Two youth reported never submitting a sick call request. An
interview with the nurse confirmed the program’s practice.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a written policy and procedures regarding the provision of episodic and
emergency care. Five youth Individual Healthcare Records (IHCRs) were reviewed and three
were applicable for episodic care encounters. Each of the three episodic care events were
rendered by a registered nurse (RN) and documented in subjective, objective, assessment, and
plan (SOAP) format. None of the episodic or first-aid care was provided by non-healthcare staff.
None of the applicable youth were sent off-site for emergency care. Each applicable youth
episodic care event was documented in the progress chronological notes and tracked on the
Episodic Care Log. The log documents the date and time of the treatment, nature of the
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complaint, person rendering aid, treatment, and if off-site care is needed. The program has five
first-aid kits located in three areas of the program. The kits are located in master control, the
medical clinic, and the kitchen. Two first-aid kits are for the two vans, which are kept in master
control; however, at the time of the annual compliance review they were located in the medical
clinic due to on-going construction. The program has a specific content list for each first-aid kit.
The list is maintained in each first-aid kit and has each item noted with an expiration date. The
first-aid kits were checked weekly by the RN to ensure they were secure and stocked properly.
Three first-aid kits were observed, and each contained the required items. The program has one
automated external defibrillator (AED) temporarily located in the medical clinic due to on-going
construction. The AED provides audio instructions on step-by-step procedures. Written AED
procedures are attached to the AED. An observation of the AED in comparison with an informal
interview with the nursing staff confirmed the AED had a blinking green light which indicates the
device is functioning adequately. Reviewed documentation confirmed the AED batteries expire
on October 31, 2028, and the pads expire on October 3, 2025. The batteries and pads were last
changed on May 30, 2023. Reviewed documentation since the last annual compliance review
confirmed the nurse checks the AED weekly. A review of five staff training records found each
reviewed non-healthcare staff who has direct contact with youth maintained current certifications
in first-aid and cardiopulmonary resuscitation (CPR) with AED. In addition, authorized direct
care staff were appropriately trained on the administration of the epinephrine auto-injector. The
program has three operational shifts. A review of the program’s emergency medical drills
reflected a drill was conducted on each shift monthly for the last twelve months. Emergency
medical drills included the demonstration of CPR and AED at a minimum annually. The
emergency medical drills consisted of both announced and unannounced type drills and were
conducted at least quarterly on each shift. Each drill replicated a medical scenario, and the drill
forms included all required elements. Emergency contact telephone numbers are located in
areas which are not accessible to youth. Observations made throughout the program during the
tour found postings informing staff of their right and responsibility to call 9-1-1. Emergency
telephone numbers were located in various areas of the program. The program did not have any
episodic care events to observe during the week of the annual compliance review. The program
has a written policy and procedures which step out the use, access, and inventory of Narcan.
The nurse secures the Narcan in the locked medical cart. The nurse reported Narcan is
inventoried weekly by the RN. The nurse reported all RNs are trained and identified program
staff have been trained on how and when to use Narcan. Five staff were interviewed, and each
reported they are allowed to call 9-1-1. Five youth were interviewed, and each reported they are
able to see a doctor or dentist if needed.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a written policy and procedures to provide timely referrals, coordination, and
documentation of medical services to off-site health providers for youth with emergent or non-
emergent needs. The designated health authority (DHA) reviews, signs, and dates the off-site
care instructions. A review of five youth Individual Healthcare Records (IHCRs) found one youth
applicable for off-site care to the dentist office. Two additional records were requested. The
program provided two additional youth who were taken off-site for a dental visit. Reviewed
documentation supported the parent/guardian was notified for one of the three youth. Two youth
were eighteen years of age or older. The program reported not having any emergency off-site
care events since the last annual compliance review. Each of the three applicable IHCRs had a
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Summary of Off-Site Care Consultation Report which was filed in the IHCR with any applicable
additional documents. The DHA reviewed and signed all forms as required. Two of the three
applicable youth required follow-up care, and each received a follow-up on August 17, 2023.
During an informal interview, the nurse reported the hospital summary, morning meetings, and
communication system are utilized to track youth who are sent off-site for emergency care. The
nurse also reported all forms relating to off-site care findings, instructions, and information are
placed in the DHA's folder for review. The DHA is also notified of all hospital orders, and they
are faxed to the pharmacy, if needed.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a written policy and procedures ensuring youth who have chronic illnesses
receive regularly scheduled evaluations with the required follow-up. A review of five youth
Individual Healthcare Records (IHCRs) indicated four of the youth were identified with a chronic
condition after being admitted into the program. None of the youth were identified as having a
communicable disease. Four youth were taking medication on an on-going basis. Two youth
were undergoing treatment for a physical health condition which included a body mass index
greater than thirty. Each applicable youth was placed on the chronic illness list and periodic
evaluations were conducted when applicable every ninety days. The program maintains a
tracking log for youth with chronic conditions and evaluation dates. The tracking log indicated
each youth’s next scheduled appointment. None of the youth were applicable for taking anti-
tuberculosis medications. When applicable, the youth had an evaluation completed prior to a
prescription renewal, change, or expiration. None of the reviewed youth were applicable for an
off-site evaluation. There was no indication of lapses in care or missed periodic evaluations in
each of the reviewed records. The Department’s Problem List for each youth was updated in
accordance with policy. The facility administrator (FA) was interviewed and reported
administration meets daily with the medical department to review any youth medical issues. The
nursing staff and designated health authority (DHA) also confirmed the process for the
completion of periodic evaluations.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a written policy and procedures which outline the process of how medications
are to be received, stored, inventoried, and administered in a safe and effective manner. Five
youth Individual Healthcare Records (IHCRs) were reviewed. Four youth were applicable for
taking medications during the annual compliance review period. All four youth Facility Entry
Physical Health Screening (FEPHS) forms documented they were admitted to the program with
medications. There was documentation the program verified the medications as required and
the designated health authority (DHA) was notified. There were no instances where a youth’s
medication could not be verified and had to be returned to the youth’s parent/guardian.
Reviewed documentation supported all medications had a current, valid order, and were given
pursuant to a current practitioner’s order. When applicable, the psychiatrist conducted the
youth’s Initial Diagnostic Psychiatric Interview within fourteen days of admission. The program
utilizes a pre-printed Medication Administration Record (MAR) to document all medication and
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treatment. Each of the reviewed MARs met all requirements outlined within Florida
Administrative Code. The nursing staff documented side-effect monitoring at a minimum of
weekly on each MAR. There were no instances where trained non-healthcare staff assisted in
the delivery of medications. There were no undocumented explanations for a lapse or errors in
medication administration. One of the four youth were applicable for having refused medication
at some point during the annual compliance review period. Refusals were found notated on
each applicable MAR and subsequently youth signed or refused to sign the refusal of treatment
form, as required. Each reviewed MAR documented all required elements. When applicable,
youth received medication monitoring every thirty days as required. There was no indication of
any type of standing orders for psychotropic medications. There were no indication of any
emergency treatment orders for psychotropic medications. There was no indication of any pro re
nata (PRN) orders for psychotropic medications. One medication pass was observed during the
annual compliance review week with no noted issues. The youth was escorted to medical by
direct care staff. The Six Rights of Medication Administration were verified by the RN. The RN
administered the medication as required and did not pre-pour any of the medications. Five staff
were interviewed regarding the medication process, and all staff reported the nurse provides
medication. Two of the five staff also reported supervisors provide medication. Five youth were
interviewed, and three youth reported medication is provided by the nurse. Two youth reported
not taking medication. During an interview, the nurse explained the program’s process and
reported the program has identified and trained staff to provide medication in the event the
nurse is not on-site.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a written policy and procedures regarding requirements for the storage and
inventory of medications and sharps and ensuring all medication is inaccessible to youth at the
program. An observation of the medical cart found all medications were stored in the locked cart
which is kept in the locked medical office. All non-controlled medications were stored in a
separate, secure, locked medication cart. Narcotics and other controlled medications are
securely stored and double locked within the medication cart. The medication cart was observed
to be clean and organized, with stock items separate from youth specific medications.
Observations found all medications were securely stored in the medical clinic inaccessible to
youth. There was one medication requiring refrigeration during the annual compliance review
week which was observed in the refrigerator. The program’s practice is for over-the-counter
(OTC) medications to be inventoried using a perpetual inventory daily and verified weekly, and
reviewed documentation confirmed the practice. Perpetual inventories with running balances
are maintained on all controlled substances with a shift-to-shift inventory conducted by the
registered nurses. Syringes and sharps are counted through a perpetual inventory and are
verified weekly. During the week of the annual compliance review three OTC medications were
reviewed, and the inventories were accurate. Three sharps were reviewed, and inventories were
accurate. One youth was prescribed narcotic or controlled medications and the reviewed
inventories were accurate. The program did not have any additional controlled medications or
narcotics on-site. An interview with the nurse verified the program’s inventory and disposal of
unused medication process which is to work with the pharmacy guardian to oversee the process
of destroying the medication in a solution or returning the medication to the pharmacy.. The
nurse also was able to explain the program’s process for inventory discrepancies in its entirety.
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4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a written policy and procedures for infection control which includes an
Exposure Control Plan and is written in accordance with Occupational Safety and Health
Administration (OSHA) and the Centers for Disease Control and Prevention (CDC) guidelines.
The infection control policy was last reviewed and signed by the designated health authority
(DHA) on August 1, 2023, and the facility administrator (FA) on August 1, 2023. The plan also
included common infectious diseases of childhood, self-limiting, episodic contagious illnesses,
viral or bacterial infectious diseases, tuberculosis, Hepatitis A, B, and C and Human
Immunodeficiency Virus (HIV), infectious diseases caused by blood-borne pathogens, other
outbreaks or epidemics caused by any other infectious agent, outbreaks of lice or scabies,
Methicillin-Resistant Staphylococcus Aureus (MRSA) and other anti-biotic resistant micro-
organisms, food-borne illnesses, bio-terrorist agents, and chemical exposures. The program
maintains procedures for staff to adhere to universal precautions and the program provides staff
with the opportunity for Hepatitis B immunizations and access to protective equipment. The
Exposure Control Plan was written in accordance with OSHA standards and was last reviewed
and signed by the DHA on August 1, 2023, and the FA on August 1, 2023. The plan includes a
process for needle stick post-exposure evaluation. In the event of an incident, the facility
administrator has a process in place to establish a separate file containing all documents for
youth and staff who experienced a facility or occupational exposure. The FA reported a copy of
the program’s Exposure Control and Infection Control Plans are maintained in the hallway of the
administrative office and master control. The nurse reported the program has not had any
instances which required notification to the local county health department, CDC, and/or the
Department’s Central Communications Center (CCC). In addition, the nurse reported nursing
staff conduct infection control training for program staff and youth. The program has not had any
reportable infectious diseases since the last annual compliance review. The program has not
had any instances involving the quarantining or hospitalization of at least ten percent of the total
population since the last annual compliance review.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a written policy and procedures requiring all program staff to promote
safety and security by maintaining active supervision of youth to include interacting positively
with youth, engaging youth in a full schedule of constructive activities, closely observing
behavior of youth, and consistently applying the program’s behavior management system
(BMS). The program has a daily youth activity schedule which was posted throughout the
program. 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. The
program’s contract requires staff-to-youth ratios to be one-to-eight during awake hours and one
to-ten during sleep hours. The ratio for off-site activities, transportation, and visitation is one
staff to five youth. Observations of staff supervision for four days during the annual compliance
review week included line movement, breaks, youth head counts, school, during meals and
snacks, transports, and groups. The observations ensured staff-to-youth ratios were maintained,
as required. A tour of the program verified the program and dormitories were clean, well
maintained, and graffiti free. Staff and youth were appropriately attired. Observations of
interactions between program staff and youth were positive and consistent with the program’s
BMS. Five interviewed staff explained if there were any discrepancies in the youth count, the
staff would stop all movement, secure all youth, conduct an emergency count, and conduct a
search of the program until the missing youth is located.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program maintains a written policy and procedures addressing the implementation and
training of the program’s behavior management system (BMS) which has not changed since the
last annual compliance review. The program utilizes the iChoose System, which is a
coordinated system of promoting, monitoring, recognizing, and rewarding a youth’s progress.
The iChoose System is a program of incentives and consequences which promote
individualized skill building, appropriate behavior, and accountability. Staff use point cards to
monitor how well the youth are progressing in the program. Youth earn points daily for
complying with the program rules. At the end of the week, the points are totaled, and the youth
are rewarded based on the number of points earned. Each youth enters the program on an
orientation level prior to starting the BMS and progresses their way up the four levels. The five
levels of the BMS include orientation, junior varsity, varsity, college, and pro levels. A review of
the BMS confirmed it is not used solely to increase a youth’s length of stay, deny basic rights or
services, promote the use of group punishment, allow youth to punish other youth, or include
disciplinary confinement. Youth learn about the BMS during the orientation process. Each youth
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is provided a program handbook which describes the BMS. A review of the youth handbook
indicated the BMS is included and clearly written. In addition, the parent/guardian handbook
includes a description of the BMS. The facility administrator (FA) trained the education staff in
the jointly combined BMS plan, to include use of BMS during school, on October 14, 2022. A
review of five youth case management records indicated each youth participated in orientation
upon arrival to the program and received a copy of the youth handbook. Five pre-service
training records were reviewed, and all staff were trained in the program’s BMS. Observations
found the BMS was posted throughout the program. Observations of staff and youth interactions
verified staff were adhering to the BMS by utilizing a ratio of four-to-one positive to negative
consequences when redirecting the youth as indicated in the program’s policy. Five youth were
interviewed, and each stated the consequences included level freezes, no canteen, no games,
and earning zero points which affects the incentives. Five youth were interviewed about the
rewards used in the program and all stated youth can earn incentives, canteen, Fantastic
Fridays, and more recreation time. All five interviewed youth were able to explain the difference
between each level and how to move from level to level. Five interviewed staff explained the
BMS consists of a level system where youth earn points, rewards, and consequences which are
based on the youth’s behavior. Five interviewed staff stated youth can earn points to receive
incentives, canteen, and Fantastic Fridays. Two staff stated nothing can be taken away from the
youth as a consequence; however, youth with infractions cannot participate in the incentives.
Three stated things can be taken away from youth as a consequence. An interview with the FA
verified the BMS is a multi-tier system which includes orientation, junior varsity, varsity, college,
and pro levels.
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, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a written policy and procedures 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 sixty-one video cameras capable of recording thirty-days of video footage. During the annual
compliance review week, all sixty-one cameras were operational. Prior to conducting checks,
staff are situated where they are able to see any movement within the dorm. Staff are required
to conduct room checks every ten-minutes and document the time of the check on the ten-
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minute check log when youth are sleeping. A review of three separate video footage samples of
Ten-Minute Checks and Log sheets reflected there were no discrepancies. Five interviewed
staff verified room checks were conducted every ten minutes when a youth is placed in their
room for sleeping or non-punishment reasons. In a formal interview, the facility administrator
(FA) stated cameras have recording capabilities for thirty days and the program has a total of
sixty-one cameras.
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 staff conduct head counts each hour and after outdoor activities. The program’s policy
indicates counts are conducted during power outages, escapes, riots, or any other disruptions
which may occur. A review of randomly selected dates and times in the program logbooks for
one full day each month for the past twelve months validated head counts and movements were
conducted at the beginning of each shift, after outdoor activities, during emergency situations
such as riots, and during drills. In addition, the program logbooks included documentation of
new admissions, releases, transfers, and youth temporarily away from the program.
Observations of the current running logbook made during the annual compliance review week
verified the program’s practice to conduct youth counts before movement to school. Five
interviewed staff explained youth counts are conducted every hour, during drills, periodically
throughout the day, and after every movement. Each of the five interviewed staff was able to
correctly state the day’s youth census.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a written policy and procedures to ensure the maintenance of a
chronological record of events, incidents, and activities in a logbook. The program maintains a
bound logbook with numbered pages for each month. The reviewed logbooks did not have any
loose pages and were not falling apart. Observations and review of logbooks for one full day
each month for the past twelve months 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
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the staff and youth involved, as well as a brief description, the name, and signature of the staff
making the entry. Logbooks included entries for education, emergency situations, population
counts, law enforcement access to youth, perimeter checks, and youth movement. In addition,
recreation, admissions, and releases were documented, as well as transports away from the
program. The program ensures direct care staff, including each supervisor, are briefed when
coming on duty. Each staff signs the shift briefing sign-in sheet to acknowledge receiving the
information. Reviewed logbooks reflected the program consistently documented internal
incidents reported to the Florida Abuse Hotline and/or 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 assignment, inventory, tracking, and storage of keys. The system includes key
assignment with restrictions on usage, inventory and tracking of keys, secure storage, and
procedures for addressing and reporting missing and/or damaged keys. The assistant facility
administrator (AFA) has overall responsibility for key control management which includes
replacing damaged keys. The program identifies keys as permanent and restricted.
Observations made throughout the annual compliance review week found all staff and visitors
surrendered their personal keys upon entering the program. Staff and visitors’ personal keys are
collected upon entering the program and stored in a secured key box located in the program’s
lobby. Upon entering the program, staff sign the key logbook, enter the date, key ring number,
and time the key was signed out. When exiting the program daily, staff enter the time in, and
sign the key logbook indicating the key was returned. A review of the key logbook verified this
practice. 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. All key rings are tagged to record the ring number, keys assigned, and
number of keys on the ring. A review of three staff and their permanently assigned keys during
the annual compliance review week verified keys matched the permanent key log. In addition, a
random check of three staff indicated they have program keys and knew their function. A review
of Department’s Central Communications Center (CCC) reports verified there were no incidents
related to key control since the last annual compliance review. Interviews with five staff
confirmed each was knowledgeable of the key control process.
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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 identify materials considered to be
contraband, to prevent contraband from entering the program, and consequences for when
contraband is found in the possession of youth in the program. The program’s youth handbook
includes a list of contraband items and informs youth of the consequences if found with
contraband. Each youth is provided with a written copy of the youth handbook upon admission
into the program and are oriented to the program rules including the list of items considered to
be contraband. The program’s policy and youth handbook included all items considered
contraband, as outlined in Florida Administrative Code. The list of contraband items included
personal cellular telephones and/or equipment or electronic devices capable of taking pictures
or video recordings, as well as smart watches, which are prohibited. The program’s policy
specifies the manner in which any unauthorized or contraband item is to be disposed, to include
return to the sender, mailed to the youth’s home, returned to the youth upon release, or in the
case of illegal contraband, turned over to law enforcement. Unannounced room searches are
conducted at least weekly at irregular and unpredictable times and common area searches are
conducted daily. A review of the program logbooks, daily incident reports, and perimeter checks
verified searches and program checks are conducted daily on each shift. The program’s policy
requires case managers to inspect all outgoing and incoming correspondence in the presence
of the youth for unauthorized items, contraband, or information which may breach the security of
the program. An informal interview with the director of case management (DCM) verified the
practice. The program’s policy and procedures and orientation training provided to all new staff
stipulate staff found in possession of contraband will be subject to disciplinary action up to and
including dismissal. All instances involving confiscation of illegal contraband require the program
to turn the item over to local law enforcement authorities and file a criminal report. There were
two calls made to the Department’s Central Communications Center (CCC) in the past twelve
months involving contraband. The facility administrator (FA) interview verified the contraband
practice.
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5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a written policy and procedures to ensure searches, and full body visual
searches, are conducted according to Florida Administrative Code (FAC) at the time of
admission, after off-campus activities, and for visitation. 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 when determined to be a security risk. 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. When same gender searches are not
possible staff ensure they use the positioning requirements outlined in policy. Searches
observed during the annual compliance review week verified youth were searched before going
to school and coming back from school, after using the restroom, and after the graduation
activity. During the annual compliance review week, a full body search was observed for a
transport. During the search, the youth was treated with dignity and respect to minimize the
youth’s stress and embarrassment. Five staff were interviewed, and each stated youth are
searched after every movement. Five youth were interviewed, and all indicated searches occur
after outdoor activities, when returning from off-site activities, after every movement, after
meals, after visitation, and when items are missing.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a written policy and procedures to ensure vehicles used to transport youth are
properly maintained and in working order. The program used one van to transport youth at the
time of the annual compliance review. Reviewed documentation verified the van received an
annual safety inspection and was regularly maintained by a certified automobile mechanic.
Observations of the program vehicle verified it was locked when not in use. The program vehicle
has the appropriate number of seatbelts, a seatbelt cutter, a window punch, up-to-date fire
extinguisher, and a first-aid kit with approved items by the designated health authority (DHA).
The program vehicle had working seatbelts and the passenger doors could not be opened from
the inside. A random check of eight vehicles in the program parking lot verified all vehicles were
locked. Four of five interviewed youth reported they wear a seatbelt during transports and one
youth reported never being transported in a program vehicle. Five interviewed staff reported
staff and youth wear seatbelts while in program vehicles.
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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 when youth are transported outside of the program. Reviewed
documentation verified all approved drivers had a valid driver’s license. The program assigns a
ratio of one staff to five youth during transport, not including the driver. Observations of a
transport was conducted as there was one transportation scheduled during the week of the
annual compliance review. An observation of a youth who was leaving the program for a court
appearance was conducted. Two transportation staff were supervising the youth, one staff was
the driver, and a staff was monitoring the youth in the back of the vehicle. Staff had all the
required safety equipment. The program does not provide secure transportation for high-risk
and secure maximum-risk youth determined to be at greater risk. Five staff were interviewed,
and all verified they use a company cellular telephone during transports. An informal interview
with the assistant facility administrator confirmed transportation staff use their two-way radios
and company cellular telephones during transportation of youth, staff and youth always wear
seatbelts, and youth are never left unsupervised in the vehicle. Five interviewed staff stated the
safety equipment in the transport vehicles included a first-aid kit, knife-for-life, window punch,
seatbelt cutter, and a fire extinguisher. All five staff confirmed they are not allowed to use
personal vehicles to transport youth. Each interviewed staff stated the transport vehicles are
searched for contraband prior to and after each use. Each interviewed staff stated they would
call 9-1-1 and/or contact the program if an emergency response arises during vehicle transport.
All interviewed staff stated the transportation ratio is one staff for five youth not including the
driver, and one staff must be the same gender as the youth being transported. Five interviewed
youth stated they never saw anyone place contraband in a transport vehicle and they feel staff
are driving transport vehicles safely.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a written policy and procedures requiring a safe and secure physical
plant, grounds, and perimeter to be maintained and for weekly safety and security audits to be
conducted. Weekly safety and security audits are conducted by the facility administrator (FA) or
designee and documented on the Safety and Security Audit Inspection form. Any deficiencies
are addressed on the form and a work order is submitted to the appropriate staff for corrections.
The FA or assistant facility administrator (AFA) are responsible for conducting weekly safety
and security audits and submitting the audits to the Department and needed items are added to
the program’s tracker. A review of the safety and security inspection forms for the past twelve
months indicated inspections were completed, as required, and documented deficiencies and
repair updates. An interview with the FA indicated the AFA completes the weekly safety and
security checks. Deficiencies are addressed on a case-by-case basis. Some are corrected by
the program while other deficiencies require the use of outside vendors for quotes and repairs.
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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 for a tool management system which
ensures youth do not use tools or equipment as weapons or for security breaches. The policy
addresses the issuance, inventory, and control of equipment and tools. A review of inventory
logs and the tool storage room verified tools are securely stored when not in use, easily marked
for identification, and inventoried prior to, and following work activities. All sharp edged and
pointed tools are inventoried daily when in use. The maintenance staff are responsible for
conducting the inventories and securely maintaining all Class A tools and equipment. The
maintenance staff complete a Daily Tool Log Inventory List which documents each tool in
inventory. All maintenance tools were inaccessible to youth and were observed to be secured in
the tool storage area. Tools were primarily stored using a shadow-board system within the
locked room and were marked for easy identification. Observations of the tool storage area
found it was well organized and secure. Class B tools, including mops, brooms, and buckets,
are maintained in a locked room which is inaccessible to the youth. The items are used by staff
and youth when performing daily cleanup activities. An observation of the kitchen found all
sharps secured in a locked cabinet within the kitchen closet. All tools were secured, had
marking for easy identification, and were inventoried accurately. Staff are required to complete a
sign-out and sign-in log when items are taken and are returned to the designated storage room.
A review of five staff training records and five youth case management records indicated staff
and youth are trained in the safe use of Class B 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. Prohibited tools at the program include machetes,
bowie knives, and other long bladed knives. If a tool is broken or inoperable, the maintenance
manager is responsible for replacing the broken tool. If a tool is missing, staff will notify
administration, the program will stop all youth movement, a tag is placed on the shadow board,
and the program will be searched until the tool is found. All five interviewed staff stated youth
can use brooms and mops and five staff stated youth can use scrub brushes.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. The program’s policy and procedures included
supervision requirements, issuing tools to youth and staff, and activities involving tools were at a
five youth to one staff ratio. A review of the program’s procedures and documentation verified
staff are required to complete a sign-out and sign-in log when Class B tools are taken and are
returned to the designated storage room. A Youth Risk Assessment is required to be completed
monthly by the case manager for youth to use Class B tools. Youth are prohibited from using
Class A tools. Five youth case management records were reviewed, and all youth had monthly
risk assessments completed. No observations of youth handling tools during the week of the
annual compliance review were conducted, due to no youth handling tools at the time of the
annual compliance review. Five youth were interviewed, and four youth responded they use
mops and brooms. Three youth stated they use scrub brushes, and three youth stated they use
a rake. One youth stated youth are not allowed to use tools. Five interviewed staff reported
youth are permitted to handle mops, brooms, and scrub brushes.
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5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures establishing guidelines for outside contractors who
come on-site to complete repairs. When a contractor arrives on campus, they sign the Outside
Contractor On-Site Work Project Log which lists unauthorized items. A review of the work
project logs since the last annual compliance review verified the contractors signed the log
confirming notification of what items are considered unauthorized. If any unauthorized items are
needed by the contractor while in the program, approval is obtained by the facility administrator
(FA) or designee. 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
Three reviewed project invoices showed the vendors signed contractor agreements and an
inventory of tools was completed and documented. An informal interview with the assistant
facility administrator (AFA) indicated when contractors are on-site, youth are not allowed near
the work area. The program’s practice is to assign a staff to the contractor to ensure the work is
being completed and all tools are secured. Observations during the annual compliance review
week verified the program was following the policies regarding on-site contractors.
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 Continuity of Operations Plan (COOP) which was reviewed
and updated on February 22, 2023, and approved by the Department on February 23, 2023,
and a written policy and procedures to ensure drills are consistent with the program’s COOP.
The COOP requires the program to conduct unannounced fire drills quarterly for each shift.
Reviewed documentation validated fire drills were conducted for all shifts each month. The
program additionally conducted monthly emergency drills on each shift ensuring disturbances,
escapes, chemical spills, medical situations, and floods were covered on a rotating basis. Drill
documentation included the type of drill, date and time, participants, a brief scenario description,
deficiencies identified during the drill, and applicable corrective actions. The program reviews
and debriefs staff on how well drills were conducted during the monthly all-staff meetings. The
fire evacuation routes are posted throughout the program. All thirteen fire extinguishers were
inspected annually. Five staff were interviewed and all reported they participated in a fire drill
during the previous twelve months. One staff stated they participated in major disturbance drills.
Five staff indicated they participated in an escape drill. Three staff stated they participated in
flooding and weather drills. Seven interviewed youth responded fire drills are conducted once a
month. All five interviewed youth stated they participated in fire drills and have been instructed
on what to do in the event of a fire. An interview conducted with the facility administrator (FA)
confirmed the program conducts monthly fire and COOP drills on all shifts.
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5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program maintains a department approved Disaster and Continuity of Operations Plan
(COOP) available for all staff to review. The facility administrator (FA) was interviewed and
indicated the COOP is available to all staff and is located in master control. The plan was
reviewed and updated on February 22, 2023, and approved by the Department on February 23,
2023, and provides for basic care and custody of youth in the event of an emergency or
disaster. The COOP addresses phases of a disaster plan as well as emergency management
including preparedness, response, and recovery. The COOP addresses emergencies including
fire prevention, bomb threats, hostage situations, evacuations, alternative housing
arrangements, chemical spills, severe weather, and terrorist attacks. A review of the plan
indicated alternative housing has been identified should the program require evacuation due to
an emergency or disaster. Reviewed documentation confirmed the program maintains critical
identifying information in hardcopy binders including case management, mental health, and
medical. The program’s hard copy records are easily accessible and mobile in the event of an
emergency resulting in the program relocating quickly or in the event needed information cannot
be accessed electronically for all youth in the program. A review of five hard copy youth records
confirmed each contained the youth’s name, a photograph, Department identification number,
admission date, date of birth, gender and race, overall health status, address, and
parent/guardian contact information which included name, address, telephone number of the
person with whom the youth resides and their relationship to the youth, and person(s) to notify
in case of an emergency. In addition, the records contained the youth’s assigned juvenile
probation officer (JPO), committing judge, state attorney, public defender, and victim notification
contact information. The interviewed facility administrator reported portable water is stored in
the kitchen and emergency supplies are stored in master control.
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 to ensure youth do not handle toxic,
combustible, or harmful chemicals and materials. The program’s assistant facility administrator
(AFA) and maintenance manager maintains a monitor system to ensure compliance with
flammable, poisonous, and toxic items. A review of the flammable, poisonous, and toxic items
list verified the items were securely stored. The program maintains a list of all staff who are
authorized to handle the materials which include the facility administrator (FA), maintenance
manager, AFA, and shift supervisor. A Safety Data Sheet (SDS) binder is located inside the
storage area with a picture of each material corresponding to the SDS. The program maintains
chemicals used daily in a locked storage area inside the program. The program has a chemical
daily usage log to track all toxic materials when in use by authorized staff. Any chemicals used
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are signed out. Observations of the storage area indicated it is clearly marked hazardous
chemicals, securely locked, and has a posted list of authorized staff. Observations of chemicals
showed the actual count and ending count of five randomly selected items were accurate. All
items were secured along with safety data sheets for each.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items, and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedures prohibiting youth from handling any flammable,
poisonous, and/or toxic items or materials. Youth are not to clean, handle, or dispose of any
toxic materials, bio-hazardous bodily fluids, or human waste. Youth are strictly prohibited from
the maintenance area where toxic items and chemicals are stored. Five youth were interviewed
and four stated they have not used any chemicals or cleaning products. One youth stated they
used laundry soap while staff observed them. Additionally, one youth stated he uses bleach;
however, the staff sprays bleach and the youth wipe the bathroom floors and sink. A follow-up
interview with the assistant facility administrator confirmed staff were pouring the laundry
detergent into the washing machine.
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 has a written policy and procedures for disposal of flammable, toxic, caustic, and
poisonous items. The program’s maintenance manager, facility administrator (FA), and the
assistant facility administrator (AFA) are responsible for disposing of unused flammable,
poisonous, and/or toxic materials to a local household hazardous waste drop off site, when
needed. The program’s disposal procedures of chemicals were created in accordance with
Occupational Safety and Health Administration (OSHA) standards. All hazardous chemicals
which are no longer used or outdated are disposed of by returning them back to the vendor or
sending the chemical to the hazardous waste center in accordance with the Safety Data Sheets
(SDS). The program maintains a SDS Log to track the disposal of such items. All material in
need of disposal is taken to a local drop-off site. A review of the Disposal Log sheets indicated
the program did not have any chemicals disposed of since the last annual compliance review. If
there are any chemicals in need of disposal, the maintenance staff fill out the Disposal Log
sheets and drop off the chemicals at the biohazardous waste station. All liquid waste from work
details is disposed by pouring the liquid in plumbing drains. Kitchen liquid waste, except for
grease, is disposed in the kitchen drain. Grease is placed in a separate container for disposal by
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an outside vendor. The program has a procedure in place in the event of a chemical spill. If a
chemical spill occurs, the shift supervisor and maintenance staff are notified, the staff shut down
the air handlers and ventilation systems and close all windows and doors at the direction of the
FA. If necessary, assistance from outside the program can be contacted. In an interview, the FA
stated all toxic and hazardous materials are disposed at the county or city disposal sites.
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.
This program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
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 ensure youth are provided the
opportunity to receive visitation and communication with approved family members. During
admission, each youth is provided with the program’s visitation, telephone, and mail policies and
guidelines. The program’s visitation policy indicated consideration for requests of alternative
visitation arrangements with parents/guardians, if needed. Visitation is held three days a week
on Wednesday 6:00 p.m. to 8:00 p.m., and Saturdays and Sundays from 1:00 p.m. to 3:00 p.m.
Youth can write letters or call by telephone at least once a week to approved family members. A
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review of the logbooks and visitation sign-in sheets verified the program allows visitation for
approved family members. A review of the telephone chronological notes verified youth have
consistent telephone communication with family members. According to the director of case
management (DCM), all incoming and outgoing mail is checked for contraband and then given
to the youth. The program has a posted visitation schedule and rules at the front of the program.
Five reviewed youth case management records documented each youth signed acknowledging
the receipt of information concerning visitation, telephone, and mail procedures upon admission.
If needed, the program contacts the youth’s juvenile probation officer (JPO) to verify the youth’s
parent/guardian and other family members are not under current or past investigation for youth
with a history of human trafficking. Five interviewed youth reported they have been provided
opportunities to communicate with their family members by mail, telephone, and/or at visitation.
Four interviewed youth stated they are not sure if the program provides an interpreter if needed,
and one youth stated they use staff to translate. Five interviewed staff stated either staff who
speak the language or a translator is provided for youth who do not speak English as their
primary language. The interviewed facility administrator (FA) stated the program offers
interpreter services provided by video remote interpreting.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program provides a variety of recreation and leisure activities. The program’s schedule has
structured indoor and outdoor recreation and leisure activities which includes large muscle
activity for a minimum of one hour each day. A review of the logbook indicated recreation was
conducted as scheduled. The program’s contract required a recreation therapist. A review of the
staff credentials confirmed they met contractual qualifications. A review of five youth records
confirmed each youth record contained a wellness plan. Five interviewed youth stated the
program allows the opportunity to exercise, play outside, down time to read a book, play a board
game, creative arts, sports, or physical fitness activities. Five youth also stated physical
activities are provided for at least one hour. Five interviewed staff confirmed recreation was
occurring and included activities such as football, basketball, weightlifting, tug of war, board
games, and playing video games.
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 67 (Revised September 2022)
5.26 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation safety checks release procedures; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 67 (Revised September 2022)

report_type: QI Residential

file_name: Broward Youth Treatment Center-FINAL-FY2324.pdf

program_name_raw: Broward Youth Treatment Center