summary: QI Residential - FY23-24 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Everglades Youth Academy and Everglades Youth Academy - Sex Offender Programs
Youth Opportunity Investments, LLC
(Contract Provider)
5050 SE 168th Street
Okeechobee, Florida 34972
Review Date(s): December 5-8, 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:
Paula Friedrich, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Robert Aguis, Office of Education, Director, Postsecondary & Workforce Education (Standard 1)
Nicos Antonakos, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Christine Calvert-Joyner, Office of Accountability and Program Support, Regional Supervisor
(Standard 1)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Rondarrell George, Office of Accountability and Program Support, Regional Monitor (Standard
5)
Carol Hickman, TrueCore Behavioral Solutions, LLC, Regional Compliance Manager (Standard
2)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Peter Keelan, Office of Education, Education Coordinator, (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Desiree Taylor, Office of Accountability and Program Support, Deputy Bureau Chief
(Standard 2)
Sharon Wong, Office of Accountability and Program Support, Regional Monitor (Interviews &
Standard 1)
Program Name: Everglades Youth Academy- Maximum Risk and Sex Offender Programs
MQI Program Code: 1481, 1482
Provider Name: Youth Opportunity Investments LLC Contract Number: 10289
Location: Okeechobee County / Circuit 19 Number of Beds: 80+16
Review Date(s): December 5-8, 2023 Lead Reviewer Code: 139
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures) and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews)
5.23 Recreation and Leisure
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 91 (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 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Overall Rating Summary for Standard 1
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Office of Accountability and Program Support Page 4 of 91 (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) Limited
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 91 (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 * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 91 (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).
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Office of Accountability and Program Support Page 7 of 91 (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 Satisfactory
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Limited
5.24 Search and Inspection of Controlled Observation Room Satisfactory
5.25 Controlled Observation Satisfactory
5.26 Controlled Observation Safety Checks and Release Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
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Office of Accountability and Program Support Page 8 of 91 (Revised September 2022)
` `Program Overview
Everglades Youth Academy provides Mental Health Overlay Services (MHOS) and Everglades
Youth Academy - Sex Offender Program provides Juvenile Sexual Offender Treatment
Services. The programs are co-located in Okeechobee Florida. The MHOS program is an
eighty-bed program for sixty-four maximum-risk and sixteen high-risk youth. The sex offender
program is a sixteen-bed program for high-risk juvenile sex offenders. Both programs serve
male youth between the ages of thirteen and twenty-one. The programs are operated by Youth
Opportunity Investments, LLC, through a contract with the Department. The program is
contracted to provide MHOS Services and Juvenile Sex Offender Treatment Services. In
addition, the programs provide Skillstreaming the Adolescent, Moral Reconation Therapy,
Impact of Crime, Thinking for a Change, Aggression Replacement Training, Living in Balance,
and Pathways curricula. Additional treatment services include individual, family, and group
therapy. The program’s administration is comprised of one facility administrator (FA), three
assistant facility administrators (AFAs), one human resources manager, and one administrative
assistant. Case management services are to be provided by one director of case management,
six case managers, and one transition services manager. The program’s clinical director serves
as the designated mental health clinician authority (DMHCA) and is responsible for supervising
all on-site clinical staff. The program’s amended contract requires four master’s-level and four
bachelor’s-level non-licensed therapists. Medical services are accessible twenty-four hours a
day, seven days a week and are provided by a registered nurse (RN) serving as the health
services administrator, two additional RNs, one licensed practical nurse (LPN), a contracted
physician, a contracted optometrist, a contracted dentist, and a contracted psychiatrist.
Educational services are provided by Youth Opportunity Investments, LLC employed staff with
oversight from the Okeechobee County School District. The building is designed with two wings,
each containing three separate living units. Everglades Youth Academy - Sex Offender Program
occupies one living unit on the west-side wing. Everglades Youth Academy occupies three east
wing living units and two west living units. Each living unit has sixteen individual sleeping rooms,
a case management office, an open-concept day room, and an adjoining classroom. The
program has one main master control and two sub-control stations, eight therapist offices, an
education office, program administration offices, a maintenance office and storage area, one
large recreation field, six small recreation courts, a kitchen, a medical clinic, two medication
pass rooms, and an automotive sally port. The program has 113 video security cameras
monitored by master control staff. Five cameras were inoperable at the time of the annual
compliance review. The video surveillance system is capable of recording over thirty days of
video footage. At the time of the annual compliance review, the program had forty-six vacancies
consisting of one master’s-level therapist position, which has been vacant since September 8,
2023, two recreation therapist positions, which have been vacant since July 1, 2021 and April 4,
2023, one payroll/receptionist position, which is a contract identified value added position, one
staff development position, three case manager positions, two bachelor’s-level therapist
positions, two educational teacher positions, one culinary arts teacher position, three shift
supervisor positions, three master control technician positions, and twenty-seven direct care
safety and security specialist positions.
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Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program maintains a written policy and procedures detailing the required background
screening process for staff, volunteers, contracted providers, mentors, and interns with access
to youth and confidential youth records. The program reported there were no new applicable
mentors, volunteers, or interns hired since the last annual compliance review. The program had
thirty-four newly hired staff since the last annual compliance review. A review of documentation
validated thirty-two newly hired staff received background screening clearance completed by the
Department’s Background Screening Unit (BSU)/Clearinghouse prior to each staff’s date of hire.
Two staff were hired and began orientation training while pending their background screening
results; however, neither had any contact to youth or confidential youth records until after their
background screening was completed. None of the reviewed staff were applicable for obtaining
an exemption prior to working with youth. One of the reviewed records was applicable for a
break in service as indicated in the Department’s Staff Verification System (SVS), and the staff
had a new background screening completed. Each newly hired staff received a passing score
on a suitability assessment and the assessment results were located within each staff’s
personnel record. A review of SVS and the Clearinghouse indicated each new staff was entered
into the appropriate employment rosters. A review of the program’s procedures confirmed the
hiring authority reviews the Department’s Central Communications Center Person Involvement
History Report, SVS module, and the Florida Department of Law Enforcement Automated
Training Management System (ATMS) results during the hiring process. The program submitted
the Annual Affidavit of Compliance with Level 2 Screening Standards to the BSU on January 13,
2023, meeting the annual requirement. Teachers at the program are employed by Youth
Opportunity Investments, LLC; therefore, the program is not required to submit an additional
affidavit for school staff.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program maintains a written policy and procedures detailing the background screening
process. Five-year rescreening due dates are based upon the initial hire/start date for all staff,
contracted providers, volunteers, mentors, and interns. Staff rescreenings are to be submitted to
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the Department’s Background Screening Unit (BSU)/Clearinghouse at least ten business days
prior to each staff’s five-year anniversary date. A review of the program’s staff roster found there
were no staff, contracted providers, volunteers, mentors, or interns eligible for a five-year
background rescreening since the last annual compliance review period.
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 requiring all allegations of abuse or
suspected abuse to be immediately reported and provision of a safe and therapeutic
environment within the program to provide for personal dignity and respect. The program had a
total of five incidents involving allegations of abuse since the last annual compliance review.
Three incidents were closed as information only or findings indicated abuse was unfounded.
Two incidents were still under investigation at the time of the annual compliance review. A
review of all five incidents reflected each was reported to the Department’s Central
Communications Center (CCC) and/or the Florida Abuse Hotline, as required. No incidents were
applicable for potential human trafficking, sexual exploitation, or labor trafficking. A review of five
pre-service staff and five in-service staff personnel records validated each staff signed the
program’s code of conduct during the hiring process. A tour of the program validated the
telephone number for the CCC and the Florida Abuse Hotline were posted in each living unit
and were accessible to youth. A review of the program’s policy and interviews with youth and
staff reflected youth in the program have unhindered access to the Florida Abuse Hotline. The
procedures indicate the direct care staff are to contact the shift supervisor immediately upon the
youth requesting a call. The shift supervisor is to notify the administrator on duty and/or the
assistant facility administrator, and staff are to assist the youth in making the call. All abuse calls
are to be documented on an internal incident report and in the program’s logbook. Reviewed
documentation indicated the program completed Trauma Responsive and Caring Environment
(TRACE) self-assessments throughout the program on May 16 and May 31, 2023. Six
interviewed youth reported they had never been stopped from reporting abuse in the program,
and each knew where the Florida Abuse Hotline number was posted in the program. Each of
the six interviewed youth reported staff are respectful when talking to them and five reported
they have never heard staff use profanity. One youth reported hearing staff use profanity
occasionally in the presence of youth when they are talking to other staff. Each youth reported
they had never exchanged personal contact information with staff. All six interviewed youth
reported feeling safe in the program. Six interviewed staff reported they either knew or had
access to the numbers for the CCC and the Florida Abuse Hotline. Each staff reported they had
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never heard a coworker threaten or intimidate a youth and never heard another staff use
profanity towards youth. Five of six interviewed staff reported youth are allowed to make an
abuse call and a supervisor would be notified. Three staff indicated they would notify a
supervisor who would make the call. Two staff reported staff are allowed to call, and one staff
said they would notify the facility administrator. Two staff added youth can call anytime. An
interview with the facility administrator (FA) indicated all staff are required to complete pre-
service training which includes training on abuse reporting and contacting the CCC. The FA
indicated no staff had disciplinary actions due to allegations of abuse towards a youth since the
last annual compliance review; however, if allegations of abuse are reported, an internal
investigation would immediately be conducted to ensure the safety of all youth within the
program’s care.
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 detailing the requirements for reporting
abuse. Once an allegation of abuse is made, the shift supervisor is to notify the program’s
administrative staff and the incident is to be documented and investigated. The program had a
total of five incidents alleging abuse against six separate staff since the last annual compliance
review. A review of the Department’s Central Communications (CCC) reports, internal incidents,
and applicable supporting documentation was conducted. Reviewed documentation supported
each incident resulted in an internal investigation and four staff were removed from youth
contact, pending the outcome of an investigation. Reviewed incident reports indicated six staff
were identified as part of three incidents. Two were closed as not substantiated; however, two
staff received staff development coaching sessions. One incident was still under investigation.
An interview with the facility administrator (FA) reported there were no staff disciplinary actions
due to allegations of abuse since the last annual compliance review; however, when an abuse
allegation is made against a staff, the program’s practice is to remove the staff from youth
contact and to conduct and internal investigation. The FA explained all allegations of abuse are
reported to the CCC within two hours of the incident or becoming aware of the incident.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program maintains a written policy and procedures regarding response to incidents in
accordance with Florida Administrative Code. The program had a total of fifty-six incidents
reported to the Department’s Central Communications Center (CCC) since the last annual
compliance review with forty-five incidents involving youth in Everglades Youth Academy and
eleven involving youth in the Everglades Youth Academy - Sex Offender Program. A review of
six incidents reflected five were reported within two hours of the incident occurring and one was
reported one minute late. A review of ten youth records, grievances, logbooks, and internal
incidents did not reveal any incidents which should have been reported and were not. The
program has experienced an increase in the number of reportable incidents from thirty-nine to
fifty-six compared to the previous annual compliance review period. The program advised
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thirteen of the CCC incidents were related to a single program disruption, and an additional
seventeen incidents were medical incidents. An interview with the facility administrator (FA)
reported all staff are knowledgeable of the reporting procedures as well as internal incident
reporting which may not require reporting to the CCC.
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program maintains a written policy and procedures to ensure safety and security and
requires the least restrictive means of physical intervention is utilized based upon the individual
needs of the youth. The procedures specify response levels in relation to management of
problem behaviors and prohibited practices, as well as requirements for reporting, orientation,
and training. The program had a total of twenty-five Protective Action Response (PAR)/Right
Interaction (RI) incidents since the last annual compliance review. A review of documentation for
five incidents reflected each report was completed on the day the incident occurred, prior to the
end of the staff’s workday, and included statements from all staff involved. None of the reviewed
incidents were applicable for the use of mechanical restraints or an incident resulting in injury.
None of the reviewed incidents were applicable for a youth alleging abuse. All five PAR/RI
Reports were reviewed by an administrator within seventy-two hours of the incident and copies
of the reports were maintained in a binder at the program. The program’s PAR/RI plan was last
updated on January 3, 2023 and approved by the Department on January 26, 2023. The
Everglades Youth Academy PAR/RI rate during the previous quarter was 0.50, and the
Everglades Youth Academy - Sex Offender Program’s PAR/RI rate during the previous quarter
was 0.00, both of which were below the statewide Residential PAR/RI rate of 1.82. The program
has experienced a decrease in the total number of PAR/RI incidents since the last annual
compliance review declining from thirty-nine to twenty-five. The Everglades Youth Academy
program had twenty-eight PAR/RIs last year compared to fifteen PAR/RIs during the current
annual compliance review period and the Everglades Youth Academy - Sex Offender Program
experienced a decrease in the number of PAR/RIs from a total of eleven last year to ten during
the current annual compliance review period. The interviewed facility administrator (FA)
explained the program submits PAR/RI summaries on a monthly basis. If applicable trends are
identified, resolutions are presented in an attempt to lower the physical intervention rate to
ensure the safety of all youth and staff. One of the six interviewed staff reported they have used
PAR/RI at the program and was able to explain the process.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program maintains a written policy and procedures requiring all newly hired staff to receive
training necessary to fulfill assigned duties and requirements to meet the needs of the program
and youth in care. All full-time and part-time staff are to receive a minimum of 120 hours of pre-
service training during their first 180 days of employment. Direct care staff are not to be in the
presence of youth until they have completed training in child abuse, cardiopulmonary
resuscitation (CPR), first-aid, automated external defibrillator (AED), emergency procedures,
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facility operating procedures, Prison Rape Elimination Act (PREA), professionalism, Protective
Action Response (PAR)/Right Interactions (RI), and suicide awareness and prevention. A
review of five staff pre-service training records was conducted. Each record documented
completion of training in CPR, first-aid, AED, PAR/RI, professionalism, suicide prevention,
emergency procedures, child abuse, PREA, adolescent development, restorative justice, the
Department’s Central Communications Center (CCC), civil rights, communication,
Confidentiality/Health Insurance Portability and Accountability Act (HIPAA), diversity,
Department history, equal employment opportunity, human trafficking, infection
control/bloodborne pathogens, information security awareness, the Department’s Juvenile
Justice Information System, mental health and substance abuse, quality report writing, youth
supervision, standards of conduct, trauma responsive practices, the grievance process,
exposure control plan, the behavior management system, Mental Health Overlay Services, and
the intended and safe use of tools. Three of the five staff had not completed training in
Motivational Interviewing. The program received written confirmation during the week of the
annual compliance review stating a Motivational Interviewing class is to be held at the program
on January 4-5, 2024. The program advised the three staff will be registered for this training. A
review of instructor credentials verified all were qualified to deliver the provided trainings.
Reviewed documentation supported all completed trainings were entered into 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 maintains a written policy and procedures requiring all staff to receive ongoing
training necessary to fulfill assigned duties and requirements to meet the needs of the program
and youth in care. Direct care staff are to successfully complete, at a minimum, twenty-four
hours of in-service training each calendar year. A review of five staff training records indicated
each exceeded the twenty-four-hour requirement. Each staff completed training in active
shooter, cardiopulmonary resuscitation (CPR), first-aid, automatic electronic defibrillator (AED),
human trafficking, information security awareness, mental health, substance abuse, Protective
Action Response (PAR)/Right Interactions (RI) update, professionalism, communication, ethics,
sexual harassment, suicide awareness and prevention, trauma responsive practices, and Prison
Rape Elimination Act (PREA). Each staff held an active CPR and PAR/RI certification. In
addition to the required twenty-four hours of in-service training, supervisory staff are to
complete, at a minimum, an additional eight hours of training in the areas of coaching,
leadership, or personal accountability each calendar year. Two staff were applicable for
supervisory training. Both staff met or exceeded the eight-hour training requirement for training
in the areas of coaching, leadership, and personal accountability. All reviewed trainings were
entered into the Department’s Learning Management System (SkillPro). A review of instructor
credentials verified all were qualified to deliver the provided trainings. The program last updated
their training plan on November 30, 2022.
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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 written policy and procedures detailing the grievance process 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 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 is designed for
complaints to be reviewed in a fair and expeditious manner and to be 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 verbal efforts to reach a
resolution to the complaint. The youth may present an informal grievance to any staff and all
staff are to make every reasonable effort to discuss the youth’s concerns or complaints and
assist the youth in resolving the issue. The program had three informal grievances filed since
the last annual compliance review. Each was reviewed, and all were completed according to
policy. The program maintained a grievance binder organized by month for completed
grievances. A tour of the program evidenced grievance forms were available to youth in wall-
mounted organizer slots on each dormitory, and a locked grievance box was positioned on the
horseshoe hallway for submission of completed forms. Six youth were interviewed, and each
youth was able to explain the steps of the grievance process. Each youth stated they can
request assistance to complete a grievance form. Six staff were interviewed concerning the
grievance process. Each staff was able to explain the steps of the grievance process. The
facility administrator (FA) was interviewed and was able to summarize the informal, formal, and
appeal phases of the program’s grievance process.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program maintains a written policy and procedures for the implementation of delinquency
intervention services and facilitator training requirements. A review of intervention group sign-in
sheets since the last annual compliance review indicated a total of seven staff facilitated various
groups. The education and work experience of the seven staff members were considered by the
program when determining which staff would deliver delinquency intervention services. All
seven staff had training in each curriculum for the groups they facilitated. A review of the
program contract indicated the program is required to conduct Impact of Crime (IOC), Thinking
for a Change (T4C), Living in Balance (LIB), Pathways, and Aggression Replacement Training
(ART), each of which was provided by trained therapists or case managers. A review of the
daily activity schedule indicated T4C, IOC and The Teen Relationship Workbook are provided
once a week. An interview with the facility administrator (FA) indicated all youth participate in
daily group sessions facilitated by a trained mental health professional using evidence-based
curricula to include IOC, T4C, Moral Reconation Therapy, LIB, Skillstreaming the Adolescent,
Pathways, and ART. A review of group sign-in sheets demonstrated groups were delivered as
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scheduled during the annual compliance review period. The program’s activity schedule reflects
the program is providing structured and planned programming or activities at least sixty percent
of the youth’s awake hours. The designated mental health clinician authority (DMHCA) was
interviewed and indicated the program provides interventions to address the youth needs
through group therapy services, family services, and individual therapy services. The trained
mental health professionals provide each youth with evidence-based curricula which aims to
develop life skills and address the youth’s mental health needs.
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 requiring the provision of life skills
training to the youth. Life skills training is provided utilizing the Skillstreaming the Adolescent
curriculum. Each youth’s time is spent in structured therapeutic activities with at least one hour a
day of treatment services targeting identified risks, 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, problem solving, and decision making. Six interviewed
youth confirmed participation in life skills groups at the program. Skillstreaming the Adolescent
is a practice with demonstrated effectiveness, as identified on the Department’s website. A
review of the program’s activity schedule identified the scheduled periods for life skills education
groups and reviewed sign-in sheets, group topics, and video surveillance footage confirmed
groups were conducted with no issues. An interview with the facility administrator indicated all
youth are to participate in daily mental health groups and all youth are also required to
successfully complete Impact of Crime (IOC) and Thinking for a Change (T4C) prior to
completing the program. The program’s designated mental health clinician authority confirmed
all youth are encouraged daily to practice skills learned in group.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s restorative justice services include the provision of Impact of Crime (IOC) and
Thinking for a Change (T4C) groups and additional reparation activities. IOC and T4C are
designated as promising practices which are designed to increase offender knowledge to the
factors of victimization and victim rights, and to increase sensitivity and understanding of the
impact crime can have on victims. The program provides opportunities for the youth to
participate in activities intended to have a restorative impact on victims and the community
which includes raising chickens from which eggs are donated to the community, and planting
vegetables which are harvested and donated to organizations within the community. The groups
and activities are designed to assist youth in accepting responsibility for the harm they caused
by their past criminal actions. An interview with the facility administrator (FA) reported
restorative justice programming included youth making donations to organizations within the
community and completing tasks within the facility grounds for victim restoration and community
restoration. Six youth were interviewed, and each stated they participated in restorative justice
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groups and activities. An interview with the designated mental health clinician authority
(DMHCA) confirmed the program’s restorative justice practices.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program maintains a written policy and procedures requiring consistent and effective
notification and communication of youth on alert status for security or safety risks, and health-
related concerns. Program alerts include medical/sports restriction, security/safety, escape risk,
asthma, gang suspicion/affiliation, mental health, suicide risk, vulnerability to victimization,
medications, food, seasonal, and medication allergies. A review of case management, medical,
mental health, and safety alerts was conducted for five youth records. The reviewed records
were applicable for twenty-one separate alerts. Each record reflected youth alert placement was
completed as required by the program’s written procedures. Each applicable alert was initiated
by the appropriate staff and documented in the logbook, the Department’s Juvenile Justice
Information System (JJIS), the program’s alert board, and the internal medical list. The
program’s alert board is wall-mounted in the main conference room and is accessible to all staff.
Alert lists were also located in the medical clinic, master control, and the kitchen. Reviewed JJIS
alerts correlated with the program’s internal alerts. The interviewed facility administrator (FA)
explained any changes in alerts or food allergies are discussed during each management
meeting and shift briefings daily. Six interviewed staff each reported alert information is shared
during shift briefings.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program has a written policy and procedures to ensure the management of all records are
consistent across operations and programs, consistent with company philosophy, goals and
objectives, and consistent with legal and contractual requirements. A review of five youth
healthcare, mental health/substance abuse, and case management records showed each was
marked “Confidential” and each record documented the youth’s name, Department identification
number (DJJID), the youth’s date of birth, county of youth’s residence, date of admission, and
committing offense. Observations during the annual compliance review week confirmed all
Individual Healthcare Records, mental health and substance abuse records, and case
management records were secured in a locked room, which was not accessible to youth.
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1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a community advisory board which meets quarterly, and reviewed meeting
minutes, sign-in sheets, and agendas documented meetings took place in person on January
31, March 28, June 27, and September 29, 2023. Although the board is located in a rural
community, the advisory board member roster consists of a law enforcement representative,
four different interested community partners, a community business member, a school district
representative, a member of the judiciary, a victim advocate agency, a representative of the
LGBTQI+ community, and a faith-based community member. The advisory board also includes
two different members who are a parent/guardian of a child with previous involvement in the
juvenile justice system. The program maintained documentation of their e-mail recruitment
efforts. A review of community advisory board agendas and meeting minutes confirmed the
program provides the board members with information regarding program updates, community
updates, and restorative justice community service activities. A telephone call was made during
the annual compliance review week to a local community partner who serves as a board
member. The board member confirmed the program’s board activities, including regular
invitations to events and meetings.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program maintains a written policy and procedures to ensure staff personnel records
contain accurate and updated information. The program’s practice is to conduct evaluations
ninety-days after hire and, thereafter, annual evaluations for all staff. The program maintains a
detailed position description for all staff and a written agreement outlining duties for all
contracted staff. A review of personnel records for five newly hired staff and five staff hired prior
to the last annual compliance review confirmed the program completed a ninety-day and an
annual evaluation for each staff, as applicable. Each staff had an evaluation which was based
upon a set of established performance standards which aligned with the duties outlined on the
staff’s position description. It was noted the program’s evaluation forms were not consistently
completed to indicate the date of the evaluation and the date of the last evaluation for each
staff. Four of ten forms had the date of the evaluation indicated and none included the date of
the staff’s last evaluation; however, of the four which indicated the date of the evaluation, two
did not match the date of the staff and supervisor signatures on the evaluation. A review of the
program vacancies reflected two recreation therapist positions have been vacant since July 1,
2021 and April 4, 2023, and one master’s-level therapist position has been vacant since
September 8, 2023. One position for a payroll/receptionist position is identified in the contract as
a value-added position which was vacant during the annual compliance review period. The
program did not have any additional vacancies identified as key/critical positions in contract. Six
staff were interviewed; one reported communication at the program was very good, two rated
communication as good, and three reported communication as fair. One staff who reported
communication was fair stated communication was delayed in non-emergent situations;
however, clarified codes are responded to very quickly. Another staff indicated communication
could be better. Four interviewed staff reported receiving a performance evaluation annually,
and two reported evaluations are received every six months. The interviewed facility
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administrator (FA) reported staff are evaluated annually on their job performance. The FA
reported the evaluations are conducted with the staff's immediate supervisor and the human
resources manager with a goal of recognizing each staff’s strengths and to assign goals to
address any identified weaknesses.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program is required to implement all items and services either negotiated or outlined in the
contract which are considered special contract conditions or listed within the scope of services
attachment. These may be referenced as the Memorandum of Negotiation (MON), summary of
negotiated points, special conditions, or simply listed in contract. These items typically exceed
the minimum requirements outlined in Florida Statute and Florida Administrative Code. The
program tracks measurable contract conditions through outcome measures entered into the
Department’s Juvenile Justice Information System (JJIS), which are administratively monitored
by the assigned contract manager annually. The program’s special contract conditions include
diverse media materials, faith-based opportunities, animal husbandry, community service
activities, resources for expectant fathers, the use of volunteers, appropriate clothing for youth,
and activities to motivate youth. A review of documentation, on-site observations, and an
interview with the facility administrator validated the program was providing special contract
conditions, as required. The program’s education staff are employed by the program; thus,
materials are shared between the education department/classrooms and the program.
Observations of youth sleeping rooms showed books and other publications were provided and
the program has a youth library. The library has educational and fictional reading materials for
youth to sign-out. Specific requests are accommodated as appropriate. Materials are screened
and vetted through the lead teacher for appropriateness. Media donations are encouraged by
parent/guardians and community stakeholders. The program partners with a local religious
organization which donated tablets for youth in 2022. Each tablet can access religious
teachings/recordings which are pre-installed. The program has volunteers who speak to youth
and lead applicable religious services and studies. The organization has donated shoes,
hygiene items, and engaged in holiday celebrations with program youth. The next celebration is
scheduled for December 14, 2023. The program has a successful animal husbandry program.
The program has fifteen hens and one rooster. The youth are responsible for the upkeep of the
chicken coop, handling of the animals, feeding, and cleanup. Approximately twelve youth have
been participating in the animal husbandry programming. All eligible youth complete all of their
community service hours while at the program. The program provides methods for youth to
complete their community service hours which include working in the greenhouse, working with
the animal program, making posters for senior homes, donating canteen points for food and
school supply drives, and working with maintenance, in food service, on clean-up details, and
painting of the program. Youth with community service requirements coordinate with the
assigned case manager to ensure performance planning reflects the need and community
service. Hours are tracked on logs and provided to the assigned juvenile probation officer. The
program provides education and support for youth expecting a child. Youth trainings include
shaken baby syndrome, car seat safety, and water safety provided by medical staff. Expectant
fathers coordinate with their therapists regarding specific family therapy. Expectant fathers are
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provided additional materials, such as books, brochures, and mentoring opportunities during
their stay. Special visitations are coordinated, when appropriate. There were approximately five
expectant fathers in the program at the time of the annual compliance review. The program
utilizes trained volunteers, mentors, and other members from the community to provide positive
modeling and experiences with the youth. The program partners with local church
volunteers and nonprofit agencies, to include a domestic violence shelter, professional athletes,
the local sheriff’s office, and staff mentors, to speak and model experiences with youth. The
program also participates in activities with partner programs run by the same provider. Activities
include sport competitions, training camps, and celebrations. On-site observations reflected the
youth had proper clothing and haircuts. Uniforms include khaki pants and polo shirts as well as
choice of haircut style. The program recently purchased a barber chair as part of the
incentivized barbershop program. Incentives and celebrations for positive behavior and youth
success include honor roll, graduations, student of the month, classroom of the week, daily,
weekly, and monthly incentives, a football team, inter-program sports tournaments, movie
nights, music studio access, canteen, gym access, quarterly dinners with administration,
academic competitions, cook-off competitions, student council, carnival/field days, family days,
holiday celebrations, and pizza parties.
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 Department’s contract requires the provider to offer career and technical education (CTE)
services, including job profiling, career planning, pre-employment training, culinary arts/food
services manager programing, telecommunications technology and career exploration, copper
and fiber optic network cabling specialist, wireless systems, grounding and bonding, and
“Exploring Careers for the 21st Century.” Career readiness is provided by a substitute teacher.
Job profiling, career planning, and pre-employment training is provided in class with a teacher.
The culinary arts/food service manager program is offered through an online course.
Telecommunications technology and career exploration is offered in the classroom with an
instructor. Copper and fiber optic network cabling specialist programing, wireless systems,
grounding, and bonding is provided through direct instruction with a teacher who is certified with
a temporary certificate in career and technical education (C-Tech) through the school district
and holds a ServSafe industry credential. CTE services are offered Monday through Friday for
fifty minutes during the regularly scheduled class periods. At the time of the annual compliance
review, the program had a full class of fifteen youth enrolled in Occupational Safety and Health
Administration (OSHA) ten-hour course and culinary program. Sixty-six youth were enrolled in
Florida Ready to Work academics. A total of forty-five youth completed certification in first-aid
and cardiopulmonary resuscitation (CPR), five certifications have been earned in forklifting, four
completed OSHA-10 and culinary, nine earned the Academic Employability Skills certificate,
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one earned the Florida Ready to Work Digital Skills certificate, three earned Florida Ready to
Work Soft Skills certifications, nineteen youth earned the Florida Safe Staff Food Handler
certification, and fifteen youth completed certification in three training programs through the
online American Hotel and Lodging Educational Institute including Certified Restaurant Server,
Certified Front Desk Representative, and Certified Maintenance Employee. Six youth were
interviewed, and all were aware of CTE services provided. Most youth received services
everyday which was consistent with the schedule. An interview with the lead teacher indicated
CTE services included the “o*net career interest survey”, hotel and hospitality assessments, C-
Tech assessments, and food handler certifications. An interview with the facility administrator
confirmed CTE services are being offered.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program maintains a written policy and procedures which address data trend analysis
components. The program’s administration and management policy addresses research efforts
to enhance operations and contribute to the base knowledge of juvenile justice. The program’s
quality assurance and program planning policy detailed a formal process for monitoring and
evaluating quality, compliance, fidelity, appropriateness, safety, and effectiveness of all
program services utilizing a framework for measurement and evaluation of outcomes and
process measures. An interview with the program’s director of compliance explained the
program’s efforts to collect and analyze data. The program participates in monthly compliance
reviews to discuss accomplishments, the facility administrator’s (FA’s) plan of action, any
corrective actions put in place, monthly staff and youth survey responses relating to perceptions
of program safety, living environment, treatment environment, whether youth community
meetings are occurring, and monthly incidents. The program conducts interviews with families
and youth at least quarterly, tracks outcome measures, monitors incident reports, conducts
internal fidelity monitoring, tracks evidence-based services, incidents, and quality improvement
audits. The program discusses scores, results, and findings in the morning management
meetings, monthly management meetings, community advisory board meetings, and all-staff
meetings.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a written policy and procedures regarding initial contact to the youth’s
parent/guardian and court notification upon each youth’s admission.
EVERGLADES YOUTH ACADEMY
Five youth case management records were reviewed, and each included chronological case
notes, the youth’s telephone call log, notification letters, and the youth handbook. The reviewed
telephone logs validated each youth’s parent/guardian was notified within twenty-four hours of
each youth’s admission, as required. A review of chronological case notes and notification
letters indicated all written notifications were made within the required forty-eight-hour time
frame to the parent/guardian, committing judge and juvenile probation officer (JPO), as required.
All records contained forms which were signed to indicate the youth received a copy of the
youth handbook.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Five youth records were reviewed, and all five documented the program notified each youth’s
parent/guardian by telephone within twenty-four hours of admission. Each of the reviewed
records included documentation indicating the program also notified the parent/guardian in
writing within forty-eight hours of the youth’s admission. All five records documented the JPO
and court were notified in writing on the day 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.
EVERGLADES YOUTH ACADEMY
There were no intakes the week of the annual compliance review; therefore, the intake process
could not be observed. Each of the five reviewed youth case management records included the
program rules, expectations, goals of the program, and services applicable to youth. Each
record contained an acknowledgement and orientation checklist form signed by the youth and
the residential case manager documenting each youth completed the orientation process. Three
youth were interviewed, and each reported the program orientation began within twenty-four
hours of admission. Each interviewed youth was able to explain the orientation process and all
three confirmed they had received a copy of the orientation handbook.
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EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth records indicated each contained documentation of orientation being
conducted with each youth on the day of admission into the program. The orientation included
services available, daily schedule, expectations and responsibilities of the youth, written
information on the program’s behavior management system, information on the availability of
and 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 the program’s zero-tolerance policy regarding sexual misconduct and how to report
allegations. The youth orientation also included information on the special accommodations for
youth who need them, youth rights to be free from sexual misconduct and from retaliation for
reporting misconduct, items considered contraband, performance plan process, dress code and
hygiene requirements, procedures regarding visitation, mail, and use of the telephone,
expectations for release, community access, grievance procedures, emergency drills, physical
design of the facility, assignment to a living unit, and treatment team. Each reviewed record
contained a signed checklist upon which the youth acknowledged receiving an orientation
packet including a copy of the youth handbook. The program did not have an admission during
the annual compliance review week; therefore, a youth admission was not observed. Three
youth were interviewed, and each indicated they received an orientation to the program within
twenty-four hours of admission which included program rules, schedules, procedures, and other
topics.
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 from
youth who are eighteen years of age or older.
EVERGLADES YOUTH ACADEMY
Three of five reviewed youth case management records were applicable for the program
obtaining written consent of youth over the age of eighteen before providing or discussing
information with the parent/guardian. All three records contained a consent form which included
the name and complete address of the person approved to receive information as well as the
consenting youth’s signature authorizing the youth’s treatment, assessments, and educational
material to be shared with the parent/guardian.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Five youth case management records were reviewed and three were applicable for the program
obtaining written consent of youth over the age of eighteen before providing or discussing
information with the parent/guardian. All three applicable youth records contained consent forms
signed by the youth allowing the program to share information related to the youth's physical or
mental health screenings, assessments, or treatment with the youth’s parent/guardian.
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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 which outline the classification process which
promotes safety and security, as well as effective delivery of treatment services, based upon the
determination of each youth’s individual needs and risk factors. The policy also addresses when
reassessments are warranted based upon behavior changes, changes in supervision status,
new and updated alerts, and any other relevant information available to the treatment team. The
initial classification forms included the physical characteristics of the youth, age, maturity level,
identified special needs, history of violence, gang affiliation, criminal behavior, sexual
aggression or vulnerability to victimization, youth’s perception of vulnerability, and youth’s
history of potential or verified human trafficking. The classification form also included suicide,
medical, escape, and security risks. An interview with the facility administrator indicated factors
such as mental health status, physical health status, cognitive performance, age, and prior
victimization are all considered when classifying youth upon intake. Youth who may be
vulnerable to victimization are to be housed towards the front of the units to ensure they are in
closer proximity to staff.
EVERGLADES YOUTH ACADEMY
A review of five youth case management records showed each record included a classification
form completed on the day of admission. The admission classification is utilized for assigning
each newly admitted youth to a living unit and sleeping room. The initial classification factors
included, at a minimum, the youth’s physical characteristics, gender, height, weight, and general
physical stature, age, maturity level, identified special needs including medical, mental health,
development or intellectual and physical disabilities, history of violence, gang affiliation, and
criminal behavior. The Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB)
screening was completed in the Department’s Juvenile Justice Information System (JJIS) for
each youth and a copy was maintained within each case management record. The program’s
practice is to complete reassessments for each youth during their formal treatment team
meetings and prior to considering an increase in privileges or freedom of movement,
participation in work projects or other activities involving tools or instruments which could be
used as potential weapons or means of escape. In addition, the program utilizes a separate risk
assessment for those youth who are to participate in the co-located vocational Home Builder’s
Institute (HBI) program to evaluate their ability to participate. The interviews indicated the
program’s admission classification form is used to determine the youth’s living unit and room
assignment based on the youth’s physical characteristics, age, maturity level, identified special
needs, history of violence, gang affiliation, criminal behavior, sexual aggression or vulnerability
to victimization, suicide risk, medical risk, escape risk, and security risk.
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EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Five youth case management records were reviewed. Each youth had an initial classification
completed on the same day of admission to the program. Each youth’s applicable risk factors
were marked on the form along with a review of the JJIS Alert List to assist in classifying the
youth to living, sleeping, and advisor arrangements. One youth did not have a medical alert
added into JJIS after the youth was identified as a medical risk on the classification form.
Another youth was identified as gang affiliated in JJIS; however, the youth did not have gang
affiliation marked on their classification form. Three youth were applicable for a reassessment to
be conducted for an increase in privileges or participation in work projects, and all three
reclassifications were completed properly and in their entirety.
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 which includes
notification to law enforcement. Each youth is assessed at intake for suspected gang
involvement. The program is to notify local law enforcement, law enforcement in the youth’s
home county, the educational provider, and the youth’s juvenile probation officer (JPO) by e-
mail if a youth is identified as having gang involvement.
EVERGLADES YOUTH ACADEMY
Five reviewed youth case management records were applicable for notifications to law
enforcement, the assigned JPO, and education. Documentation reflected gang status was
shared with local law enforcement, law enforcement in the youth’s home county, the educational
provider, and the youth’s JPO as required for each youth. A review of the Department’s Juvenile
Justice Information System (JJIS) indicated gang alerts were entered in JJIS upon identification.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Five youth case management records were reviewed, and one was applicable for suspected
gang activity. One additional record was provided for review since the program had a total of
only two youth with suspected gang activity throughout the annual compliance review period.
Both applicable youth records indicated local law enforcement, law enforcement in the youth’s
home county, the educational provider, and the youth’s JPO were all provided notification of the
suspected gang activity. Both youth had the appropriate gang alerts entered in the program’s
internal alert system and JJIS.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program maintains a written policy and procedures addressing prevention and intervention
activities for youth identified with gang affiliation, which includes providing youth with assistance
and guidance in formulating a plan to disassociate from their respective gang affiliation, if
requested. The program has a gang binder which contains information on youth who have been
documented as gang members or associated with a gang. An interview with the facility
administrator (FA) indicated gang intervention and prevention strategies are utilized to assist in
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identifying youth who are active or affiliated gang members and to ensure they are provided the
opportunity to disaffiliate from the gang if they wish.
EVERGLADES YOUTH ACADEMY
Five youth case management records were reviewed, and all were applicable for participation in
gang interventions. The program utilizes the ARISE Foundation’s Life Skills Gangs: 50+ Stories
of Fractured Lives curriculum with the gang affiliated youth. The program conducts monthly
groups related to gang prevention. A review of group sign-in sheets confirmed the groups were
delivered as designed.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Five youth case management records were reviewed, and one was applicable for suspected
gang activity. One additional record was provided for review since the program only had two
youth with suspected gang activity throughout the annual compliance review period. Both youth
records included the identification of gang affiliation, gang prevention and intervention strategies
in which the youth participated, and the performance plan which included relevant goals and
objectives related to the gang intervention strategies provided. The program utilizes the ARISE
Foundation’s Life Skills Gangs: 50+ Stories of Fractured Lives as the selected gang prevention
and awareness curriculum. A review of the gang intervention group sign-in sheets confirmed the
groups were provided as required. One applicable youth who completed the gang prevention
curriculum had received a certificate of completion, and the other youth was still in the process
of completing the service.
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 ensuring each youth receives a Residential
Assessment for Youth (RAY) within thirty days of admission and a reassessment at least every
ninety-days thereafter.
EVERGLADES YOUTH ACADEMY
A review of five youth case management records indicated each contained an initial RAY which
was completed within thirty days of each youth’s admission to the program. A review of the
Department’s Juvenile Justice Information System (JJIS) validated the initial RAY was
maintained in JJIS. Five reviewed records indicated all five youth were eligible for RAY
Reassessments. Three reassessments were completed as required; however, one RAY
Reassessment was not completed as required, and one RAY Reassessment was completed
nine days late. All initial RAYs and completed reassessments were maintained in each youth’s
case management record.
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EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Five youth case management records were reviewed, and the documentation validated the
program assessed each youth within thirty days of admission. Each initial assessment was
maintained in JJIS. Four of the reviewed records were applicable for a RAY Reassessment and
one youth had not been in the program for ninety days at the time of the annual compliance
review. Each of the four applicable youth had a reassessment completed every ninety days, as
required, with two exceptions. One youth had their initial reassessment completed thirty-five
days late and one youth had their initial reassessment completed forty-nine days late. The
program developed an internal corrective action plan to address late reassessments and the
case manager responsible for completing the late reassessments was no longer employed by
the program. After the corrective action plan was in place, no additional late reassessments
were noted. One youth had an additional reassessment completed prior to the ninety-day
requirement as it was deemed necessary by the program. Each applicable youth record
contained the reassessment documentation, as required.
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 addressing the Youth Needs Assessment
Summary (YNAS) process, which is to be completed within thirty days of the youth’s admission.
EVERGLADES YOUTH ACADEMY
Five youth case management records were reviewed, and each contained a YNAS completed
within thirty days of admission which had the signature of each treatment team member. Each
YNAS was documented in the Department’s Juvenile Justice Information System (JJIS).
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Five youth case management records were reviewed, and each contained a YNAS which was
completed within thirty days of the youth’s admission to the program. Each YNAS was
documented in JJIS, included the signature of each treatment team member, and a copy was
maintained in each youth’s case management record.
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 to address the development of performance
plans, goals, and plan transmittal.
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EVERGLADES YOUTH ACADEMY
Five youth case management records were reviewed. All five youth’s records documented the
Individualized Performance Plans (IPPs) were developed within thirty days of each youth’s
admission and after the initial assessment. Each reviewed IPP was developed and signed by
the treatment team leader, youth, administrative representatives, treatment staff, living unit
representatives, and education staff. Reviewed documentation in each youth case management
record demonstrated each IPP was mailed to the parent/guardian; however, the signature page
was not returned. Each reviewed youth case management record documented the IPP was
mailed to the youth’s parent/guardian, committing court, and juvenile probation officer (JPO)
within ten days of completion. Each reviewed IPP included individualized goals based upon the
prioritized needs identified during the initial assessment. Each IPP addressed the youth’s three
top criminogenic needs, specific delinquency interventions based on Residential Assessment for
Youth (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. Three interviewed youth reported they participated in the
development of their IPP, were knowledgeable of their current IPP goals, and reported receiving
a copy of their plan.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Five youth case management records were reviewed, and each documented the IPP was
developed within thirty days of the youth’s admission and after the initial assessment. Each
reviewed IPP was developed and signed by the treatment team leader, youth, administrative
representative, living unit representative, treatment staff, education staff, and other parties with
a significant responsibility in goal completion. Each signature sheet was attached to the original
performance plan in the youth’s official case record. There was documentation indicating the
signature sheet was sent to each parent/guardian in an attempt to obtain their signature;
however, none of the signature sheets were returned. Each performance plan documented
individualized goals based on the prioritized needs of each youth. Each youth’s top three
criminogenic needs were addressed in the plan along with specific delinquency interventions
based on the RAY results. Two applicable youth had court-ordered sanctions included in their
plans. Each plan also included transition activities targeted for the youth’s last sixty days in the
program, youth responsibilities for goal completion, program staff responsibilities for enabling
youth to complete goals, and all goals had target dates for completion. Within ten working days
of the completion of each plan, the program sent a transmittal letter and a copy of the plan to
each youth’s committing court, JPO, and parent/guardian. Three youth were interviewed, and
each indicated they participated in the development of their performance plan, could identify the
goals which were included in their plan, and each confirmed they received a copy of their 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 maintains a written policy and procedures requiring each youth’s Individualized
Performance Plan (IPP) to be revised as needed for completion.
EVERGLADES YOUTH ACADEMY
Four of five reviewed youth case management records were applicable for revisions made to
the performance plan based upon the Residential Assessment for Youth (RAY) Reassessment,
and one did not have any revisions made to his IPP based upon the new information acquired.
The records documented IPPs were completed every ninety days; however, there was no
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change in the interventions assigned to each youth throughout their stay, other than added
goals based upon the results of a RAY Reassessment and projected completion dates. It is the
program’s practice to deem all interventions as on track while in progress and interventions
were only noted as successfully completed at the time of discharge.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Five youth records were reviewed, and four were applicable for performance plan revisions
based on the RAY Reassessment results, newly acquired information which warranted a
change, demonstrated progress towards goal completion, or demonstrated lack of progress.
None of the five reviewed records were applicable for youth in transition; therefore, they did not
contain information needed to facilitate transition activities for the last sixty days of the youth’s
stay in the program. The program’s practice is to consider all interventions as on track while in
progress without specific notation of successful completion of interventions until the time of
discharge.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a written policy and procedures which address the completion of performance
and release summaries.
EVERGLADES YOUTH ACADEMY
All five reviewed youth case management records were applicable for Performance Summaries,
and each contained Performance Summaries which were completed within ninety days of the
Initial Performance Plan. Three of the five reviewed youth case management records
documented the youth received a copy of their Performance Summary; however, all five were
signed and contained comments written by the youth. All Performance Summaries included the
youth’s status on each performance plan goal, overall treatment progress, academic status,
behavior, and level of motivation/readiness to change. Each summary was reviewed and signed
by all treatment team members. All Performance Summaries were mailed to the committing
court, juvenile probation officer (JPO), and parent/guardian. Three closed youth records were
reviewed for release summaries. Each record contained a copy of the summary which noted the
reason of release from the program. All three closed records documented a Performance
Summary and Pre-Release Notification (PRN) were submitted at least forty-five days prior to the
tentative release date. Each closed record documented notification to the youth’s
parent/guardian of the youth’s release date once the program obtained the approved PRN from
the youth’s committing court. Each reviewed record contained a Residential Assessment for
Youth (RAY) exit assessment.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Five records were reviewed, four were applicable for Performance Summaries to be completed
every ninety days, and the remaining youth had not been in the program for ninety days. Each
youth had Performance Summaries completed every ninety-days except for one which was
completed one day late. Each summary included the youth’s status on each performance plan
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goal, overall treatment progress, academic status, behavior, level of motivation and readiness to
change, interaction with peers and staff, overall behavior adjustment to the program, and
significant positive and negative events. One youth was applicable for the inclusion of the
justification for release, discharge, or transfer which was documented within the youth’s most
recent Performance Summary. Reviewed documentation indicated each youth was allowed to
read and add any comments prior to signing, each youth received a copy of the summary, and
the original summary was filed in the youth’s case management record. Each Performance
Summary was signed and dated by the treatment team leader, staff preparing the summary,
facility administrator or designee, and the youth. Reviewed documentation indicated a copy of
each summary was sent to the youth’s committing court, JPO, and parent/guardian within ten
working days of completion of the summary. Three closed records were reviewed for release
summary documentation. Each release summary included the original summary, justification for
release, and a PRN sent to the JPO. Two of the three release summaries were sent one and
two days late; the remaining was sent within the required time frame. Each record contained a
signed copy of the summary. One youth’s summary indicated the court objected to the youth’s
release and a PRN was resubmitted with a Performance Summary once the youth
demonstrated more progress towards goals and met the court’s expectations. Once each
summary was approved, the program provided written notification to the youth’s parent/guardian
regarding the planned release and the program completed an exit RAY. None of the three youth
were accepted into the Sexually Violent Predator Program (SVPP). Each youth’s JPO was
notified ninety-days prior to the youth’s release, as required. The program provided each youth’s
JPO with the SVPP eligibility form, performance plan, summary of the youth’s adjustment to the
program, physical health summary, and any psychological/psychiatric reports. Upon completion
of the program, the Performance Summary, transition plan, and any psychological/psychiatric
reports completed while the youth was at the program were provided to the JPO. One youth
was applicable for victim notification, and the program mailed the Victim Notification of Release
letter to the victim or designee at least ten days prior to the youth’s release.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program maintains a written policy and procedures to address the encouragement of
parent/guardian involvement through advanced notification in case management services
including assessment, performance planning and development, progress reviews, treatment
teams, and transition planning. An interview with the facility administrator (FA) indicated case
managers attempt to contact the parent/guardian during the intake process along with mailing
various correspondence as it pertains to the program. The interviewed FA indicated the program
encourages parental/guardian involvement by contacting the youth’s parent/guardian during
treatment team meetings, encouraging “Family Day” participation on a quarterly basis, and
facilitating family therapy sessions. During these sessions any issues are discussed and
attempted to be resolved to allow for a healthy and pro-social relationship upon the youth’s
discharge from the program.
EVERGLADES YOUTH ACADEMY
A review of five youth case management records confirmed all five demonstrated the
parents/guardians were informed of the youth’s treatment team schedule for the duration of their
stay in the program. Reviewed documentation found each applicable youth’s case management
record reflected the program encouraged and facilitated involvement of each youth’s
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parent/guardian in case management activities, to include the assessment process,
development of the youth’s performance plan, and monthly progress reviews. Documentation
supported the program provided an advanced notice of formal treatment team meetings and
transition planning. Treatment team was not scheduled the week of the annual compliance
review; therefore, an observation of treatment team was not completed. Three interviewed youth
each reported their parent/guardian was involved with case management activities.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth case management records was conducted. Reviewed documentation
indicated each parent/guardian was contacted by e-mail, mail, and telephone in order to
facilitate their involvement. If the parent/guardian was unable to participate, the program offered
the opportunity to participate virtually or by telephone, or to provide written input for any
meetings scheduled. A treatment team meeting could not be observed during the annual
compliance review week because none were scheduled. Three youth were interviewed, and
each indicated their parent/guardian is involved in their treatment team meetings and treatment
planning process.
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 stipulating incorporation of other applicable
plans into each youth’s Individualized Performance Plan (IPP).
EVERGLADES YOUTH ACADEMY
Each of the five reviewed youth case management records included separate performance
plans, education plans, and treatment plans. Each reviewed IPP referenced and/or incorporated
education and treatment plans. There were no applicable youth for current involvement with the
Department of Children and Families (DCF) or the Agency for Persons with Disabilities (APD).
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Five youth records were reviewed, and each of the youth’s performance plans incorporated
additional plans including the youth’s academic and mental health plan. There were no
applicable youth with plans from the DCF and/or APD needing to be addressed and/or
incorporated into the performance plan.
2.14 Treatment Team Members and Meetings (Formal and
Limited Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
The program maintains a written policy and procedures to address requirements for formal and
informal treatment team meetings and members.
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EVERGLADES YOUTH ACADEMY
A review of treatment team meeting forms confirmed all required formal and informal reviews
were completed with all required treatment team members. During the week of the annual
compliance review, an observation of treatment team was conducted. Treatment team members
included the treatment team leader, youth, mental health staff, education staff, the assistant
facility administrator (AFA), the parent/guardian, and juvenile probation officer (JPO). The
program’s medical staff provided written documentation. The treatment team staff provided a
brief synopsis of the youth’s progress in the program by reviewing and discussing the youth’s
performance plan. Each youth was provided an opportunity to demonstrate skills acquired in the
program and comment on progress. A review of five youth case management records
demonstrated the program held formal treatment team meetings at least every thirty-days as
required. All five youth case management records contained formal treatment team
documentation; however, none of the five reviewed records included an evaluation of the
progress on performance plan goals or results of the Residential Assessment for Youth (RAY)
Reassessments. The remaining elements were included and addressed during treatment team
meetings. Three interviewed youth reported staff review youth performance, behavior, and
treatment progress. Each interviewed youth reported they are given an opportunity during
treatment team meetings to demonstrate skills learned in the program. This indicator was
preliminarily rated as limited compliance.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Five youth records were reviewed, and each included documentation of a formal treatment team
review held at least every thirty days. Reviewed documentation included the youth’s name, date
of the review, all required attendees, comments, a brief synopsis of the youth’s progress at the
program, any performance plan revisions, and notable behaviors. Each youth was provided an
opportunity to demonstrate skills acquired in the program by explaining what they had learned in
the program and giving examples of how to use those new skills. Formal treatment team
meetings also included treatment progress and RAY Reassessment results when applicable.
None of the treatment team documentation indicated any youth’s progress on performance plan
goals. All documentation for formal treatment teams was maintained in each youth’s record.
Although the program is not required to hold informal meetings with maximum-risk youth, the
program held informal treatment teams with each youth on a bi-weekly basis. Informal treatment
team documentation included the youth’s name, date of review, attendees, comments, a brief
synopsis of the youth’s progress at the program, any performance plan revisions, and notable
behaviors. Each youth was provided an opportunity to demonstrate skills acquired in the
program by explaining what they had learned in the program and giving examples of how to use
those new skills. One of the five youth records documented progress on performance plan
goals, and four did not. The youth’s JPO, parent/guardian, and other pertinent parties were
invited and encouraged to attend the meetings or to provide verbal or written input. A treatment
team meeting could not be observed during the annual compliance review week because none
were scheduled. Three youth were interviewed, and all responded they are given an opportunity
to demonstrate any skills they have learned in the program during treatment team. One youth
stated they work with their therapist, one said they put themselves in their victims’ shoes and
said they use the “ABC” method, and the remaining youth said they can explain what they have
accomplished. Each interviewed youth confirmed staff review their performance and progress
with them. This indicator was preliminarily rated as limited compliance.
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2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program maintains a written policy and procedures requiring the intervention and treatment
team to plan for each youth’s successful transition to the community upon release from the
program. The policy outlines the process for transition planning, conferences, and Community
Re-Entry Team (CRT) meetings.
EVERGLADES YOUTH ACADEMY
A review of three closed youth case management records documented each youth had a
transition conference at least sixty days prior to the youth’s targeted release date. Transition
conference documentation reflected the youth, treatment team leader, facility administrator (FA)
or designee, and other applicable team members were in attendance. Notification
documentation supported the youth’s juvenile probation officer (JPO) and parent/guardian, were
encouraged to participate. No youth were applicable for the attendance of a human trafficking
specific service provider. Transition documents supported the conference included a review of
transition activities, necessary performance plan revisions, additional transition activities, target
completion dates, and persons responsible for transition activities. Transition conference
documentation contained acknowledgement of transition goals and responsibilities of members
through signatures of participants. A copy of each transition plan was sent to the assigned JPOs
who participated by phone; however, two of the three were not returned with signatures. Each of
the three closed records documented a CRT invitation was sent and a meeting was held prior to
the youth’s release.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of three closed youth case management records indicated each youth had a transition
conference held at least sixty days prior to their targeted release date. Each record documented
the youth, youth’s JPO, FA or designee, and other required members attended the transition
conference. The program documented attempts to facilitate involvement from the JPO,
parent/guardian, education staff, and other pertinent parties and noted their input in the
transition conference documentation. During the transition conference the participants reviewed
transition activities on the youth’s performance plan, revised the performance plan as
necessary, identified additional transition activities as needed, identified target completion
dates, and the persons responsible for completion. The treatment team leader obtained all
attendees’ dated signatures and noted those who participated over the telephone, virtually, or
through writing. A copy of the plan was sent to those not able to join in-person and the e-mail
acknowledgement was printed and filed with the plan. Each of the records documented a CRT
meeting was conducted prior to the youth’s release. The documentation included the invitation
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for attendees to participate and indicated the youth and case manager participated in the CRT
meeting.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program maintains a written policy and procedures to address the completion of an exit
portfolio for youth being released back into the community.
EVERGLADES YOUTH ACADEMY
A review of three closed youth case management records was completed. Each record
contained an exit portfolio which included a Florida State identification card, a copy of the
youth’s transition plan, a calendar of upcoming appointments, a Social Security card or
application, birth certificate, educational/vocational certificates earned at the program, school
transcripts, a sample employment application, and a résumé. Documentation supported each
youth’s exit portfolio was verified during the exit conference, provided to the youth upon release,
and forwarded to the assigned juvenile probation officer (JPO).
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Three closed youth case management records were reviewed, and each documented the exit
portfolios were discussed or initiated at each youth’s transition conference. All five exit portfolios
contained a copy of the youth’s state-issued identification card, a copy of the youth’s transition
plan, a calendar with all dates, times, and locations of upcoming community appointments, birth
certificate, certificates earned while in the program, educational records/documents, school
transcripts, a résumé, and a sample of completed employment applications. Two youth records
did not contain a Social Security card; however, the completed applications were included in the
portfolio. There was documentation to support the exit portfolio was verified during the exit
conference and was provided to the youth and JPO upon release for all three youth. Each youth
was provided with completed forms and clear instructions as to how to obtain information
necessary for employment. During the transition conference, a plan documenting the persons
responsible for working with the youth to obtain the needed information was created.
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program maintains a written policy and procedures for the review and finalization of
transition conference items and release plans by way of the exit conference.
EVERGLADES YOUTH ACADEMY
A review of three closed youth case management records was completed. Each reviewed
record documented an exit conference was held after the program notified the assigned juvenile
probation officer (JPO) of the youth’s release and at least fourteen days prior to release.
Conference documentation included a summary of pending transition goals, and the date and
signatures of attendees. Attendees included the team leader, parent/guardian, education
representative, JPO, youth, and other pertinent parties. Documentation supported the exit
conference was held separately from the transition conference and Community Re-Entry Team
Florida Department of Juvenile Justice Residential Annual Compliance Report
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(CRT) meeting for each youth. A review of the Department’s Juvenile Justice Information
System (JJIS) admission and release dates corresponded with each youth’s record.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Three closed youth case management records were reviewed, and documentation indicated the
exit conferences were conducted after the program notified the youth’s JPO of the youth’s
pending release and at least fourteen days prior to the youth’s release date. The exit conference
documentation in each of the records contained the date, participant’s signatures, the names of
those participating by telephone, and a summary of pending transition goals. Each youth’s date
of admission and date of termination documented in their record correlated with JJIS. The status
of transition activities established at the transition conference and plans were reviewed for each
youth. Each exit conference included the intervention and treatment team leader,
parent/guardian, education representative, JPO, the youth, and all other pertinent parties. All
three youth records documented the exit conference was conducted separately from the
transition conference and CRT meeting.
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 foster youth input for improvement of
program practices and procedures. The program utilizes “Request to Speak” forms for youth to
be able to submit during their time at the program, exit surveys for the youth and
parent/guardian to complete upon the youth's release, and the program conducts town hall
meetings where youth can speak about any issues they are having within the program. The
program has a youth advisory board meeting where elected youth represent their respective
living units by meeting with program administration to give feedback, discuss issues and plan
implementation of new ideas, or to help resolve any conflicts.
EVERGLADES YOUTH ACADEMY
A review of the youth town hall meeting binder reflected the agendas, sign-in sheets, and
meeting minutes were maintained and summarized the subject areas which were discussed.
Additionally, two youth representatives are selected to attend portions of the community
advisory board meetings. Three youth were interviewed, and each reported the program does
provide a process for youth to provide input regarding what happens at the program.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of town hall minutes, youth advisory board minutes, submitted “Request to Speak”
forms, and exit surveys maintained within three closed youth records confirmed the program
utilizes multiple ways to promote feedback. The program’s policy requires youth advisory boards
and town hall meetings to be held monthly, which was validated through a review of sign-in
sheets. Three youth were interviewed and two indicated they can speak with the shift supervisor
who relays the information to the assistant facility administrator (AFA) and facility administrator
(FA). Two interviewed youth noted town hall is where they provide input, and one youth
indicated they fill out grievance or “Request to Speak” forms. The FA indicated the program
created a youth advisory board and the management staff identify specific youth to participate
on the advisory board as advocates for others. The youth discuss ideas they would like
implemented within the program and voice any concerns they may have.
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2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program maintains a written policy and procedures to ensure the instruction of a career
education curriculum. The program is identified as a Type 3 career education program which
includes instruction of interpersonal communication skills, personal accountability skills, and
behaviors leading up to appropriate work habits for positive post-release employment and living
standards. The content of this programming provides the youth an orientation to the broad
scope of career choices based upon personal abilities, aptitudes, and interests, in addition to an
understanding of the needed prerequisites for entry into a specific occupation. The program
provided certified vocational coursework through career and technical education (C-Tech)
computer technology, and small business entrepreneurship. The youth also have the
opportunity to complete vocational coursework certification through a co-located vocational
program operated by the Home Builder’s Institute under a separate contract with the
Department. Interviews with the facility administrator and lead teacher confirmed the Type 3
programming provided.
EVERGLADES YOUTH ACADEMY
A review of three closed youth records was completed. Each record contained a résumé and
completed employment applications. All reviewed records also contained a post release
calendar entitled Plan for Success, which identified immediate post-release appointments,
appointment locations, and location and business hours of a Career Source Center near the
youth’s residential address. Each record contained copies of documentation needed to gain
employment, including a valid Florida identification card. Each reviewed record included
documentation showing the youth’s parent/guardian, juvenile probation officer (JPO), and case
manager were aware of the youth’s vocational plan and the post-release discharge plan.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of three closed youth records was completed. All f three reviewed records contained a
résumé and completed employment applications. One youth record did not contain a résumé or
completed employment application due to the youth repeatedly refusing the program’s requests
to complete these items. All three reviewed records contained a post release calendar entitled
Plan for Success, which identified immediate post-release appointments, appointment locations,
and location and business hours of a Career Source Center near the youth’s residential
address. Each record contained copies of documentation needed to gain employment, including
a valid Florida identification card. Each reviewed record included documentation showing the
youth’s parent/guardian, JPO, and case manager were aware of the youth’s vocational plan and
the post-release discharge plan.
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’s education staff are program staff. The educational program receives oversight
from the Okeechobee County School District. Reviewed documentation and informal interviews
with the lead teacher indicated the program provides 250 days of instruction, which includes a
maximum of ten days for teacher planning and/or professional development. Classes are
scheduled for twenty-five hours each week. A review of the program’s logbooks for six separate
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days and randomly selected video for six separate days confirmed classes were being provided
as scheduled with minimal interruption. Six interviewed youth reported there are no interruptions
to the school day.
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 written policy and procedures to address transition planning and exit
portfolios. The transition plan is to be developed in collaboration with the program staff,
educational staff, parent/guardian, if available, the assigned juvenile probation officer (JPO),
and post residential services provider who will provide post residential supervision. Target
completion dates and persons responsible are to be identified during the conference. Each
youth’s exit portfolio is to include a state-issued identification card, copy of the youth’s transition
plan, and a calendar with all dates, times, and locations of follow-up appointments in the
community. Six youth were interviewed. Five youth stated they were involved in the
development of their educational transition plan, and one was not applicable. All six interviewed
youth stated they felt the program was preparing them either very well or well for the high school
equivalency diploma (GED), high school, vocational school, employment, and/or college. An
interview with the lead teacher indicated education and employment are addressed in each
youth’s Education Transition Plan.
EVERGLADES YOUTH ACADEMY
A review of three closed youth records was conducted. Each reviewed record had an Education
Transition Plan in place at the time of their release from the program. Each plan documented
key services and monitoring responsibilities by individuals essential to the plan’s creation. Items
addressed on the plans included academic placement upon release, specific monitoring
responsibilities, and individuals assigned coordination responsibilities. Each reviewed plan was
signed by the youth, parent/guardian, the assigned JPO, an education representative, and the
transitional services manager. One youth’s plan was not signed by personnel from the post
release school district, and two youth were not applicable.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of three closed youth records was conducted. Each reviewed record had an Education
Transition Plan in place at the time of their release from the program. Each plan documented
key services and monitoring responsibilities by individuals essential to the plan’s creation. Items
addressed on the plans included academic placement upon release, specific monitoring
responsibilities, and individuals assigned coordination responsibilities. Each reviewed plan was
signed by the youth, parent/guardian, the assigned JPO, an education representative, and the
transitional services manager. One youth was applicable for, and the plan documented
involvement of, a representative of the youth’s home school district, while two youth were not
applicable.
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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 stating the facility administrator is
responsible for the administrative oversight and management of the mental health and
substance abuse services in the program. The program provides specialized treatment services
and must have a single licensed mental health professional designated as the designated
mental health clinician authority (DMHCA) who is responsible for the coordination and
implementation of mental health and substance abuse services in the program. The program
has a full-time State of Florida licensed clinical social worker (LCSW) who serves as the
DMHCA. The DMHCA’s license is clear and active, with an expiration date of March 31, 2025.
The DMHCA is on-site weekly Monday through Friday, for enough time to ensure appropriate
coordination and implementation of mental health and substance abuse services. Copies of the
DMHCA’s position description were reviewed for accuracy of the program’s requirements. The
program provides specialized treatment services where the licensed mental health professional
(LMHP) is responsible for the coordination and implementation of mental health/substance
abuse services with specialization of Juvenile Sexual Offender Treatment Services. These
services are provided by the DMHCA. The program has a full-time licensed mental health
counselor (LMHC) in the position of assistant clinical director who serves as the back-up when
the DMHCA is not available. The LMHC has an active license in the State of Florida with an
expiration date of March 31, 2025. An interview with the DMHCA revealed their responsibility of
the daily mental health/substance abuse group scheduling. At the intake process, the LMHP,
gathers current information from youth and within five days the LMHP confirms the youth's
reports by referring to collateral information obtained in the youth's Department record to
complete the brief behavioral health status exam. Each youth receives a comprehensive
assessment within twenty-one days of the intake, based on their current and past behavior, by a
licensed or non-licensed mental health professional which is reviewed by the DMHCA.
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 requiring all substance abuse and
mental health services to be provided by licensed and/or non-licensed clinical staff. The clinical
supervisor ensures the licensed clinical staff working under their supervision are performing
services they are qualified to provide based on education, training, and experience. A review of
their position descriptions, and an informal interview with the designated mental health clinician
authority (DMHCA) confirmed this requirement. The licensed mental health and substance
abuse clinical staffing is in accordance with the current contract and Florida Administrative
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Code. At the time of the annual compliance review, copies of the licenses of all mental health
professionals were reviewed. The program has a full-time licensed mental health counselor
(LMHC) in the position of assistant clinical director who serves as the back-up when the
DMHCA is not available. The contract requires a certified behavior analyst or board-certified
behavior analyst who is not a licensed mental health professional (LMHP) to provide services
under the direct supervision of a LMHP in the program. This contracted position shall provide
behavior analysis services, behavioral therapy, or behavioral interventions as needed. A review
of clinical supervision and sign-in sheets reflected the program’s behavior analyst provided
services as required. An informal interview with the program’s regional clinical director indicated
the program has not utilized the services of the contracted psychologist since the last annual
compliance review. The program maintains an independent contractor agreement with a
licensed psychologist to provide pro re nata (PRN) services. The psychologist’s license is
active, in the State of Florida, with an expiration date of May 31, 2025.
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 outlining the requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program’s
clinical director serves as the designated mental health clinician authority (DMHCA) and is
responsible for supervising all on-site clinical staff. The clinical supervisor assures the non-
licensed clinical staff working under their supervision are performing services they are qualified
to provide based on education, training, and experience. This information was verified through a
review of their position descriptions and an informal interview with the DMHCA. The reviewed
documentation reflected each non-licensed mental health clinical staff working under the direct
supervision of a licensed mental health professional (LMHP) received a minimum of one hour a
week of on-site, face-to-face direct supervision by a LMHP for the purpose of overseeing and
directing the mental health services provided in the program during the annual compliance
review period. Reviewed direct supervision was recorded 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. The program has a Chapter 397
license, displayed in the front of the building outside of master control, which has an expiration
date of April 01, 2024. The program’s contract requires two recreation therapists; however, at
the time of the annual compliance review one recreation therapist position had been vacant
since July 20, 2021, and the second had been vacant since April 4, 2023. The program’s
staffing roster was reviewed, as well as the therapist’s credentials, schedule, and services
provided to youth. During an informal interview with the facility administrator, it was revealed the
program coach had been held in the position; however, did not have the credentials to do so;
therefore, the non-licensed mental health and substance abuse clinical staffing was not in
accordance with current contract. At the time of the annual compliance review, there were
vacancies to include one master’s-level therapist, which was vacant since August 21, 2023, and
two bachelor’s-level therapist positions which have been vacant since September 18, 2023. Two
of four non-licensed mental health clinical staff held a master’s-level degree from an accredited
university or college in the field of psychology or a related human services field. The other two
non-licensed mental health clinical staff held a bachelor’s-level degree from an accredited
university or college in the field of educational psychology and human services and had fifty-two
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hours of pre-service training, prior to working with youth. The fifty-two hours of pre-service
training included a minimum of sixteen hours of documented clinical training in their duties and
responsibilities. When pre-service training has been successfully completed, the non-licensed
staff may begin working with youth, but shall receive training in mental disorders and substance-
related disorders, counseling theory and techniques, group dynamics and group therapy, and
treatment planning and discharge planning for one year by a mental health clinical staff person
who holds a master’s-level degree. Each of the four non-licensed substance abuse clinical staff
providing substance abuse services were working for a service provider licensed under Chapter
397. Additionally, each of the four non-licensed mental health clinical staff who conducted
Assessments of Suicide Risk had completed twenty hours of training and supervised experience
in assessing suicide risk, mental health crisis intervention, and emergency mental health
services. The non-licensed mental health and substance abuse clinical staffing was not in
accordance with current contract to include the number of hours, due to the program having a
total of three vacancies at the time of the annual compliance review; however, caseload sizes
were within the required limits.
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 requiring identification of each youth’s
mental health and substance abuse treatment needs through a comprehensive screening
process to ensure referrals are made for youth identified with substance and/or mental health
needs or as a possible suicide risk. The program screener is to review available information to
include the commitment packet, reports, and/or records for existing documentation of mental
health or substance abuse problems or history of human trafficking. The program completes a
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2). It is the program’s
practice to complete an Assessment of Suicide Risk (ASR) on all intake youth regardless of the
MAYSI-2 assessment outcomes. The facility administrator (FA) is responsible for developing
written policies and procedures for the implementation of a standardized admission/intake
mental health and substance abuse screening process. These procedures consist of a
standardized screening process, which includes a review of commitment packet information,
reports and records, administration of the MAYSI-2 on the Department’s Juvenile Justice
Information System (JJIS) by a qualified professional, referral of juvenile offenders identified by
screenings as in need of further evaluation or immediate attention, staff training in mental health
and substance abuse issues, administration of the MAYSI-2, and standardized process for
referral of youth identified as in need of further mental health and/or substance abuse evaluation
to an appropriate service provider/professional or, when immediate attention is needed, to a
hospital or Baker Act or Marchman Act receiving facility. An interview with the FA revealed upon
intake, all youth are evaluated by a licensed mental health counselor (LMHC). During the
process, it is determined if the youth is at risk for suicide. Crisis Assessments are conducted if a
mental health referral is submitted, and all youth will then complete an evaluation.
EVERGLADES YOUTH ACADEMY
A total of five youth records were reviewed for mental health and substance abuse admission
screening. Each record contained a completed MAYSI-2. Reviewed documentation
demonstrated the screener utilized available information for each youth, which included the
commitment packet, reports, and documentation concerning each youth’s mental health and/or
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substance abuse problems or history. Each of the reviewed MAYSI-2s were completed on the
date of admission to the program. The screenings were conducted by trained staff, and each
screening was completed in full. Each of the five reviewed youth were applicable for a referral. It
is the program’s practice to refer all youth for further evaluation. Each referral documented a
reason for referral. Reviewed documentation supported the FA and the designated mental
health clinician authority (DMHCA) were notified. One of five reviewed youth was applicable for
requiring an ASR. None of the reviewed youth required emergency services. The FA ensured
an ASR was conducted for the applicable youth, within twenty-four hours of the youth’s
admission. Each of the five reviewed youth records were applicable for completion of a
comprehensive evaluation and the reason for referral was documented in each of the youth
records reviewed.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth records revealed upon admission the program completed a MAYSI-2 for
each youth. Each of the five reviewed screenings were completed by trained staff, and the
screenings were completed in JJIS on the day of the youth’s admission in a confidential
manner. Each of the five reviewed MAYSI-2s documented the staff conducted the full mental
health and substance abuse admission screening and reviewed each youth’s commitment
packet information and records for existing documentation of mental health and substance
abuse problems. It is the program’s practice to generate a referral for further evaluation or
immediate attention, with a referral reason, and the utilization of a tracking log when the MAYSI-
2 indicated further assessment was required. One of the five youth case records reviewed was
applicable for a staff believing the youth had a mental health or substance abuse problem or
was at risk of suicide. The staff made a referral for further evaluation regardless of MAYSI-2
findings. One of the five MAYSI-2s or other admission information indicated the need for an
assessment, crisis intervention, or emergency services, where the FA or designee was notified,
and a referral was made to alert the DMHCA. One of the five reviewed youth case records
indicated the need for an ASR. This was ensured by the FA and was completed within twenty-
four hours of when the MAYSI-2 category “suicide ideation” indicated further assessment was
needed, or other information obtained at intake/admission suggested potential suicide risk. Each
youth received a comprehensive evaluation, with the reason for the referral documented.
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 outlining the provision of mental health
and substance abuse assessment/evaluations. 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 an updated evaluation. The program’s practice is to complete a new comprehensive mental
health and substance abuse evaluation within thirty-days of each youth’s admission.
EVERGLADES YOUTH ACADEMY
A total of five youth records were reviewed for mental health and substance abuse assessment
and evaluation. The reviewed youth were each applicable for completion of a new mental health
evaluation. Each new mental health evaluation was completed within thirty calendar days of
admission to the program. Each of the mental health evaluations were completed by a non-
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licensed mental health clinical staff and subsequently reviewed and signed by a licensed mental
health professional (LMHP). The LMHP completed each review within ten calendar days after
each evaluation was completed. The reviewed mental health evaluations contained identifying
information of the youth, reason for evaluation, relevant background, behavioral observations, a
Mental Status Examination, discussion of findings, diagnostic impression, and
recommendations for treatment. The five reviewed youth records were all applicable for
completion of a substance abuse assessment. A consent was obtained in each youth record
reviewed. Each of the new substance abuse assessments was completed within thirty calendar
days of the youth’s admission to the program. The reviewed substance abuse assessments all
contained a reason for the assessment, relevant background, behavioral observations, methods
of assessment, patterns of alcohol and other drug abuse, impact of alcohol and other drug
abuse, risk factors, clinical impression, and recommendations for treatment. Each of the five
reviewed mental health evaluations and substance abuse assessments addressed the original
referral reason.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth records revealed the program completed a combined mental health and
substance abuse evaluation referral at admission. A new mental health evaluation was
completed for each of the five youth. The evaluations were completed within thirty calendar
days of admission. A non-licensed mental health clinical staff or non-licensed substance abuse
clinical staff completed the evaluations. The evaluations were reviewed and signed by a LMHP
within ten calendar days after the evaluation was conducted. Each evaluation included
identifying information/demographics, the reason for the evaluation, relevant background
information including home environment and family functioning, history of physical abuse,
sexual abuse, neglect, witnessing violence and other forms of trauma, behavioral functioning,
physical health, mental health and substance abuse history, and education functioning.
Additionally, the evaluations included behavioral observations, a Mental Status Examination,
interview or procedures administered, the discussion of findings, diagnostic
impression/formulation including, Diagnostics and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) diagnosis, and recommendations. Each of the five youth records had a consent
for substance abuse services, and a new substance abuse evaluation was completed within
thirty calendar days of admission and included the reason for the assessment. The substance
abuse assessments included relevant background information, including home environment and
family functioning, history of physical abuse, sexual abuse, neglect, witnessing violence and
other forms of trauma, behavioral functioning, physical health, mental health and substance
abuse history, and education functioning, behavioral observation, methods of the assessment,
and patterns of alcohol and other drug abuse. Additionally, assessments included the impact of
alcohol and other drug abuse on major life areas, risk factors of continued alcohol and other
drug abuse, clinical impression, including DSM-5 diagnoses, and recommendations. None of
the five youth records reviewed were applicable for an updated comprehensive mental health
evaluation. Each new mental health/substance abuse assessment addressed the original
referral reason.
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3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a written policy and procedures requiring the designated mental health
clinician authority (DMHCA), mental health and substance abuse clinical staff, and other
multidisciplinary treatment team members to ensure each youth’s treatment plans are
individualized and relevant to each youth’s specific needs. Youth determined to have a serious
mental disorder or substance abuse impairment and are receiving mental health or substance
abuse treatment in a program, are to 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 to be completed.
EVERGLADES YOUTH ACADEMY
A review of five youth records indicated the initial treatment plans were developed within seven
days of initiation of treatment. The initial plans were documented on the program’s form which
included the elements from the Department’s Initial Mental Health/Substance Abuse Treatment
Plan form. Each reviewed initial treatment plan was signed by the DMHCA as well as signed by
all treatment team members who participated in the development of the plan. Two of five
reviewed youth records were applicable for psychiatric needs, including medication and
frequency of monitoring by the psychiatrist, which were included on the initial plans.
Each of the five reviewed youth records also included an individualized treatment plan, signed
by the DMHCA, which was developed within thirty days of the youth’s admission and signed by
all treatment team members who participated in the development of the plan. Two of the five
reviewed youth records were applicable for inclusion of psychiatric needs including psychotropic
medication. A total of twenty-seven individualized treatment plan reviews were completed for
the five reviewed youth. Reviews were completed at least every thirty-days, as required. The
youth’s individualized treatment plans documented each youth’s prescribed services, including
twice monthly individual counseling, daily group counseling, and monthly family therapy
sessions. The plans for the two youth applicable for inclusion of psychiatric needs, included
monthly medication management and monitoring by the psychiatrist. The other three youth were
not applicable. The review of treatment plans indicated the services prescribed were
individualized for each youth. A comparison of video surveillance footage of three randomly
selected mental health groups to logbooks, sign-in sheets, and facilitator documentation
validated the groups occurred as required and for the required duration.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth records demonstrated each included an initial treatment plan developed
within seven days of initiation of treatment, the date it was developed, and an initial treatment
note. The initial plan was documented on the program’s form which included all elements of the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form, and the date of the
onset of treatment. The initial plans were developed within seven days of the onset of treatment,
or for youth prescribed psychotropic medication, within seven days of the Initial Psychiatric
Diagnostic Interview. Each initial treatment plan was completed and signed by the DMHCA.
Each plan was also signed by all treatment team members who participated in the development
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of the plan, the youth, and parent/guardian, when available. One of the five reviewed initial
treatment plans was applicable and included the youth’s psychiatric needs, including medication
and frequency of monitoring by the psychiatrist. The other four youth were not applicable.
Individualized treatment plans were developed for each youth within thirty days of admission
and documented the date the plan was developed. The individualized treatment plans were
developed on the program’s form which included all elements of the Department’s Individualized
Mental Health/Substance Abuse Treatment Plan form. Each of the five reviewed records
indicated the individualized treatment plans were signed by the mental health or substance
abuse clinical staff completing the plan. Each reviewed plan was completed and signed by the
DMHCA and signed by all treatment team members who participated in development of the
plan, as well as the youth, and the parent/guardian. One of the five individualized treatment
plans was applicable for inclusion of psychiatric services and addressed psychotropic
medication and frequency of monitoring by the psychiatrist. The other four youth were not
applicable. Individualized treatment plan reviews were completed on the program’s form which
included all elements of the Department’s Individualized Mental Health/Substance Abuse
Treatment Plan Review form. Each identified the dates of the treatment plan reviews. A review
of five youth individualized treatment plans validated the inclusion of each prescribed service.
Four youth were prescribed thirty-minute individual counseling sessions four times a month, and
one youth was prescribed twice monthly thirty-minute individual counseling sessions. Four youth
were prescribed sixty-minutes of daily group therapy services, and the one remaining youth was
prescribed group therapy five times a week for sixty minutes. Each of the five youth were
prescribed family counseling once monthly for thirty minutes. Additionally, one of the five youth
was applicable for medication management at least once each month. Observations of a
comparison of surveillance video footage from three randomly selected groups in comparison to
logbooks, sign-in sheets, and facilitator documentation validated the groups occurred as
documented and for the required duration.
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 outlining requirements for mental health
and substance abuse treatment and discharge planning. Mental health and substance abuse
treatment planning focuses 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 the program are to 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
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the program. Treatment teams are to be comprised of the youth, administration, the residential
living unit, and other staff responsible for delinquency intervention and treatment services for the
youth.
EVERGLADES YOUTH ACADEMY
Five youth records were reviewed for treatment and discharge planning. Each of the youth were
assigned to a treatment team upon arrival to the program. Reviewed documentation reflected
the members in attendance during treatment team meetings included the youth, program
administration, representatives of the youth’s residential living unit, the program’s education,
medical, mental health, and substance abuse staff, as well as the youth’s parent/guardian, when
available. Reviewed documentation validated the five youth were in need of, and received,
substance abuse services including individual, group, and/or family counseling services
provided by a non-licensed clinician working under the direct supervision of a qualified licensed
professional. All five reviewed youth receiving mental health treatment had a properly executed
Authority for Evaluation and Treatment (AET) form. Three of the five youth were eighteen years
of age; however, it is the program’s practice to get a signed AET from a parent/guardian, if
available, in addition to a youth over eighteen consent form. Each youth receiving substance
abuse treatment provided consent through a signed Youth Consent for Substance Abuse
Treatment form. Additionally, Youth Consent for Release of Substance Abuse Treatment
Records forms are to be signed if records are being released. Mental health and substance
abuse treatment notes were documented on the program’s form which contained all elements of
the Department’s Counseling/Therapy Progress Notes form. Each youth’s mental health and
substance abuse group therapy included individual psychotherapy or one-to-one counseling
between a youth with diagnosed mental health disorder and a mental health clinical staff
professional. The reviewed psychosocial skills training activities were designed to address
specific skill deficits or maladaptive behaviors and promote skill development and improve
functioning of youth with mental disorders. Each of the five youth had progress notes to indicate
the youth received services as stipulated on their treatment plans. A review of five youth records
indicated none were applicable for a discharge plan; therefore, an additional three youth records
were requested. Each of the three closed youth records indicated a discharge plan was
completed and documented on the Department’s Mental Health/Substance Abuse Treatment
Discharge Summary form. None of the youth were applicable for being released while on
suicide alert/precautions; therefore, a notification regarding the youth’s suicide risk was not
needed. Each Mental Health/Substance Abuse Treatment Discharge Summary documented the
services needed for daily maintenance of the positive improvement in behavioral, emotional,
and social skills made by the youth during treatment. Reviewed documentation reflected the
discharge plans were discussed with the youth, parent/guardian, and juvenile probation officer
(JPO) during the exit conference. Documentation validated a copy of each Mental
Health/Substance Abuse Treatment Discharge Summary was provided to each youth, their
JPO, and to the parent/guardian.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth records indicated each youth was assigned to a treatment team upon
arrival to the program. Reviewed documentation reflected the members in attendance during
treatment team meetings included the youth, program administration, representatives of the
youth’s residential living unit, the program’s education, medical, mental health, and substance
abuse staff, as well as the youth’s parent/guardian, when available. Each of the five reviewed
records documented the youth’s mental health and substance abuse treatment services
included individual, group, and/or family counseling provided by a licensed qualified
professional, or a non-licensed substance abuse clinical staff in accordance with the youth’s
initial or individualized substance abuse treatment plan. All five reviewed youth receiving mental
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health treatment had a properly executed AET form. Three of the five youth were eighteen years
of age; however, it is the program’s practice to get a signed AET from a parent/guardian, if
available, in addition to a youth over eighteen consent form. Each youth receiving substance
abuse treatment provided consent through a signed Youth Consent for Substance Abuse
Treatment form. Additionally, Youth Consent for Release of Substance Abuse Treatment
Records forms are to be signed if records are being released. Mental health and substance
abuse treatment notes were documented on the program’s form which contained all elements of
the Department’s Counseling/Therapy Progress Notes form. Each youth’s mental health and
substance abuse group therapy included individual psychotherapy or one-to-one counseling
between a youth with diagnosed mental health disorder and a mental health clinical staff
professional. The reviewed psychosocial skills training activities were designed to address
specific skill deficits or maladaptive behaviors and promote skill development and improve
functioning of youth with mental disorders. Each of the five youth had progress notes to indicate
the youth received services as stipulated on their treatment plans. A review of five youth records
indicated none were applicable for a discharge plan; therefore, an additional three youth records
were requested. Each of the three closed youth records indicated a discharge plan was
completed and documented on the Department’s Mental Health/Substance Abuse Treatment
Discharge Summary form. None of the youth were applicable for being released while on
suicide alert/precautions; therefore, a notification regarding the youth’s suicide risk was not
needed. Each Mental Health/Substance Abuse Treatment Discharge Summary documented the
services needed for daily maintenance of the positive improvement in behavioral, emotional,
and social skills made by the youth during treatment. Reviewed documentation reflected the
discharge plans were discussed with the youth, parent/guardian, and JPO during the exit
conference. Documentation validated a copy of each Mental Health/Substance Abuse
Treatment Discharge Summary was provided to each youth, their JPO, and to the
parent/guardian.
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.”
EVERGLADES YOUTH ACADEMY
The program is contracted to provide specialized treatment for sixty-four maximum-risk and
sixteen high-risk youth with Mental Health Overlay Treatment Services (MHOS) through
individual, group, or family therapy seven days a week to each youth as part of the
individualized treatment plan. Mental health clinical staff provide daily therapeutic activities, with
co-occurring substance abuse services if needed. A contracted psychologist provides services
as needed. Therapist caseloads are limited to sixteen or fewer youth, as required by contract.
Therapy groups are limited to ten or fewer youth for mental health treatment groups. Substance
abuse groups offered did not exceed fifteen youth. The program is licensed under Chapter 397
through the Department of Children and Families and has a qualified professional on-site at
least five days a week. Substance abuse clinical staff are on-site seven days a week. The
program provides individualized, trauma-informed, and developmentally appropriate mental
health and substance abuse treatment services to youth identified in need of such services. All
treatment services are guided by an individualized treatment plan which addresses the youth’s
needs in accordance with Florida Administrative Code. The program’s contract requires clinical
groups including Moral Reconation Therapy (MRT), Aggression Replacement Training (ART),
Living in Balance (LIB), Skillstreaming the Adolescent, Impact of Crime (IOC), Thinking for a
Change (T4C), and Teen Relationships. Three groups were reviewed by video, which verified
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groups were conducted as documented. A review of surveillance video footage, logbooks and
sign-in sheets validated the groups were conducted for at least one hour each session, as
required. An interview with the facility administrator (FA) indicated the program is providing
specialized treatment services which include IOC, T4C, MRT, LIB, Skillstreaming the
Adolescent, and ART. An interview with the designated mental health clinician authority
(DMHCA) confirmed the mental health department provides individualized treatment through
individual, family, and daily group therapy services to address mental health and substance
abuse needs of the youth. Three interviewed youth stated they participate in family and
individual counseling. Three interviewed staff stated direct care staff do not facilitate mental
health or substance abuse groups.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
The program maintains a written policy and procedures regarding specialized treatment
services. The program had one licensed clinical social worker (LCSW) serving as the
designated mental health clinician authority (DMHCA) and one licensed mental health counselor
(LMHC) who serves as the assistant clinical director. According to the contract the program’s
required non-primary clinical groups consist of LIB and Anger Control. LIB and Anger Control
groups are provided as supplemental services, based on the individual youth needs. An
interview with three youth revealed each youth attend individual counseling, group, and family
counseling services. Each youth reported services are only facilitated by mental health staff. An
interview with three staff indicated youth attend family, group, and individual counseling
services. An interview with the DMHCA confirmed mental health and substance abuse
treatment services are provided at the program and include individual, family, and group therapy
services. The interviewed DMHCA confirmed the groups were provided. An interview with the
FA confirmed the specialized treatment services were provided. Reviewed documentation
revealed a full-time juvenile sexual offender therapist was on-site five days a week for forty
hours a week. The program had a licensed psychiatrist to provide psychiatric evaluations and
medication management and participate in treatment planning. The program’s Juvenile Sexual
Offender Treatment Services were conducted, managed, and supervised in accordance with the
program’s contract.
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 specific to the psychiatric services
provided to the youth in the program. The program maintains an independent contractor
agreement with a licensed psychiatrist to oversee the psychiatric services and supervise the
treatment of youth who are prescribed psychotropic medications. Psychiatric services include
psychiatric evaluations, psychiatric consultation, medication management, and medical
supportive counseling provided to youth with a diagnosed Diagnostics and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth receiving psychotropic
medication in the program. The psychiatrist is scheduled to be on-site biweekly for four hours
and provides medication evaluation and ongoing monitoring of psychiatric medications. The
psychiatrist’s license was free and clear and expires on January 31, 2026. The psychiatrist is
available for emergency consultation twenty-four hours a day, seven days a week. A review of
documentation revealed the psychiatrist is a brief representative of the treatment team for each
youth receiving psychiatric services who are scheduled for treatment team review. A review of
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sign-in/out logs confirmed visits during the annual compliance review period were conducted as
required. The psychiatrist actively participated in, managed, and supervised psychotropic
medication services in the program. An interview with the psychiatrist confirmed they meet with
the designated mental health clinician authority (DMHCA) and the facility administrator to
discuss youth receiving psychiatric services once each month. An interview with the DMHCA
indicated they meet with the psychiatrist to discuss youth receiving psychiatric services
biweekly.
EVERGLADES YOUTH ACADEMY
A review of five youth records revealed two youth were applicable for entering the program on
psychotropic medication. The program had one additional youth admitted with psychotropic
medications since the last annual compliance review. All five youth received a diagnostic
interview within fourteen days of admission as it is the program’s practice to refer youth entering
the program for a psychiatric interview. The five records applicable for an Initial Diagnostic
Psychiatric Interview included the youth’s history, medical mental health and substance abuse
history, Mental Status Examination, and a DSM-5 diagnosis. Each documented diagnosis was
consistent with the youth’s treatment plan. Three of the five reviewed youth were prescribed
medications and an explanation of the need for psychotropic medication related to the youth’s
diagnosis and the targeted symptoms were listed. The interviews also listed potential side
effects, risks and benefits of taking medication, and frequency of the medication
monitoring/management. All three youth had an Initial Diagnostic Psychiatric Interview
documented on the Department’s Clinical Psychotropic Progress Note (CPPN) form. Each
CPPN form was clearly identified as an Initial Diagnostic Psychiatric Interview. Three youth had
an Initial Psychiatric Diagnostic Interview resulting in the prescription of psychotropic
medications or changes to the youth’s existing psychotropic medication regimen, where page
three of the CPPN was completed. Two of the three applicable youth receiving psychotropic
medication also received medication reviews by the psychiatrist, at a minimum, every thirty
days; while the third youth received one medication review fourteen days late due to having
been out of the program to attend court. Each psychiatric evaluation was documented on the
Department’s three-page CPPN form. All three applicable records documented each youth’s
identifying data, diagnosis, the targeted symptoms of each medication, an evaluation/description
of the effect of prescribed medication on target symptoms, the name of the prescribed
psychotropic medication, including the dosage and quantity of the medication, normal dosage
range, ordered dosage, the frequency and route of administration, and the reason for any
change in medication or dosage. A list of side effects for each of the three applicable youth
included a description of both positive and adverse responses to the medication, each youth’s
adherence to their medication regime, height, weight, blood pressure, most recent serum drug
levels or laboratory findings, whether telephone contact was made with the youth’s
parent/guardian to discuss medication, as well as the signature/date of the psychiatrist. All three
applicable youth records documented the nursing staff monitored youth for Tardive Dyskinesia
on a monthly basis, as indicated on the CPPN.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth records revealed one youth was applicable for entering the program on
psychotropic medication. The program had one additional youth admitted with psychotropic
medications since the last annual compliance review. Each youth received a diagnostic
interview within fourteen days of admission, and one additional youth was referred for an
evaluation after admission. The program’s practice is to refer all youth entering the program for
a psychiatric interview. The three records applicable for an Initial Diagnostic Psychiatric
Interview included the youth’s history, medical, mental health, and substance abuse history,
Mental Status Examination, and a DSM-5 diagnosis. Each documented diagnosis was
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consistent with the youth’s treatment plan. Two of the reviewed youth were prescribed
medications and an explanation of the need for psychotropic medication related to the youth’s
diagnosis and the targeted symptoms were listed. The interviews also listed potential side
effects, risks and benefits of taking medication, and frequency of the medication
monitoring/management. All three youth had an Initial Diagnostic Psychiatric Interview
documented on the Department’s CPPN form. Each CPPN form was clearly identified as an
Initial Diagnostic Psychiatric Interview. Two youth had an Initial Psychiatric Diagnostic Interview
resulting in the prescription of psychotropic medications or changes to the youth’s existing
psychotropic medication regimen, where page three of the CPPN was completed, regardless of
the format used to document the psychiatric interview. These two youth were also receiving
psychotropic medication and medication reviews. A review of documentation indicated the youth
were seen for a medication review by the psychiatrist at a minimum of every thirty days. Each
psychiatric evaluation was documented on all three pages of the Department’s CPPN form. A
review of five youth case records reflected two were applicable for psychotropic medication.
Each of the two youth records documented the identifying data and diagnosis. Both evaluations
listed the targeted symptoms of each medication, an evaluation and description of effect of
prescribed medication on target symptoms, prescribed psychotropic medication including the
name, dosage, and quantity of the medication, normal dosage range, ordered dosage,
frequency and route of administration, and the reasons for changes in medication and/or
dosage. A list of side effects for the two applicable youth listed the description of response to
medication, both positive and adverse experiences, the youth’s adherence to the medication
regime, height, weight, blood pressure, most recent serum drug levels or laboratory findings,
whether there was telephone contact with the youth’s parent/guardian to discuss medication, as
well as the signature/date of the psychiatrist. Only one youth was applicable for the psychiatrist
and the nursing staff monitoring for Tardive Dyskinesia on a monthly basis as indicated on the
CPPN, upon which monitoring was documented.
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 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 Florida
Administrative Code. The program maintains a written Suicide Prevention Plan to ensure
essential guidelines for the identification and assessment of the youth at risk of suicide, staff
trainings, suicide precautions, levels of supervision, referrals, communication, notifications,
documentation, immediate staff response, and a review process. The review process for suicide
attempts and mortality review included circumstances surrounding the event, the program’s
process relevant to the incident, all relevant training received by the involved staff, pertinent
medical and mental health services involving the victim, possible precipitating factors, and
recommendations for changes in policy, training, physical plant, medical or mental health
services, and/or operational procedures. The Suicide Prevention Plan was last reviewed and
approved by the facility administrator and the designated mental health clinician authority
(DMHCA) on June 7, 2023.
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3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
The program maintains a written Suicide Prevention Plan which outlines essential guidelines for
the identification, management, and assessment of potentially suicidal or at-risk youth. All newly
admitted youth are screened for suicide risk factors as part of the initial intake and admission
classification meeting process. 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, 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 (ASR). The program’s practice is to complete an ASR for every youth admitted into
the program. An interview with six staff indicated if a youth expresses suicidal thoughts, direct
care staff are responsible for notifying mental health, searching the youth and their room for
contraband, maintaining constant sight and sound monitoring, and to document supervision.
Interviewed staff were also able to identify the location of the program’s suicide response kits.
EVERGLADES YOUTH ACADEMY
A review of five youth records indicated each was determined to be an at-risk youth during the
admission screening. Each record contained a completed ASR, to include an ASR referral with
the date. Each ASR was completed on the Department’s ASR form and included the level of
supervision. Three of the five reviewed youth were placed on standard supervision. Each ASR
documented a conference with the program’s clinical staff and the facility administrator (FA).
Each ASR was completed by a licensed clinician or a non-licensed clinician and signed by the
licensed staff the same day. Two youth records were applicable for youth placement on
precautionary observation (PO); therefore, one additional record was reviewed for suicide
prevention services. All three applicable reviewed ASRs were completed by a licensed mental
health professional on the Department’s ASR form within twenty-four hours of
screening/concerns. Two of the three youth were initially placed on constant supervision, while
one youth was placed on secure one-to-one observation. The parent/guardian and the assigned
juvenile probation officer (JPO) were notified of the youth’s potential suicide risk in all three
instances. Each youth was maintained on suicide precautions and either one-to-one or constant
supervision until the Follow-Up ASR indicated suicide precautions could be discontinued.
Reviewed documentation validated a Follow-Up ASR was completed on the Department’s
Follow-Up ASR form for each youth prior to the youth being stepped down to close supervision
and subsequently to normal routine and standard supervision. Each youth was maintained on
close supervision until the designated mental health clinician authority (DMHCA) determined it
was no longer necessary. In each instance documentation supported a conference between the
licensed mental health professional and the FA was conducted before reducing the level of
supervision. The discontinuation of close supervision was documented by the DMHCA in
accordance with the program’s Suicide Prevention Plan and maintained in each youth’s record.
All required alerts were entered into the Department’s Juvenile Justice Information System
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(JJIS) and closed following the recommendation of the Follow-Up ASR. The logbook and ASRs
indicated the administration provided instruction related to the suicide risk assessment findings
and suicide precaution decisions for all three youth. Logbook entries also documented the
discontinuation of close supervision. While on PO, each of the youth were allowed to participate
in activities as deemed appropriate, and the youth were not restricted to their room. Video
footage could not be observed as no youth had been placed on PO in the previous thirty days.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth records indicated each was determined to be an at-risk youth during the
admission screening. Each record contained a completed ASR, to include an ASR referral with
the date. Each ASR was completed on the Department’s ASR form and included the level of
supervision. Each of the five reviewed youth were placed on standard supervision. Each ASR
documented a conference with the program’s clinical staff and the FA. Each ASR was
completed by a licensed clinician or a non-licensed clinician and signed by the licensed staff the
same day. The program’s practice is to complete an ASR for every youth admitted into the
program.
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 written Suicide Prevention Plan which defines essential guidelines for
the identification, management, and assessment of potentially suicidal or at-risk youth. The plan
outlines procedures to safely screen, refer, assess, monitor, and protect youth with an elevated
risk of suicide in the least restrictive means possible. Youth placed on suicide precautions are to
be maintained on one-to-one or constant supervision. The staff assigned to observe the youth
are required to provide the appropriate level of supervision and record observations of the
youth's behavior every thirty minutes, at a minimum.
EVERGLADES YOUTH ACADEMY
A total of five youth records were reviewed for Suicide Precaution Observation Logs and two
were applicable. Two youth records and one additional requested youth record were reviewed
for suicide prevention services. Each of the precautionary observation logs were documented
on the Department’s Suicide Precaution Observation Log form. Each of the completed
precautionary logs contained documentation of observations for the youth’s behavior. All three
youth had the appropriate level of supervision and observations of the youth’s behavior
documented in real time, at least every thirty-minutes or less. There were warning signs
observed, and notification to the facility administrator and mental health clinical staff was
documented on the Suicide Precaution Observation Logs. Each of the reviewed precautionary
observation logs contained shift supervisor review dates and signatures. Each reviewed
precautionary observation log included the mental health clinical staff review date and
signatures. Each of the precautionary observation logs had notation of designated safe housing
areas.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth records indicated none were applicable for being placed on suicide
precautions. At the time of the annual compliance review the program did not have any youth
applicable for suicide precautions. An interview with the statewide director revealed the program
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did not have any youth on suicide precautions since the last annual compliance review;
therefore, no observation logs were reviewed.
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 written Suicide Prevention Plan which details suicide prevention
training requirements. 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. Additionally, all staff with direct contact, on a day-to-day basis, with youth, must
participate in/attend at least one drill which includes the use of cardiopulmonary resuscitation
(CPR) annually. Staff are to be evaluated and if any deficiencies are noted a corrective action is
to take place immediately to ensure all protocols are followed as in policy. A review of five pre-
service and five in-service staff training records was completed for completion of suicide
prevention training, with no noted issues. Completed training included simulated suicide drills,
which were conducted at least quarterly on each shift. There was no indication of youth having
been utilized for simulated suicide drills. The reviewed mental health and medical drills since the
last annual compliance review confirmed the mock suicide drills were conducted for all staff who
come in contact with youth, including kitchen and maintenance staff, and occurred more
frequently than quarterly, on each of the program’s two shifts, as required. Reviewed
documentation validated drills demonstrated the use of life-saving measures including the use
of CPR and/or an automated external defibrillator (AED). The program documented a total of
thirty staff who participated in two drills or more over the previous twelve months, including
participation in at least one drill which involved the use of CPR annually. Staff not present during
quarterly suicide drills had the opportunity to review each drill scenario, in an effort to
understand the process and receive the necessary training to respond to an incident of a suicide
attempt or incident of serious self-inflicted injury in the program. The program had a total of four
suicide response kits, which included a knife-for-life, wire cutters, and needle nose pliers. The
kits were maintained in master control, the two sub controls, and in the medical clinic. Each of
the suicide response kits were co-located with the first-aid kits. An interview conducted with the
facility administrator indicated mental health drills are conducted three times a month.
Additionally, an interview was conducted with six staff revealed medical emergency and suicide
drills are conducted on each shift monthly and facilitated by a mental health staff. The knife-for-
life, wire cutters, and needle nose pliers are kept in master control, both sub controls, and
medical.
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 written Crisis Intervention Plan which details the requirements of the
notification and alert system, means of referrals, including youth self-referral, communication,
supervision, documentation, and review process. The program is to respond to youth in crisis in
the least restrictive means possible to protect the safety of the youth and others, while
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maintaining control and safety of the program. The program must be able to differentiate a youth
who has an acute emotional problem or serious psychological distress from one who requires
emergency services.
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 maintains a written Crisis Intervention Plan, which addresses mental health crisis
intervention services and Crisis Assessments. A Crisis Assessment is a detailed evaluation of a
youth demonstrating acute psychological distress 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 facility administrator (FA) or
designee is to be notified of the crisis and need for a Crisis Assessment. A Crisis Assessment is
to be utilized only when the youth’s crisis 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.
EVERGLADES YOUTH ACADEMY
The program’s designated mental health clinician authority (DMHCA) reported only one youth
required a Crisis Assessment since the last annual compliance review. The youth had a Crisis
Assessment administered due to a Prison Rape Elimination Act (PREA) allegation. The
completed assessment 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 the parent/guardian of follow-up treatment. The assessment was
completed by the licensed DMHCA. None of the reviewed youth were applicable for an increase
in supervision or an alert in the Department’s Juvenile Justice Information System. The program
has no youth applicable for a Follow-Up Crisis Assessment, as a precautionary measure. 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 (CCC) PREA incidents did not identify any additional youth requiring a
Crisis Assessment since the last annual compliance review.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth records indicated two youth were applicable for a Crisis Assessment;
therefore, one additional youth record was requested. All three assessments identified the date
the youth was determined to be in crisis, and the date of the Crisis Assessment. Each Crisis
Assessment was conducted immediately or within two hours for emergencies, or within twenty-
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four hours based on the needs of the youth. The Crisis Assessments included the reason for the
assessment, Mental Status Examination and interview, the determination of danger to self
and/or others including imminence and intent of behavior, clarity and lethality of behavior, initial
clinical impressions, supervision recommendations, treatment recommendations,
recommendations for follow-up or further evaluation, and a notification to parent/guardian. Each
Crisis Assessment was conducted by a LMHP, or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP. Each of the three youth were alleged to be
victim in a PREA incident, and a Mental Health and Substance Abuse Referral Summary was
submitted immediately for a Crisis Assessment. Each youth was offered ongoing mental health
treatment services. All three youth were determined to be appropriate for standard supervision
and did not require an alert.
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 Emergency Mental Health and Substance Use Services Plan.
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 outlined by the
program’s Emergency Care Plan, which was last revised and approved by the facility
administrator on January 3, 2023. The Emergency Mental Health and Substance Abuse
Services Plan included immediate staff response, notifications, communication, supervision,
authorization to transport for emergency mental health or substance abuse services, transport
for emergency mental health evaluation and treatment, transport for emergency substance
abuse assessment and treatment, 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 address the safety planning process
for each youth. The procedures establish a planning process designed to identify areas which
affect the youth and incorporate trauma responsive practices. The program is to conduct on-
going safety planning for each youth to identify stimuli which have both positive and negative
effects on the youth. The intervention and treatment team is to meet with each youth within
fourteen days of admission to develop a safety plan. An interview with six youth revealed each
youth provided input and this information was used to create their safety plan. Six interviewed
staff reported safety plans are accessible to staff and located in the clinical director’s office and
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the sub-controls on the east and west living units. Six interviewed staff reported youth safety
plans are reviewed before their shift and during admission and when a youth has a change in
behavior. Staff reported reviewing plans daily, weekly, monthly, and as needed. The interviewed
facility administrator reported youth safety plans are updated at a minimum of every thirty days.
EVERGLADES YOUTH ACADEMY
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 any
significant behavioral or mental health event. The five reviewed records were applicable for a
total of thirty-two reviews, which were completed at a minimum of every thirty days as required.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth records was conducted pertaining to the safety planning process for each
youth. Reviewed documentation revealed the youth’s safety plans included warning signs
identified by the youth or collateral contacts, parent(s)/guardian(s) indications a youth is
escalating in their behavior(s), youth’s baseline behavior(s) gathered from collateral contacts,
the parent/guardian, youth’s history, and evaluations, crisis recognition to include the youth and
program staff’s perception of verbal and non-verbal stimuli with both positive and negative
effects on the youth, jointly developed coping strategies to include people and healthy
environments as defined by the youth, the intervention strategies preferred by the youth, and
the debriefing process. A review of five youth records indicated the safety plans were developed
and updated as required. The safety plans were completed within fourteen days upon the
youth’s admission. Each plan was jointly prepared by the youth, parent(s)/guardian(s) or family
member, the program’s clinical staff, and behavioral specialist, if applicable. Each safety plan
incorporated any recommendations from previous or current clinical assessments or screening
instruments and incorporated trauma responsive practices. Each plan was reviewed and
updated as necessary at least every thirty days, and the plans were reviewed and updated as
necessary following any significant behavioral or mental health events identified by the youth’s
intervention and treatment team, with the documented dates. Documentation confirmed the
safety plans were reviewed by the staff who had contact with the youth, were maintained, and
located in the youth’s record under the clinical assessment tab, as well as in the clinical
director’s office.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program maintains a written policy and procedures for the provision of medical services to
youth. The program maintains a written contractual agreement for a licensed physician/medical
doctor (MD) to serve as the designated health authority (DHA). The program’s written policy and
procedures were reviewed and signed by the DHA on August 2, 2023. The DHA holds a clear
and active unrestricted license under Chapter 458 in the State of Florida with an expiration date
of January 31, 2026. A review of documentation indicated the Florida Department of Health had
no disciplinary cases/public complaints on record. The program does not utilize a designated
physician assistant or advanced practice registered nurse for clinical services. A review of sign-
in/out logs during the annual compliance review period confirmed the DHA was on-site at least
once a week, with a week defined as the seven-day period beginning on Sunday and ending on
Saturday. The DHA has specialty training and education in pediatrics, meets all requirements
for independent and unsupervised practice in the State of Florida, and is a member of the
American Board of Pediatrics. The DHA is responsible for the development, review, and
approval of all health-related procedures and protocols utilized in the program. The DHA has the
final clinical decision-making authority for the provision of healthcare and is clinically responsible
for the medical care of all youth. The program has a contract with a licensed MD for coverage in
place if the DHA is on vacation or has scheduled absences. Documentation confirmed the back-
up MD has equal licensure and is qualified to provide services. The back-up MD holds a clear
and active unrestricted license under Chapter 458 in the State of Florida with an expiration date
of January 31, 2025. The program’s health services administrator (HSA) reported the DHA was
on-site weekly, and the back-up MD services were not required. Documentation reflected the
DHA was on-site for a minimum of two and up to eight hours each week for the annual
compliance review period, as required. The DHA is responsible for communication with program
staff regarding youth medical needs and consultation twenty-four hours a day, seven days a
week for acute medical concerns, emergency care, and coordination of off-site care. The scope
of services included medical screening, assessment and evaluation, and on-going monitoring of
medication and chronic medical conditions. An interview with the DHA confirmed their role in the
coordination and implementation of health services at the program. The DHA reported
responsibilities include performing Comprehensive Physical Assessments (CPA), conducting
periodic evaluations, completion of all needed physician visits, follow-up visits, oversight of
medical policy and procedures, and provision of on-call services for the program. All clinical
services are provided on-site by the DHA. The DHA meets with the HSA or registered nurse one
time each week during on-site visits.
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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 maintains a written policy and procedures to address the orientation,
communication, and licensure/credentialing process for all healthcare providers. The program
must maintain daily clinical care by a licensed medical staff according to developed and
authorized protocols. Procedures require licensed nurses to practice in accordance with the
Florida Nurse Practice Act and the applicable Florida Board of Nursing Rules. The program
utilizes licensed nurses for on-site nursing coverage. The program has two full-time registered
nurses (RNs) and one licensed practical nurse (LPN). A review of the licensure credentials
confirmed a clear and active license in the State of Florida for all the nurses with expiration
dates of July 31, 2024 for the two RNs, and July 31, 2025 for the LPN. The program’s nursing
staff all hold current cardiopulmonary resuscitation (CPR) certifications. The programs contract
requires on-site licensed nursing coverage seven days a week for a total of one hundred twenty
hours. One full-time RN works three twelve-hour shifts a week with alternating weekends. The
LPN works three twelve hour shifts a week, alternating weekends with the RN, and the licensed
health services administrator works forty-hours a week and provides coverage when needed.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program maintains a written policy and procedures detailing requirements for all health-
related procedures and protocols. The program’s assigned designated health authority (DHA) is
to conduct a review of all health-related policies, procedures, and protocols at least annually.
Reviewed documentation confirmed the DHA signed all healthcare policies and procedures on
August 2, 2023, and the psychiatrist signed the applicable policies and procedures on June 7,
2023. The facility administrator (FA) signed all healthcare policies and procedures on August 2,
2023. Reviewed documentation indicated all nursing staff, including the health services
administrator, reviewed, signed, and dated a cover page indicating their review of the facility
operating procedures (FOPs), treatment protocols, and other procedures on August 10, August
23, August 27, and August 28, 2023. The program had each nurse sign and date any new or
revised policy to acknowledge their review of the individual policy changes. The DHA last
reviewed and signed all nursing protocols on August 2, 2023. Reviewed documentation
confirmed all newly hired healthcare personnel received a comprehensive clinical orientation to
the Department’s healthcare policies and procedures by a registered nurse.
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4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program maintains a written policy and procedures providing the parent/guardian the right
to provide or withhold consent to the healthcare provided to their children. The Authority for
Evaluation and Treatment (AET) form is to be signed by the parent/guardian who have legal
custody and the AET serves as informed consent for non-invasive medical procedures which
can be performed by healthcare staff or for minor ailments requiring over-the counter (OTC)
medication. The parent/guardian is to be notified of any significant changes in a youth’s
condition and/or when new medications are prescribed. A separate, specific consent for
treatment is required for the parent/guardian to provide consent for any invasive procedure. The
signed AET is valid until the youth leaves the custody of the Department and is required prior to
providing medical services, except for emergency care and routine medical/mental health intake
screenings. The program utilizes a separate form for all youth eighteen years of age or older to
give consent for release of specific information, including to whom the information may be
released or shared.
EVERGLADES YOUTH ACADEMY
A review of five youth Individual Healthcare Records (IHCRs) validated three youth records
contained a valid AET; one of which also had a signed eighteen-year-old consent form which
was completed after admission to the program and upon the youth reaching age eighteen. Two
youth were over eighteen years of age at the time of their admission, and both had signed
eighteen-year-old consent forms. The program had no applicable youth under the supervision of
the Department of Children and Families where parental/guardian rights had been terminated.
Each reviewed AET and/or eighteen-year-old consent form was filed in each youth’s IHCR in
the appropriate section. There were no original AETs reviewed, as all were marked as a copy.
Each AET or eighteen-year-old consent form was obtained prior to providing medical services.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth IHCRs was conducted. Four of five records included an original AET form
signed by the youth’s parent/guardian, and a Department representative. Each of the four
records were filed in the youth’s IHCR. One was not applicable due to the youth being over age
eighteen at the time of admission and the record included a signed eighteen-year-old consent
form. Two of the five reviewed records were applicable for youth who turned eighteen
subsequent to their admission to the program and each contained a signed eighteen-year-old
consent form. Each reviewed eighteen-year-old consent form was filed in the youth’s IHCR in
the appropriate section. There were no applicable youth in the care of the Department of
Children and Families (DCF).
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program maintains a written policy and procedures outlining requirements for
parental/guardian notification and written consent from the parent/guardian. The program is to
inform the parent/guardian of any significant changes in the youth’s condition and obtain
consent when new medications and/or treatment are prescribed. An interview with nursing staff,
indicated parental/guardian notifications are to be completed if there are any significant changes
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in the youth's condition and/or when new medications are prescribed. Verbal/telephone
attempts are to be made by the prescribing healthcare provider and the call is to be documented
in the progress notes of the Individual Healthcare Records (IHCRs). An interview with nursing
staff confirmed immunization records are obtained on the day of admission through Florida
Shots and are verified within thirty days by the clinical manager. The nurse reported the
Exemption of Immunization form is to be completed when a parent/guardian requests
exemption. Verbal/telephone contact or attempts to verbally contact the parent/guardian by the
prescribing healthcare provider are to be documented in the progress notes of the IHCR for
each encounter in which the medication regimen or medical condition changes.
EVERGLADES YOUTH ACADEMY
A review of five youth IHCRs was conducted. None of the five records were applicable for
requiring parental/guardian notification for over-the-counter (OTC) medications; therefore, three
additional applicable records were reviewed. Each of the applicable youth records contained
documentation of parental/guardian consent obtained for newly ordered medication. The three
reviewed youth records validated the program’s practice of documenting telephone call attempts
to the parent/guardian in the progress notes when new medication was ordered. A review of
three youth records confirmed subsequently written parental/guardian notices were sent
regardless of telephone notifications. One of the five reviewed youth records was for a youth
prescribed a psychotropic medication and the consent was documented on page three of the
Department’s Clinical Psychotropic Progress Note. No youth were in the care of the Department
of Children and Families (DCF). All five reviewed youth IHCRs reflected vaccinations were
verified within thirty days of the youth’s admission. Each record contained a copy of the youth’s
immunization record received from the Florida Shots website. One reviewed youth record was
applicable for a vaccination consented to utilizing the Department’s Parental Notification of
Health-Related Care form. No reviewed records were applicable for any religious exemptions.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth IHCRs found three of the youth had required parental/guardians
notifications for OTC medications beyond those covered by the Authority for Evaluation and
Treatment (AET). Two records were not applicable due to the youth being over the age of
eighteen. Two reviewed records were applicable for new medication being ordered and
documentation of attempts to contact the parent/guardian were included in the progress notes.
Each of the three applicable records confirmed written notifications were sent utilizing the
Department’s Parental Notification of Health Related Care form. Two of three reviewed records
confirmed youth were taking psychotropic medications and the records confirmed staff
witnessed all telephone call attempts and conversations for psychotropic medications. The
parent/guardian consent for psychotropic medications was documented on page three of the
CPPN in each applicable record. Both records confirmed parental/guardian verbal consent was
received for psychotropic medication whenever a new psychotropic medication was prescribed,
discontinued, or the dosage was significantly changed. No youth were applicable for being in
the care of DCF. Five youth IHCRs reflected vaccinations were verified within thirty days of the
youth’s admission. None of the five youth records were applicable for any religious exemptions.
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4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program maintains a written policy and procedures to ensure each youth receives a
screening for health concerns upon admission or, at a minimum, each time the physical custody
of the youth changes and they are returned or re-admitted to the program. An interview with
nursing staff indicated the medical department is notified by e-mail of the anticipated admission
date prior to the youth's arrival to the program. The nursing staff make every effort to have a
nurse on-site at the time of the youth’s arrival at to the program, to complete the Facility Entry
Physical Health Screening (FEPHS) form. In the event the FEPHS is completed by direct care
staff, it must be reviewed and signed by a licensed nurse, or higher, within twenty-four hours.
EVERGLADES YOUTH ACADEMY
A review of five Individual Healthcare Records (IHCRs) confirmed all youth received an
admission screening utilizing the Department’s FEPHS form. The five reviewed youth admission
screenings confirmed each was completed by a registered nurse (RN) or licensed practical
nurse (LPN) on the date of the youth’s admission to the program. There were no applicable
youth with a change in physical custody requiring a rescreening.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth IHCRs confirmed all contained an admission screening utilizing the
Department’s FEPHS form. Four IHCRs confirmed the admission screenings were completed
by a RN, and one was completed by a LPN on the date of the youth’s admission to the program.
No youth were applicable for a change in physical custody requiring a new FEPHS rescreening
form to be 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 maintains a written policy and procedures requiring all youth to be oriented to the
general process of healthcare service delivery at the program.
EVERGLADES YOUTH ACADEMY
A review of five youth Individual Healthcare Records (IHCRs) supported each youth received a
general healthcare orientation within twenty-four hours of admission to the program. Reviewed
documentation in each IHCR validated a health education packet was provided and all elements
outlined by the Department were discussed with each youth including access to medical care,
sick call, what constitutes an emergency and when to notify staff, the medication administration
process to include side effect monitoring, the right to refuse care and how it is documented,
what to do in the case of a sexual assault or attempted sexual assault, the non-disciplinary role
of the healthcare providers, and standard universal precautions. A signed and dated receipt of
healthcare orientation was maintained in all five reviewed records. In addition, the program’s
case managers addressed access to medical services upon each youth’s admission into the
program.
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EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth IHCRs confirmed each youth received a general healthcare orientation
within twenty-four hours of admission to the program. Reviewed documentation confirmed each
youth’s orientation included access to medical care, sick call, what constitutes an emergency
and when to notify staff, the medication administration process to include side effect monitoring,
the right to refuse care and how it is documented, what to do in the case of a sexual assault or
attempted sexual assault, the non-disciplinary role of the healthcare provider, and standard
universal precautions.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program maintains a written policy and procedures requiring the designated health authority
(DHA) to be notified of all youth admitted with chronic health conditions or when any youth is in
need of emergency care. An interview with the nursing staff confirmed the DHA is to be notified
when a youth is admitted to the program with a known or suspected chronic condition or
requires emergency treatment upon admission. The healthcare staff are to ensure all admitted
youth receive a preliminary screening including a review of medical history to assess medical
needs. The assessment is to be conducted within initial intake processes upon program
placement. Notification is to be completed by telephone and documented in the Individual
Healthcare Records (IHCRs).
EVERGLADES YOUTH ACADEMY
A review of five youth IHCRs reflected DHA notification was applicable for three youth. Each
record reflected telephonic notification was made to the DHA of the youth’s admission to the
program which was documented in the IHCR. None of the youth presented a condition requiring
an emergency response. Each of the three applicable records confirmed the youth was placed
on the Chronic Conditions Log of DHA Notification and placed on the Physicians Referral Log
for follow-up. An interview with the nursing staff confirmed the program’s practice.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Four of five reviewed youth IHCRs confirmed youth with known or suspected chronic conditions
were referred to the physician and one youth was not applicable for having a chronic condition.
Documentation confirmed notification to the DHA was completed and documented in the
chronological progress notes. None of the reviewed youth were identified as needing an
emergency response upon admission. Each reviewed IHCR confirmed the DHA was notified
within twelve hours of each youth’s admission but no later than noon on the day following
admission. One reviewed youth was taking psychotropic medication at the time of admission
and the psychiatrist was notified, while four youth were not applicable.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program maintains a written policy and procedures detailing the process for conducting or
reviewing each youth’s health-related history. The program utilizes and completes the
Department’s Health-Related History (HRH) form for all youth admitted into the program’s
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physical custody. An interview with the program’s nurse indicated the HRH is to be conducted or
reviewed by a nurse through an interview of the youth and then made available to the
designated health authority (DHA) prior to or at the time of the Comprehensive Physical
Assessment (CPA). The form may be updated at the discretion of the healthcare staff as the
youth’s history changes. It is the responsibility of the practitioner who conducts the CPA to
review the HRH and verify or clarify the history as documented on the HRH at the time the CPA
is conducted. If the screening is completed by a direct care staff, it must be reviewed within
twenty-four hours by the nurse. The interviewed nurse indicated the DHA is responsible for
reviewing the HRH form and completing the CPAs.
EVERGLADES YOUTH ACADEMY
A review of five Individual Healthcare Records (IHCRs) indicated a HRH form was completed by
a registered nurse (RN) within seven days of admission and prior to the Comprehensive
Physical Assessment (CPA), as evidenced by the signature and date. All five youth HRH forms
confirmed each was reviewed by the DHA and was maintained in the youth’s IHCR. In addition,
the DHA documented a review of the HRH on the completed CPA. The HRH was completed
before or at the same time as the CPA for each youth and reflected the most current admission.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth IHCRs confirmed each record contained a dated HRH form. Each youth’s
HRH form confirmed each was completed within seven calendar days of the youth’s admission.
Each reviewed HRH form was completed prior to the CPA as evidenced by signature and date
notating the DHA reviewed each HRH form.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program maintains a written policy and procedures requiring a Comprehensive Physical
Assessment (CPA) to be completed for all youth admitted to the program to determine the
health and well-being of the youth. An interview with the nursing staff indicated a current CPA is
an assessment which has been performed within one year for youth with a Medical Grade of
two through five and within two years for youth with Medical Grade of level one. All youth, who
have not received a Tuberculosis Skin Test (TST) within one year of admission to the program
shall receive a TST within seven days of admission.
EVERGLADES YOUTH ACADEMY
A review of five youth Individual Healthcare Records (IHCRs) indicated each youth’s physical
assessment was completed on the CPA form. All CPAs were completed by the designated
health authority (DHA) within seven days of the youth’s admission. Each youth record
documented all sections of the CPA were completed in full utilizing “O” or “X” markings and the
Medical Grade was documented. Any portion of the examination refused by the youth was
noted appropriately on the CPA, and all refusals were included on the CPA with the youth’s
signature. Each Problem List was updated, as required. A review of five youth’s IHCRs showed
each youth had at least one verified TST documented on the CPA within the last year to
determine exposure to Tuberculosis (TB). Documentation confirmed nursing staff administered
a TST on the day of admission for each youth which was documented on the Department’s
Infectious and Communicable Disease (ICD) form. A review of five youth records indicated no
youth required further evaluation prior to entering the general population.
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EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth IHCRs confirmed each youth’s physical assessment was completed on
the CPA form. Each youth had a new CPA completed within seven calendar days of admission
by the DHA. Five of the reviewed CPAs documented the Medical Grade for each youth and no
youth had any missing/incomplete elements not documented. A review of five youth IHCRs
indicated no youth had changes in the youth’s medical condition. Each reviewed IHCR form
confirmed part of the exam was refused by the youth. Each youth signed a refusal form which
reflected the refused portion on the CPA exam. Each youth’s Department’s Problem List was
updated, as required. Each reviewed CPA confirmed there was at least one verified TST
documented in the IHCR within the last year and results of the TST were documented on the
CPA and the ICD form.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program maintains a written policy and procedures ensuring all youth are evaluated and
treated, if necessary, for sexually transmitted infections (STIs). All sexually active youth are to
be clinically screened and evaluated for STIs. After the screening, the youth is to be referred to
the designated health authority (DHA) to determine if further testing is indicated. The results of
the STI are to be noted on the Department’s Infectious and Communicable Disease (ICD) form
and the lab results must be filed in the youth’s Individual Healthcare Record (IHCR). The
program maintains a written policy and procedures requiring all youth at risk for human
immunodeficiency virus (HIV) infection to be offered counseling, testing, referral for medical
treatment as indicated, education, and prevention counseling. During the healthcare admission
process, a HIV risk assessment is to be completed. The assessment is signed by the youth and
the nurse conducting the assessment. The youth are to be presented with the Department’s HIV
Antibody Youth Consent form, which allows the youth to consent or refuse a HIV test in writing.
An interview with six youth was conducted and each reported being able to request a HIV test.
An interview with the program’s nurse indicated STI screenings, evaluations, referrals, and
testing are conducted if further evaluation is needed. The nurse stated all sexually active youth
are to be clinically screened and evaluated for STIs and, if further evaluation is needed, the
youth is to be referred to the DHA for evaluation and testing as recommended.
EVERGLADES YOUTH ACADEMY
A review of five IHCRs indicated all youth received a clinical screening and evaluation for STIs.
Each of the five youth were referred for further testing based on the results of their STI
screening. There were no applicable youth out of the Department’s custody for thirty days or
more; therefore, none required rescreening. A review of five youth IHCRs validated each youth
was provided the opportunity to receive counseling, testing, and treatment for HIV. Two of the
five youth consented to a HIV test and documentation of consent from the youth was obtained.
Reviewed IHCRs validated when each applicable youth received pre-counseling, testing, and
post-counseling. Counseling was provided by the DHA and documented on each youth’s Health
Education Record form. Each youth’s results were placed in a sealed envelope marked
“Confidential” with the youth’s name and test date documented on the outside of the envelope.
The outside of each envelope was stamped with the DHA’s information to confirm review of the
test results.
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EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
A review of five youth IHCRs confirmed each youth was clinically screened and evaluated for
STIs. Each youth required further evaluation and was referred to the DHA. Reviewed
documentation confirmed each referral was documented on the STI form and testing was
ordered and performed. Reviewed documentation confirmed each test, screening results,
clinical evaluations, and diagnosis were documented on the ICD form and filed in the lab section
of the IHCR. There were no applicable youth who were out of the Department’s physical
custody; therefore, there were no rescreenings required. All five reviewed youth IHCRs
confirmed each youth was offered testing and all declined consent to an HIV test.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program maintains a written policy and procedures to address sick call requests. The
program conducts sick call seven days a week for a healthcare professional to respond to a
youth’s medical illness or injury of a non-emergent nature. The shift supervisors and unit
managers are trained in the sick call procedures and are to review sick call requests in the
absence of the healthcare professionals. The program conducts sick call at 9:30 a.m. and 2:15
p.m. on weekdays and 7:30 a.m. and 4:30 p.m. on weekends. The sick call hours are posted in
the sub-control window and are observable by the youth in the youth living units. The sick call
hours were also observed to be posted outside the medical clinic door. Sick call forms were
observed in each living unit and sub-control and were accessible to youth. A locked sick call box
was observed outside of the program’s two sub-controls. Youth who require a sick call may
inform staff of their complaint and staff are to provide a sick call form to the youth. Observations
of the daily posted schedule in comparison to the nurse’s interview validated sick call is
conducted daily in accordance with the program’s contract. An interview with six staff indicated
medical staff review sick call requests. Additionally, one staff indicated shift supervisors also
respond to sick call requests. In an interview with six youth, four reported they can see a nurse
within one day of submitting a sick call request and two indicated they are seen immediately. An
interview with nursing staff validated the program’s sick call process. Six staff were interviewed
and stated the program's nurse responds to and conducts sick calls. Additionally, two staff
stated medical staff responds or conducts sick calls. An interview with the nursing staff indicated
all youth are able to make sick call requests and have their complaints treated appropriately
through the sick call system. Sick call care, including dental, is to be available to all youth at
least once each day, seven days a week. Sick call care is to be provided by licensed healthcare
professionals, pursuant to their scope of practice and according to protocols approved by the
designated health authority (DHA). When a licensed healthcare professional is not on-site, the
shift supervisor is to review all sick call requests within two hours after the request is submitted.
Any complaint of severe pain, including dental pain, is to be treated as an emergency with
immediate referral to the program’s healthcare staff or DHA. Emergency dental care services, to
include complaints of severe pain, shall be provided by a licensed dentist. At the time of the
annual compliance review, there were no sick call requests; therefore, sick call observations
were not completed.
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EVERGLADES YOUTH ACADEMY
A review of five youth Individual Healthcare Records (IHCRs) revealed three youth were
applicable for having completed a Sick Call Request form at least once during their stay at the
program. There were no applicable youth who presented a similar sick call complaint three or
more times within a two-week period, and/or were in restricted housing. Reviewed
documentation supported the registered nurse (RN) documented the treatment and/or services
provided to the youth during each sick call event on Sick Call Request forms. Each Sick Call
Request form was filed in the youth’s IHCR in reverse chronological order and documented in
accordance with Florida Administrative Code. Each sick call was documented on the Sick Call
Index and the Sick Call Referral Log. An observation of the medical clinic confirmed the
program had an examination room and examination table to perform sick calls and maintain the
youth’s privacy.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Three of five reviewed IHCRs showed the youth completed at least one Sick Call Request form
while at the program and two had not. Each of the three applicable records documented none of
the youth presented with similar sick call complaint three or more times within a two-week
period. Each reviewed youth record confirmed the Sick Call Request form was completed by a
nurse and filed in the youth’s IHCR in reverse chronological order. Each sick call form and
related nursing progress notes were documented to include vital signs, treatment, education
and follow-up plans in accordance with Florida Administrative Code. All three reviewed youth
IHCRs confirmed each youth’s sick call was documented on the Sick Call Index and the Sick
Call Referral Log. Each Sick Call Request form in the IHCRs corresponded with the dates listed
on the Sick Call Index and the Sick Call Referral Log.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program maintains a written policy and procedures requiring a written plan for the provision
of twenty-four-hour emergency medical, mental health, and dental care to youth, as they may be
needed in response to unexpected illnesses, accidents, or conditions requiring immediate
attention or an immediate professional assessment to determine the severity. The program
utilizes an Episodic Care Log to document episodic care and first-aid treatment. The log
documents the date and time of the treatment, nature of the complaint, person rendering aid,
treatment, and whether the youth was recommended for off-site care. A review of the program’s
episodic emergency care procedures stipulated twenty-four-hour emergency care is to be
provided to each youth. All staff with youth contact are to be trained in sick call complaints and
emergency complaints. The program has a total of eight first-aid kits which are located in
medical, east sub-control, west sub-control, master control, the kitchen, the co-located
vocational program’s workshop, and the two transport vehicles. Three first-aid kits were
observed and checked for designated health authority approved contents, and each contained
the required items. The nursing staff conduct a monthly review of the first-aid kits and items are
replenished upon use and/or expiration date and documented on the program’s First-Aid Kits
Check List form. A review of the check list forms verified this practice. The program maintains
two automated external defibrillators (AEDs) located in master control and the medical office.
Each AED is equipped with automated audible and written instructions. The nurse checks each
AED monthly to ensure the devices are operable. A review of the AED check log for the
previous twelve months validated the program’s practice. During the week of the annual
compliance review, each AED was self-tested in front of the annual compliance review team to
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ensure each was operational. The expiration date of the AED batteries for medical is March
2024, and August 2, 2027, for master control. The last date the AED batteries were changed for
medical was April 13, 2020, and August 2, 2023, for master control. The expiration date of the
AED pads for medical and master control is June 27, 2025, and November 17, 2025. The last
date the AED pads were changed for medical and master control was June 30, 2023. The
program conducts emergency medical drills monthly on each shift and emergency drills
including cardiopulmonary resuscitation (CPR)/AED are conducted quarterly on each shift. A
review of emergency drills since the last annual compliance review indicated both announced
and unannounced drills were conducted at least quarterly and on each shift, as contractually
required. The program did not have any episodic care events during the annual compliance
review week; therefore, an episodic care event could not be observed. An informal interview
with the nursing staff indicated the program is equipped with NARCAN® and all staff, including
direct care staff, are trained in its administration. Five pre-service and five in-service staff
training records confirmed staff received episodic, emergency care, CPR, AED, and first-aid
training. The program trains all supervisory staff in the use of the epinephrine auto-injector. A
review of the licensed healthcare staff records verified each healthcare staff held a current
certification in CPR, AED, and first-aid. The program maintained a list of emergency numbers
accessible to staff and inaccessible to youth. An interview with nursing staff confirmed the
program’s process for completing and documenting on-site episodic care and emergencies. In
addition, nursing staff indicated the program tracks all off-site episodic and/or emergency care in
the logbook and the medical alert log. The nurse indicated announced and unannounced
emergency/medical drills are conducted on each shift on a monthly basis, and the nursing staff
follow a drill calendar and plan drills accordingly. The drill calendar has various drill scenarios
which incorporate the demonstration of CPR at least quarterly throughout the year. Five of six
interviewed staff stated they are personally allowed to call 9-1-1 if a youth has a medical
emergency and one stated, if on the floor, they can’t call 9-1-1 because there’s no access to a
telephone, and they would need to call a supervisor. Six youth were interviewed and stated they
can see a dentist and doctor as needed. Interviewed nursing staff stated first-aid kits including
kits for transportation vehicles, are maintained in the medical department, east sub-control, west
sub-control, master control, the vocational program’s workshop, and one for each of the
program’s two transport vehicles.
EVERGLADES YOUTH ACADEMY
A review of five Individual Healthcare Records (IHCRs) indicated each youth required on-site
first-aid/episodic care. Each on-site care event was provided by a registered nurse (RN) and
documented in problem-oriented charting. Each of the reviewed IHCRs documented problem-
oriented elements which were used to capture pertinent information pertaining to the nature of
the youth’s ailment including identification of the subjective, objective, assessment, and plan
(SOAP) elements to address the complaint for each incident.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Two of five reviewed youth IHCRs showed the youth required on-site first-aid or episodic care
conducted by nursing staff and three were not applicable. One additional applicable youth IHCR
was requested. Each applicable IHCR confirmed the on-site care provided by licensed
healthcare staff was documented in a problem-oriented narrative which identified SOAP
charting.
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4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site healthcare provider (emergent and non-emergent), and document such services, as
required by the Department.
The program maintains a written policy and procedures requiring provision of timely referral for
off-site healthcare. An interview with the program’s nurse indicated youth in need of emergency
care are transported off-site and medical staff document the transport in the medical off-site
care log and in the youth’s Individual Healthcare Record (IHCR). Healthcare staff also notify the
program’s facility administrator (FA), assistant facility administrator (AFA), and master control
for the information to be documented in the logbook. Nursing staff document and track all off-
site appointments and/or referrals in the youth’s chart and nursing tracking calendar. The
designated health authority (DHA) also follows up on off-site referrals and discharge information
during their next on-site visit. An interview with the program’s nurse indicated youth who are
transported off-site for first-aid or emergency care is documented in the off-site care log,
reported to the FA and AFA and documented by master control in the program’s logbook.
EVERGLADES YOUTH ACADEMY
A review of five youth IHCRs found three youth were applicable for off-site care. Documentation
confirmed the DHA was notified of each off-site medical event. The program documented the
off-site care event on the Episodic Care Log for each youth. One applicable record contained
documentation of the parental/guardian notification. The other two applicable youth were over
the age of eighteen and did not require parental/guardian notification. The DHA documented a
review of the off-site care findings, instructions, and information. Each reviewed IHCR contained
a Summary of Off-site Care form, discharge documentation, and instructions. Each youth
required additional referrals for follow-up testing and/or appointments. Documentation validated
the referrals were made for the youth and entered on the Sick Call/Referral Logs for tracking,
and follow-up appointments were conducted, as recommended.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Three of five reviewed youth IHCRs confirmed youth were applicable for off-site care and the
Summary of Off-Site Care Consultation Report form was utilized and filed in the IHCR. Two
youth were not applicable. Two of three provided notification to the parent/guardian and one
was not applicable due to the youth being eighteen years of age. Each reviewed discharge and
Summary of Off-site Care form was filed in the IHCR. Documentation confirmed the DHA
reviewed and signed all off-site care findings, instructions, and information for each youth. Two
of the three applicable youth required follow-up testing, referrals and/or appointments, and one
did not. Documentation confirmed each referral was tracked and the youth received appropriate,
timely follow-up care as 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 maintains a written policy and procedures to require youth identified with chronic
conditions to receive regularly scheduled evaluations and necessary follow-up care. An
interview with the program’s nursing staff indicated youth with chronic conditions are
documented in the daily alert log and all appointments and periodic evaluations are tracked by
the clinical manager. An interview with the designated health authority (DHA) confirmed periodic
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evaluation results are completed every ninety-days, or earlier, and the medical department has
a log with the list of youth who are listed for periodic evaluations. Additionally, the DHA indicates
the medical staff maintain a tracking log with the list of youth requiring periodic evaluations and
youth requiring follow-up care. An interview with the program’s facility administrator (FA)
indicated healthcare staff and administration meet daily during management and admission
classification meetings to discuss important youth medical issues. The interviewed nurse
indicated the clinical manager schedules and tracks periodic evaluations as determined by the
DHA and documented on the program’s daily alert log.
EVERGLADES YOUTH ACADEMY
A review of five youth Individual Healthcare Records (IHCRs) found three youth were applicable
for having been identified as having a chronic condition on the Facility Entry Physical Health
Screening (FEPHS) form upon admission to the program. None of the five reviewed records
were applicable for a communicable disease. Three of the reviewed youth records confirmed
youth were taking prescribed medication on an on-going basis. All three were classified with a
Medical Grade between two and four and were placed on a chronic illness list. Each youth
received periodic evaluations at least every ninety days. The program maintains a youth roster
and tracking log of youth requiring periodic evaluations identifying the youth’s name, date of
admission, whether youth was admitted with prescribed medication, chronic condition, date of
last visit, and the date of the next scheduled visit. Reviewed records reflected each youth
received periodic evaluations, as required. None of the youth were applicable for taking anti-
tuberculosis medication. Reviewed documentation found one youth was applicable for off-site
care and a Summary of Off-Site Care form was filed in the youth’s IHCR chronological progress
notes. Documentation confirmed the DHA documented a review and follow-up of the off-site
care findings, instructions, and information. There was no indication of lapses in care or missed
periodic evaluations. Reviewed documentation supported the Department’s Problem List was
updated in each instance, as required.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Five reviewed youth IHCRs confirmed no youth were identified on the FEPHS form with a
current chronic condition upon admission to the program. None of the five reviewed youth were
applicable for a communicable disease. All five youth were taking prescribed medication on an
ongoing basis. Four of five reviewed youth records indicated the youth was identified with a
chronic health condition subsequent to admission, each youth was classified with a Medical
Grade between two and four and placed on the chronic illness list. Each youth received a
periodic evaluation at least every ninety-days and progress notes were reviewed for
documentation of each completed periodic evaluation. There were no applicable youth taking
anti-tuberculosis medication. Each periodic evaluation was conducted prior to renewing a
prescription medication which expired. One youth had an evaluation conducted off-site which
was documented on the Summary of Off-Site Care form and filed in the IHCR chronological
progress notes. The DHA followed-up with the applicable youth after the off-site care and the
DHA signed off on the documents. Reviewed documentation supported the Department’s
Problem List was updated, as required for all four youth.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program maintains a written policy and procedures for medication management to ensure
all medication and pharmaceutical products are procured, dispensed, administered, and stored
safely. The program has a policy and procedures ensuring the standard Department Medication
Administration Record (MAR) will be utilized for each youth receiving either prescription
medications on a routine basis or over-the-counter (OTC) medication. When a youth arrives to
the program with medication or an order/prescription for medication, the healthcare staff will
conduct a preliminary assessment and an interview to determine the medication is verified and
documented. Nursing staff complete the Facility Entry Physical Health Screening (FEPHS) to
determine medical needs. The signed Authority for Evaluation and Treatment (AET) serves as
the authority to continue the present medication and administer the medication, as ordered. An
interview with nursing staff confirmed the program’s process and indicated when youth are
admitted to the program and arrive with prescribed medications, the clinical manager/registered
nurse (RN) will determine and verify the medication regimen for the youth. In addition, the RN
completes the admission and the medication verification process with the youth’s medical
records, physician/pharmacist, and the youth’s parent/guardian. The program does not have
any standing or pro re nata (PRN) orders for psychotropic medications. Observations of the
medication cart found it was clean and very well organized with medications separated. OTC
medications are stored in the medical clinic accessible to trained non-healthcare staff to
dispense in the absence of licensed medical staff. The program had three controlled
medications on-site during the week of the annual compliance review. Reviewed documentation
validated shift-to shift perpetual inventories of controlled medications are conducted by the
nursing staff. The program maintains one refrigerator in the medical clinic for the exclusive
storage of medication. There was no medication on-site which required refrigeration during the
week of the annual compliance review. Observations of the program’s medication pass process
were conducted. Four youth were observed, and each youth was escorted by the assistant
facility administrator (AFA). The nurse had the medication cart stored inside the medication
pass room and each youth approached the nurse at the window individually. The RN requested
the youth’s name, the name of the youth’s medication, any allergies/alerts, and if the medication
had any side effects. The RN dispensed the medication in front of the youth and administered
the medication, and the Six Rights of Medication Administration were verified for each youth.
The nurse pulled the medication from the secured medication cart and checked it against the
MAR. The medication was administered, the MAR was updated accordingly, and the staff
initialed the MAR indicating delivery of the medication. The program contracts with a licensed
vendor and a State of Florida licensed consultant pharmacist. The consultant pharmacist
maintains a clear and active license in the State of Florida with an expiration date of December
31, 2024. Observations and reviewed documentation confirmed the program utilizes a local
pharmacy and the consultant pharmacist is on-site monthly to conduct quality assurance
reviews. The disposal and destruction of all medication is conducted by two RNs monthly or as
needed with the consultation of the pharmacist which is documented on the Destroyed
Medication Log. An interview with six youth was conducted and five indicated the nursing staff
and/or doctor provide youth with their medication. One youth indicated they do not take any
medication. An interview with six staff was conducted and each indicated the nurse dispenses
medications. One staff stated the doctor and/or supervisor are also able to dispense medication.
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EVERGLADES YOUTH ACADEMY
A review of five youth Individual Healthcare Records (IHCRs) showed there were no applicable
youth taking prescribed medication upon admission. Each of the five youth had medication
prescribed after admission. Each medication had a valid order and received the medications
pursuant to a current prescription. Each of the five youth records confirmed the DHA placed an
order on the Practitioner Order form when current medications were continued, discontinued,
changed, or new ones were ordered. Reviewed documentation confirmed medication
administration was documented on the MAR which included the youth’s name, the Department
identification number (DJJID), date of birth, allergies, precautions, Medical Grade, medical
alerts, youth’s current picture, start and stop dates, and monitored side effects. A review of
MARs indicated the youth received the medication as ordered and both staff and youth initialed
the MAR after the administration of the medication. There were no lapses or errors noted on the
MARs. Three youth records contained a signed refusal of medication, and the MARs clearly
documented all refusals. None of the youth required parenteral medications. Four of the five
youth records confirmed nursing staff documented side effect monitoring daily at each
administration meeting. One record was not applicable as the youth had not used the pro re
nata (PRN) asthma inhaler. All applicable youth records confirmed the Six Rights of Medication
Delivery/Administration were maintained for each youth. One youth was applicable for currently
prescribed psychotropic medication. Documentation showed the youth received an Initial
Diagnostic Psychiatric Interview within fourteen days of admission and the youth’s IHCR
contained the medication monitoring review, completed every thirty days as required.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
Five youth IHCRs were reviewed and one was applicable for a youth taking prescribed
medication upon admission. The youth was applicable for medication management and nursing
admission notes documented the youth’s current medication and notification made to the
designated health authority (DHA) and psychiatrist. The youth’s IHCR confirmed the licensed
nurse obtained an order from the DHA and/or psychiatrist to resume the applicable medication
and consent was documented in the youth’s IHCR. The youth’s IHCR confirmed the medication
had a current, valid order and was administered pursuant to a current prescription. All five
reviewed youth records were applicable for the DHA placing an order on the Practitioner Order
form for a new medication or, for current medications, the continuation, discontinuation, or
change to a current medication. Two of five youth records were applicable for OTC medications
not listed on the AET form. All five reviewed youth records confirmed the standard Department
MAR was used to document all medication and treatment. The MAR clearly indicated
medication start and stop dates. A review of each MAR documented the staff initialed each
administered medication entry. Each youth record confirmed nursing staff documented side
effect monitoring daily at each administration. There were no undocumented explanations for a
lapse or errors noted on the MARs and no instances of refused medication. Each MAR
contained the youth’s name, DJJID, date of birth, youth allergies, precautions, Medical Grade,
medical alerts, youth’s current picture, and youth’s initials when provided medication. One of the
five reviewed youth required parenteral medication and the medication was administered by a
licensed healthcare staff. The IHCR for the one youth prescribed psychotropic medication at the
time of admission into the program, documented the psychiatrist was notified upon admission
and conducted an Initial Diagnostic Psychiatric Interview within fourteen days.
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4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program maintains a written policy and procedures requiring medical equipment classified
as medications/sharps to be secured and inventoried using a routine perpetual inventory. All
medications were securely stored in the medical clinic, which is inaccessible to youth.
Documentation of each individual dosage of medication administered to youth is maintained on
the Medication Administration Record (MAR) to demonstrate the distribution of medications. The
program maintains an inventory of all sharps and medical equipment classified as sharps to
include syringes, scissors, needles, and suture removal kits are secured and inventoried
utilizing a routine perpetual inventory with a descending count as each sharp is utilized and
disposed. A review of three perpetual inventory logs found sharps inventory counts for nail
clippers, staple removers, and tweezers were confirmed to be accurate. A locked medication
cart is located in the medical clinic and stores oral prescription and over-the-counter (OTC)
medications prescribed for youth. Three OTC medications were inventoried and were confirmed
to be accurate. A review of the daily inventory of all prescription and OTC medications matched
the counts. A review of the weekly counts for all opened OTC medications and perpetual and
weekly inventory counts for the previous twelve months validated inventory counts were
accurate. A review of the OTC inventories since the last annual compliance review indicated all
were counted on a weekly basis, as well as having a perpetual count. All storage areas were
found to be clean, organized, and inaccessible to youth. Medication in the cart is separated by
each youth’s name. A second locked medication box is in the medication cart and is designed to
store controlled medication. The program did not have any narcotics at the time of the annual
compliance review week. The program had three controlled medications on-site during the
annual compliance review week. A review of the controlled medications was conducted, and
reviewed documentation confirmed the counts for the controlled medications were accurate.
The program has five shift supervisors who were trained by the clinical manager/registered
nurse (RN) to assist youth with self-administration of OTC medication. The nursing staff send all
non-controlled medications back to the local pharmacy for credit. The program disposes of
controlled medication through the utilization of a commercial ready-to-use chemical digestion
solution which is conducted jointly by the RN and consultant pharmacist. The program maintains
one refrigerator located inside of the medical clinic exclusively for the storage of medication and
medical supplies requiring refrigeration. The program did not have any medication requiring
refrigeration and a review of the temperature check log confirmed the nursing staff conduct daily
temperature checks for the refrigerator. In an interview with the clinical manager, it was reported
inventories are counted weekly and perpetually by the nursing staff. The inventories are
conducted with nursing staff on each shift, and medications are counted perpetually and weekly.
All medications are stored in the clinic and in the locked medication administration room. All
controlled substances are kept in a separate lock box in the medication cart. A review of five
staff training records indicated each staff was trained in the delivery and oversight of medication
self-administration by a registered nurse (RN).
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Office of Accountability and Program Support Page 71 of 91 (Revised September 2022)
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program maintains a written policy and procedures ensuring there is an approved plan for
infection control and exposure control to ensure staff, youth, and visitors are not exposed to
infectious and communicable diseases. The program’s Exposure Control Plan/Infection Control
Plan includes prevention, containment, treatment, and reporting requirements related to
infectious diseases, as outlined in the guidelines and recommendations of the Occupational
Safety and Health Administration (OSHA) federal regulations and the Centers for Disease
Control and Prevention (CDC) guidelines. The plan included common infectious diseases of
childhood, self-limiting, episodic contagious illnesses, viral or bacterial infectious diseases,
tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus (HIV), infectious diseases
caused by blood-borne pathogens, 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, bioterrorist agents, and
chemical exposures. The plan was reviewed and approved by the designated health authority
(DHA) and facility administrator (FA) on August 2, 2023. The health services administrator
(HSA) reviewed the plan on August 10, 2023. The infection control training included hand-
washing techniques, universal/standard precautions, prevention/transmission of communicable
diseases, vaccinations, and the CDC guidelines for infection control. The program ensures
Hepatitis B immunizations are made available for staff and staff have access to protective
equipment. Reviewed documentation confirmed the Exposure Control Plan was written in
accordance with OSHA standards and is available to all staff. The plan was reviewed and
signed annually by the administration of the program and/or designees. The Exposure Control
Plan is available to all staff for review. The program did not have any instances during the
annual compliance review period in which ten percent of the total population of youth or staff
had to be quarantined or hospitalized. The program has a comprehensive process in place for
needle stick post-exposure evaluation and records shall be maintained confidentially for a ten-
year period. The FA has a file maintained for youth and staff who have experienced a
facility/occupational exposure, which are maintained confidentially for a ten-year period. The
nurse interview indicated the Exposure Control/Infection Control Plan is available for review in
the program’s operating procedures, as well as a copy maintained in the clinic. The HSA/clinical
manager conducts infection control/exposure control training for the staff. Each youth receives
training on infection control during the admission process. The FA interview indicated the
Exposure Control/Infection Control Plan is located in the administration conference room and in
the medical office and staff review them on a monthly basis. A review of five youth Individual
Healthcare Records (IHCRs) indicated each youth received infection and exposure control
training within twenty-four hours of admission as part of their orientation to the program’s
healthcare services. A review of five staff training records showed each staff had training on the
infection control plan, bloodborne pathogens, and exposure control.
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Office of Accountability and Program Support Page 72 of 91 (Revised September 2022)
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.
The program is an all-male program; therefore, this indicator is rated non-applicable.
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Office of Accountability and Program Support Page 73 of 91 (Revised September 2022)
Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a written policy and procedures requiring all program staff to promote
safety and security by maintaining active supervision of youth to include interacting positively
with youth, engaging youth in a full schedule of constructive activities, closely observing
behavior of youth, and consistently applying the program’s behavior management system
(BMS). The program’s contract requires staff-to-youth ratios to be one-to-eight during awake
hours and one-to-twelve during sleep hours. The ratio for off-site activities, transportation, and
visitation is one staff to five youth. The program staff are required to account for the
whereabouts of youth under their supervision and ensure staff-to-youth ratios are in compliance
with contract requirements. A program tour verified the daily youth activity schedule was posted
throughout the program and is designed to keep youth engaged in a full schedule of activities.
Observations of staff supervision for four days during the week of the annual compliance review
included classroom activities, line movement, school breaks, youth head counts, mental health
groups, vocational activities, youth searches, and outdoor/indoor recreation activities. In
addition, youth were observed working in the kitchen, cleaning bins with a hose, and using tools
while participating in projects under the co-located vocational construction program. The
observations validated the required staff-to youth ratios were maintained. A tour of the program
verified the facility and living modules were clean, well maintained, and graffiti free. A perimeter
check was conducted, and fencing appeared to be in good repair. Staff and youth were
appropriately attired. During outdoor activities and/or movement, observations verified staff were
strategically positioned to ensure proper supervision of youth and to ensure there were no
physical obstructions of their view of the youth. Observations of interactions between program
staff and youth reflected the interactions were positive and consistent with the program’s BMS.
Observations of video surveillance footage of youth during sleep hours was conducted. The
observations verified the overnight youth to staff ratio was in compliance, staff were awake and
alert, and staff conducted ten-minute checks as required. Six interviewed staff explained if there
were to be a discrepancy in the youth count, all movement would stop until an accurate count
was completed and all youth were accounted for.
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 to address implementation and training
related to the program’s behavioral management system (BMS) which has not changed since
the last annual compliance review. The program utilizes the iChoose System BMS which is a
coordinated system of promoting, monitoring, recognizing, and rewarding a youth’s progress. It
is a program of incentives and consequences which promotes individualized skill building,
appropriate behavior, and accountability. Staff utilize point cards to monitor how well the youth
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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 four levels of the BMS include beginner,
intermediate, veteran, and expert levels. Youth learn about the BMS during the orientation
process. Each youth is provided a program handbook which describes the BMS. A review of the
youth handbook indicated the BMS is designed to promote safety, respect, and fairness. The
BMS promotes and protects youth rights and has opportunities for positive reinforcement. The
BMS includes positive and negative consequences and uses constructive disciplinary actions.
The BMS promotes socially acceptable means for youth to meet their needs, includes a process
for explaining to youth the reasons sanctions are imposed, youth have the opportunity to explain
their behavior, there are opportunities for staff and youth to discuss the impact of behavior to
others, includes reasonable reparations for harm caused by others, there are discussions of
alternative behaviors, promotes positive dialogue, and minimizes separation of youth from the
population. A review of the BMS confirmed it is not used solely to increase a youth’s length of
stay, deny basic rights or services, promote the use of group punishment, allow youth to punish
other youth, or include disciplinary confinement. In addition, the parent/guardian handbook
includes a description of the BMS. A review of five staff training records confirmed staff were
trained on the BMS by the staff development coordinator. Additionally, education staff are
program staff and receive BMS training during new hire orientation. A review of three position
descriptions confirmed the job functions include the implementation of the BMS. A review of ten
youth case management records indicated each youth participated in orientation upon arrival to
the program and received a copy of the youth handbook. Observations found the BMS was
posted throughout the program. 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. The incentives for youth include using
points to purchase items from canteen, participating in Mega Monday and Phat Friday activities,
and meals. Three staff were informally interviewed, and each knew the number of youth they
were supervising. Six staff were interviewed, and each reported they were trained in the BMS.
Four staff stated the BMS consists of a point system, six stated the BMS has a level system,
two staff stated the BMS consists of rewards and consequences by utilizing a four-to-one ratio,
three staff stated the BMS is posted throughout the program, and two staff stated the BMS is
detailed in the youth handbook. Each of the interviewed staff confirmed youth receive canteen
and can participate in Mega Mondays and Phat Fridays as incentives. Two staff stated nothing
can be taken away from youth as a consequence, four staff stated youth can lose incentives, or
receive an early bedtime. Each interviewed staff stated youth are informed of the consequences
and they are able to explain their behavior during the review of the behavior reports. Each staff
stated they receive feedback on the implementation of the BMS during shift briefings and
monthly meetings. All six staff verified youth have not been placed in room restriction during the
annual compliance review period. Six youth were interviewed, and each stated the program’s
consequences included level freezes, privilege suspension, early bedtime, being placed in
controlled observation (CO), and the issuance of behavior reports. Six youth were interviewed,
and each youth stated they receive incentives such as special meals, snacks, and participate in
Mega Mondays and Phat Friday. All six youth were able to explain the difference between each
level and how they move from level to level. All six youth verified youth are never allowed to
punish other youth. Five of six interviewed youth stated staff use rewards equally for all youth.
One youth stated staff reward youth with whatever incentive they have at the time. One youth
stated the BMS was very good, two stated it was good, one stated it was fair, and two stated it
was poor. One of the two youth reported the system was poor due to staff not consistently
issuing rewards, and one youth offered no additional comments. An interview with the facility
administrator (FA) confirmed the program utilizes the iChoose System, which is focused on
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modeling, coaching, and incentivizing pro-social healthy behaviors. Youth are incentivized
through earning credits by demonstration of healthy, on-task behaviors throughout a structured
daily agenda. Basic hygiene and wellness-related tasks are incentivized, as are educational,
vocational, and treatment participation, and pro-social healthy interaction with peers and staff.
Incentive calendars are posted throughout the program. Each youth has the opportunity to earn
an incentive on a nightly, weekly, and monthly basis. Canteen items are distributed bi-weekly,
and youth have the ability to earn additional items as they progress and level-up through the
program. Consequences are monitored by conducting a behavior review team meeting. These
meetings are conducted and discussed by management and treatment team members.
Consequences are given to the youth and are reflected on the daily tracker which is updated
daily and posted on every unit. Staff are given point cards for each youth. These point cards are
filled out in real time and address program expectations and behaviors. Youth are given a
handbook which explains the BMS to ensure accuracy.
5.03 Use of Room Restriction Satisfactory Compliance
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 maintains a written policy and procedures specific to the use of room restriction.
An interview with the facility administrator (FA) verified the program did not use room restriction
during the annual compliance review period. Six staff were interviewed, and each stated the
program does not utilize room restriction. Six youth were interviewed and five stated they had
not been placed in room restriction. One youth stated they asked to be placed in their room and
staff monitored the youth at least every nine minutes.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program maintains a written policy and procedures in place to conduct and document ten-
minute checks during sleep hours or at other times, such as during an illness or room restriction.
The program has a total of 113 video cameras capable of recording thirty-days of video footage.
During the annual compliance review week, 108 of the cameras were operational. In an informal
interview the facility administrator (FA) stated a work order was submitted to repair the five
cameras which were not operational. When conducting checks, staff are to be situated where
they are able to see any movement within the living unit. Staff are required to conduct room
checks every ten-minutes and document the time of the check on the ten-minute check log
when youth are sleeping. A video review of twelve randomly selected half-hour periods of ten-
minute checks over the previous two weeks was conducted inclusive of each shift and each of
the program’s living units. The review verified staff were conducting checks every ten-minutes
and documented the times accurately on the ten-minute check logbook. In addition, the ten-
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minute check logs since the last annual review were examined. A random sample of various
days, times, and shifts indicated the ten-minute checks were completed within the required
frequency. Six 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
FA stated the program has 113 cameras with video recording capabilities for thirty-days.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program maintains a written policy and procedures requiring youth to always be accounted
for through a system of physically counting youth at various times throughout each day. The
program’s policy is to conduct formal head counts each hour and after outdoor activities. In
addition, the policy indicates counts are to be conducted during power outages, escapes,
program disturbances, or any other disruptions which may occur. A review of the Continuity of
Operations Plan (COOP) verified program staff must always account for the whereabouts of the
youth in the care and custody of the program. This includes continual head counts to be
conducted at least at the beginning of each shift, at regular intervals throughout each day, and
during any emergency situation. Twelve randomly selected full days in the program’s logbook
were reviewed for census counts during the annual compliance review period. Documentation
validated head counts and movements were conducted at the beginning of each shift, after
outdoor activities, during emergency situations such as program disturbances, and during actual
and/or simulated drills. In addition, the program logbooks included documentation of new
admissions, releases, daily census counts, youth movements, transfers, and youth temporarily
transported away from the program. Observations made during the annual compliance review
week indicated it is the program’s practice to conduct hourly youth counts. Six interviewed staff
verified formal counts are conducted every hour. Each staff stated emergency counts are
conducted anytime a code is called, during power outages, if there is a discrepancy in the count,
if a youth is missing, and during drills. Five of the six interviewed staff knew the youth census
during the annual compliance review week, and one staff gave an incorrect census count.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a written policy and procedures requiring the maintenance of a
chronological record of events, incidents, and activities in a central logbook. The program
maintains a bound logbook with numbered pages for each month. Observations and a review of
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logbooks since the last annual compliance review found logbook entries were documented in
ink with no erasures or white-out areas. Errors were typically struck through with a single line,
dated, and initialed by the staff correcting the error. Reviewed documentation of randomly
selected dates within the logbooks reflected each entry included the date and time of the event,
the name of the staff and youth involved, as well as a brief description, the name, and signature
of the staff making the entry. A review of the activity schedule and logbook documentation
verified there was minimal interference with educational instruction. A video review of three
randomly selected school days verified there were no deviations from the school bell schedule.
A review of randomly selected entries in the logbook reflected youth started and ended school
on time. A review of logbook entries indicated recreation was conducted as scheduled. The
program ensures direct care staff, including each supervisor, are briefed when coming on duty.
Each staff signs the shift briefing sign-in sheet to acknowledge receiving the information. A
review of shift reports since the last annual compliance review verified reports were completed
on a daily basis. A video observation of a shift briefing verified staff were briefed prior to the
start of their shift. In addition, staff have access to the shift report for at least forty-eight hours
after each briefing. Reviewed logbooks included entries for emergency situations, incidents,
special instructions for monitoring youth, population counts, law enforcement access to youth,
perimeter checks, and youth movement. In addition, admissions and releases were documented
as well as transports away from the program. Reviewed documentation and a review of the
Department’s Central Communications Center (CCC) reports indicated there were no instances
of escapes or attempted escapes during the annual compliance review period. Reviewed
logbooks reflected the program documented internal incidents which were reported to the
Florida Abuse Hotline and/or the CCC.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a written policy and procedures for assignment, inventory, tracking, and
storage of program keys. Keys are bound on a tamper resistant ring which includes a brass-
colored tag with the number of keys and a tracking number. Program keys are maintained in
master control on a board with the corresponding tracking number. The program has a daily key
log to track keys. The log indicates the staff name and what type of key(s) they are assigned
according to their position. The program maintains a master inventory list of program keys. A
random check of five different sets of program keys compared to the inventory list indicated the
keys were accounted for, and the master control staff knew which area each key was assigned
to. Active keys are assigned to direct care staff while restricted keys are designated for medical
staff, kitchen staff, case managers, and therapists. An informal interview with master control
staff indicated the program’s practice is when direct care staff arrive to the program, personal
keys are collected by master control and placed on a board in master control. Medical staff,
kitchen staff, case managers, and therapists receive their respective restricted keys from master
control after their personal keys are collected. Both the master control operator and the staff
receiving a program key initial the key log prior to and at the end of the shift when the keys are
returned. A review of the key logs and logbooks since the last annual compliance review verified
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this practice. In addition, the program has a list of staff who are assigned permanent keys.
Permanent keys are issued, and staff sign an acknowledgment form indicating their key
identification number and the number of keys issued. A review of the signed acknowledgment
forms indicated each staff signed for the use of permanent keys. A random check of three staff’s
keys verified the number of keys on the key ring matched the inventory and each staff knew the
function of each key on their ring. A review of the Department’s Central Communications Center
(CCC) reports since the last annual compliance review indicated there were no incidents related
to key control. Six staff were interviewed and were able to explain the program’s key control
process.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a written policy and procedures which identify materials considered to
be contraband to prevent contraband from entering the program, and consequences when
found in the possession of youth in the program. The program’s youth handbook and policy
include a list of contraband items and informs youth of the consequences if found with
contraband. Each youth is provided with a written copy of the youth handbook upon admission
into the program and is oriented to the program rules including the list of items considered to be
contraband. The program’s policy and youth handbook included all items considered
contraband as outlined in Florida Administrative Code. The list of contraband items include
sharps, escape paraphernalia, tobacco products, lighters and matches, electronic and vaporless
cigarettes, unauthorized food or clothing, any intoxicating beverages, any controlled substance,
any prescription and non-prescription drug, any firearm or weapon, any explosive substance,
non-program issued keys, unauthorized currency, non-program issued cellular telephones
and/or equipment or electronic devices capable of taking pictures or video recordings, as well as
smart watches. In addition, the program’s policy and youth handbook detail the consequences if
found with contraband, search procedures of the physical plant, program grounds, youth, and all
incoming and outgoing mail. The program’s policy specifies the manner in which any
unauthorized or contraband item is to be disposed by either returning the item to the sender,
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mailing the item to the youth’s home, returning the item to the youth upon release or, for
instances of illegal contraband, turning the item over to law enforcement. Unannounced room
searches are conducted at least weekly at irregular and unpredictable times and common area
searches are conducted daily. During the program tour, several randomly selected rooms were
checked, and no contraband was found. A review of shift reports, the master control logbook,
visitation forms, and common area search forms validated the program’s practice of regularly
monitoring areas of the program, grounds, and youth rooms for contraband. The program’s
policy requires case managers to inspect all outgoing and incoming correspondence in the
presence of the youth for unauthorized items, contraband, or information which may breach the
security of the program. The program’s policy and procedures stipulate all staff, including
supervisors and administrators, who are found in possession of contraband will be subject to
disciplinary action up to and including dismissal. The program is to document the confiscation
and disposal of contraband. All instances involving confiscation of illegal contraband require the
program to turn the item over to local law enforcement authorities and file a criminal report. A
review of the Department’s Central Communications Center (CCC) reports since the last annual
compliance review indicated there were four instances of illegal contraband found at the
program, each of which was turned over to law enforcement. The interviewed facility
administrator (FA) reported the discovery of any contraband and/or illegal contraband is
immediately reported to the CCC. Law enforcement is then contacted at which time all
contraband items are turned over to the responding law enforcement agency. Six staff were
interviewed, and each stated room checks are conducted weekly, randomly throughout the day,
and during youth shower time.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a written policy and procedures to ensure searches and full body visual
searches, are conducted according to Florida Administrative Code at the time of admission,
after off-campus activities, and visitation. Parents/guardians are notified of searches during
visitation by way of the parent/guardian intake letter, which is mailed at the time of each youth’s
admission. Youth are searched prior to entering and departing the classroom, after outdoor
recreation activities, after work detail, and before and after all movement. Youth are full body
searched at the time of their admission, re-admission, return from visitation, return from off-
campus activities and/or appointments, when suspected of possessing contraband, or are
indicated a security risk. Observations made throughout the annual compliance review week
validated youth are provided instructions regarding the search, youth searches were conducted
by staff of the same gender as the youth, and were conducted in a manner so as not to degrade
the youth and based on the Protective Action Response (PAR)/Right Interactions (RI) training
manuals. Searches observed during the annual compliance review week verified youth were
searched after every movement. During the annual compliance review week, observations
verified the program conducted full body visual searches by same gender staff of two youth
during the admission process, after transport, and a youth returning from an off-site activity. Six
staff were interviewed, and each stated youth are searched after every movement by same
gender staff. Six youth were interviewed, and all indicated searches occur during all movement,
when items are missing, after visitation, after meals, and when returning from off-site activities.
In addition, four youth stated they are searched after work detail.
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5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a written policy and procedures for transportation, operation, and
maintenance of each vehicle used to transport youth. The program has a total of three vehicles;
two are used to transport youth and one is for program use. Each vehicle had an annual safety
inspection conducted by a certified automobile mechanic. Observations of the three program
vehicles verified each was locked when not in use. All three vehicles had the appropriate
number of seatbelts, a seatbelt cutter, a window punch, up-to-date fire extinguishers, and a first-
aid kit containing items approved by the designated health authority (DHA). Weekly visual
vehicle inspection checks were conducted on all vehicles as required and documented on the
preventative maintenance check sheets. The two vehicles used to transport youth had
passenger doors which could not be opened from the inside and had a safety screen separating
the front seat from the rear passenger compartment. All three vehicles had functional seatbelts.
A random check of six staff personal vehicles and three program vehicles during the annual
compliance review week found all but one of the vehicles were locked and secured when not in
use. Six staff were interviewed, and each stated youth are secured in the vehicle with hand and
leg cuffs, and by wearing the seatbelt. Six youth were interviewed, and each stated they are
secured with leg and hand cuffs, and they utilize the seatbelt during transports.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a written policy and procedures to ensure the safety and security of
youth and the community when youth are transported outside of the program. The policy does
not permit the youth to drive program vehicles. Reviewed documentation verified all approved
drivers had a valid driver’s license. The program requires a ratio of one staff to five youth during
transport, not including the driver. The program provides transportation for secure maximum-risk
youth determined to be at greater risk. An observation of two youth arriving to the program for
an admission was conducted. Two transportation staff, one the same gender as the youth, were
supervising the youth. One staff was the driver, and one staff was monitoring the youth in the
back of the vehicle. The transportation staff had a program cellular telephone while transporting
the youth. The youth were not attached to any part of the vehicle other than the seatbelt. An
observation of the transport verified the staff and youth were wearing their seatbelts and both
youth were secured with leg and hand cuffs. The vehicle had a security screen between the
driver and passenger seats. Six staff were interviewed, and each staff confirmed they are not
allowed to use personal vehicles to transport youth. Each interviewed staff verified the program
provides a cellular telephone during transports. Six interviewed staff stated the safety equipment
in the transport vehicles included a first-aid kit, seatbelt cutter, and fire extinguisher. Six
interviewed staff stated the transport vehicles are searched for contraband prior to and after
each use. Six interviewed staff stated they would call 9-1-1 and/or contact the program if an
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emergency arose during vehicle transport. Six interviewed youth stated they never witnessed
anyone placing contraband in a transport vehicle and they all indicated staff operate transport
vehicles safely. An interview with the facility administrator verified all vehicles transporting youth
have a safety cage to ensure youth remain safe and secure during transport.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a written policy and procedures to ensure safety and security is
maintained. The policy addressed who is responsible for conducting the audits, procedures to
implement corrective actions for deficiencies, and an internal system to verify deficiencies are
corrected. Weekly safety and security audits are conducted by the facility administrator (FA) or
designee and documented on the Safety and Security Audit Inspection form. Any deficiencies
are addressed on the form and a work order is submitted to the appropriate staff for correction.
In addition, deficiencies are discussed during the morning management meeting. A review of
the safety and security inspection forms since the last annual compliance review indicated
inspections were completed as required. Supervisors also conduct perimeter checks on each
shift which are documented in the program logbook. A review of the program logbooks verified
this practice. A review of deficiencies entered in the Department’s Juvenile Justice Information
System (JJIS) verified there were no deficiencies assigned in regard to safety and security
audits during the annual compliance review period. An interview with the FA indicated weekly
safety and security audits are conducted by the FA or designee and documented on the Safety
and Security Audit Inspection form. A deficiency report which includes deficiencies, potential
issues with the program, and anticipated resolution dates are submitted to the Department
weekly.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a written policy and procedures to have a tool management system
which ensures youth do not use tools or equipment as weapons or for security breaches. The
policy addresses the issuance, inventory, and control of equipment and tools. The policy states
prohibited tools at the program include machetes, bowie knives, and other long bladed knives. A
review of inventory logs and observations verified tools are securely stored when not in use, are
easily marked for identification, and are inventoried prior to and following work activities. All
sharp edged and pointed tools are inventoried daily when in use. The maintenance staff are
responsible for conducting the inventories and securely maintaining all Class A tools and
equipment. The maintenance staff completes a tool inventory list which documents each tool in
the inventory. All maintenance tools were inaccessible to youth and were observed to be
secured in the maintenance building. Observations of the tool storage area found it was
organized and secure. Class B tools including mops, brooms, and buckets are maintained in a
locked closet in the hallway between the east and west wings which is inaccessible to the youth.
The items are used by staff and youth when performing daily cleanup activities. Staff are
required to complete a sign-out and sign-in log when items are retrieved and returned to the
designated storage room. Kitchen staff are responsible for securing, maintaining an inventory
log, and sign-out/sign-in log for all kitchen utensils and sharps. A random review of ten unique
kitchen utensils and sharps and ten unique tools in the maintenance building validated the tool
inventory in the logs were accurate. Reviewed documentation and the Department’s Central
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Communications Center (CCC) reports verified there were no instances of missing or lost tools
since the last annual compliance review. If a tool is broken or inoperable, the physical plant
manager is responsible for replacing the broken tool. If a tool is missing, staff are to notify
administration, fill out an incident report, document the incident in the logbook, call the CCC,
and the program is to be searched until the tool is found. The program has a vocational
woodshop program on-site which is operated by the Home Builder’s Institute (HBI) in which
Class A tools are utilized by the youth. Observations of tools in the vocational building indicated
tools are maintained under lock and key with access only by HBI staff.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injury. The program’s policy and procedures include
supervision requirements when youth are using tools, the issuing of tools to youth and staff, a
youth assessment to determine the youth’s risk, established ratios which include one staff to five
youth during work detail or vocational training, and one staff to three youth for disciplinary work
projects. A review of the program’s procedures verified staff are required to complete a sign-out
and sign-in log when Class B tools are taken and returned to the designated storage room. A
Youth Risk Assessment is completed by the case manager for youth to use Class A and Class
B tools. In addition, the Home Builders Institute (HBI) program completes a risk assessment
prior to youth participating in the program. Ten youth case management records were reviewed,
and each youth had a Youth Risk Assessment completed by the case manager prior to youth
using tools. Ten youth case management records included documentation each youth was
trained on the intended and safe use of Class B tools. An observation of three youth working
kitchen detail and cleaning pans with a hose was conducted. In addition, youth were observed
using Class A tools while participating in the HBI program. The youth were properly supervised
and followed safety protocols. Six youth were interviewed, and each stated they use mops and
brooms. Three youth stated they used scrub brushes, two youth stated they used a rake, and
one youth stated they used a screwdriver, hammer, and saw. Six staff were interviewed, and
each indicated youth are allowed to use mops and brooms. Four staff stated youth can use
scrub brushes. Two staff reported youth can use tools when enrolled in the HBI program with a
risk assessment conducted prior to their use of tools.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a written policy and procedures establishing guidelines for outside contractors
who come on-site to complete repairs. When a contractor or vendor enters the program, they
are to sign the Outside Contractor On-Site Work Project Log which lists unauthorized items. The
program’s policy stipulates personal cellular phones, electronic devices capable of taking
pictures and/or audio/video recording, including smart watches, are prohibited in the secure
area. The physical plant manager or designee inspects all tools upon the arrival of outside
contractors and is responsible for providing approval if tools are required. The program’s
guidelines for external workers include checking of tools upon arrival and departure, the search
of all vendors prior to entering the program, tool restriction while in the program, missing tool
follow-up, and restriction of youth from the work area. The outside contractor is to complete the
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program’s Outside Contractor form upon entrance to the program, where they list the tools
required to complete the work order. Maintenance will review the form and sign once the tools
are inventoried and approved. Upon exiting the program, the Outside Contractor form is
reviewed, all tools are verified, then the form is signed. Any tools required to be used within the
program are inventoried and recorded on the contractor’s agreement form before and after the
repair is completed. Reviewed documentation for three project invoices showed the vendors
signed contractor agreements and each vendor did not bring tools into the program.
Documentation review of the outside contractor forms verified the forms were completed and all
requirements were met. A review of the work project logs since the last annual compliance
review validated the contractors signed the log to acknowledge their understanding of the listed
unauthorized items. If any unauthorized items are needed by the contractor while in the
program, approval is to be obtained by the facility administrator (FA) or designee.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program’s Continuity of Operations Plan (COOP) addresses fire, safety, and evacuation
emergency processes and the required frequency of drills at random times and under varied
conditions. Reviewed documentation validated fire drills were conducted on each shift each
month, as required. In addition, the program conducted emergency drills on each shift ensuring
fire, riot, severe weather, flooding, active shooter, hostage situation, chemical spills, medical
situations, and bomb threat scenarios were covered on a rotating basis. Drill documentation
included the type of drill, date and time, participants, a brief scenario description, deficiencies
identified during the drill, and applicable corrective actions. Observations and an informal
interview with the facility administrator (FA) verified there were twenty-six annually inspected fire
extinguishers and egress plans posted throughout the program. Six interviewed staff all reported
they had participated in a fire drill since the last annual compliance review. In addition,
interviewed staff stated they participated in weather, major disturbance, bomb threat, hostage
situation, flooding, terrorism, escape, and chemical spill drills. Six youth were interviewed, and
each indicated drills are conducted at least monthly and each confirmed they had been
instructed on what to do in the case of an emergency. An interview with the FA indicated fire,
COOP, mental health, and medical drills are conducted on a monthly basis for each shift. The
drills are conducted and later discussed with staff to identify deficiencies and strengths during
the drills.
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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 Continuity of Operations Plan (COOP) which is
available for all staff to review. The COOP was reviewed and submitted to the Department on
February 22, 2023. The Department approved the COOP on February 23, 2023. The COOP
addresses the basic care and custody of youth in the event of an emergency or disaster. The
COOP also outlines phases of a disaster plan as well as emergency management including
preparedness, response, and recovery. The COOP addresses emergencies including fire
prevention, severe weather, riots, bomb threats, hostage situations, chemical spills, flooding,
and terrorist threats. The COOP includes staff roles and responsibilities, equipment and needed
supplies, youth information, provisions for continuity of care and custody of youth, and
provisions for public protection. The COOP is readily available to all staff and copies are located
in the administration conference room, the facility administrator’s (FA’s) office, and in the
assistant facility administrator’s (AFA’s) office. A review of the plan indicated alternative housing
has been identified should the program require evacuation due to an emergency or disaster.
The program also has provisions of equipment and supplies maintained in the kitchen and
master control to ensure a continuous operation of services during emergency or disaster
situations. The program has a generator to provide continuous power. The program maintains
critical identifying information for each youth in the program in the event of needed evacuation
where the youth record would accompany the youth to the temporary location. A review of ten
youth case management records indicated each included the youth’s name, Department
identification number, admission date, gender, race, contact information, emergency contacts,
assigned juvenile probation officer (JPO), committing judge, victim information, physical
description, health status, and a photograph. The interviewed FA reported copies of the COOP
are maintained in the administration conference room, the FA’s office, and in the AFA’s office.
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 for the storage and inventory of
flammable, poisonous, and toxic materials. Toxic items are stored outside the program in locked
cabinets within a locked chain link fence. A list of staff authorized to use chemicals is
maintained in the storage cabinet and includes the facility administrator (FA), assistant facility
administrators (AFAs), unit managers, medical staff, shift supervisors, and food service staff. All
caustic materials are stored according to type and use. A Safety Data Sheet (SDS) binder is
located inside the storage area with a picture of each chemical item and a number
corresponding to the SDS for each chemical. A perpetual chemical inventory list is maintained,
and the chemicals are checked daily. A review of the inventory list validated this practice. The
program also has a chemical daily usage log used to track all toxic items when in use by
authorized staff. The form identifies the chemical number, description, amount used, amount
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remaining, the date the chemical was used, and initials of staff. Observations of the storage
area indicated it is clearly marked hazardous chemicals and securely locked. Items were stored
on metal shelving and numbered according to the SDS. Flammable items are stored in a metal
cabinet clearly marked as containing flammable items. Chemicals used to clean the program
are stored in a locked closet located in the main hallway of the program and in a secured closet
in the kitchen. An inventory sheet is maintained to document the daily use of the cleaning
chemicals. A review of the storage closet accurately verified the number and type of chemicals
maintained on the inventory list. A random sample of five cleaning products located in the
kitchen and five chemicals located in the outside storage area verified the actual count matched
the inventory logs, the chemicals were secured, and the SDSs were present for the items
reviewed.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a written policy and procedures which prohibit youth from handling any
flammable, poisonous, and/or toxic items or materials. Youth are not to clean, handle, or
dispose of any toxic, bio-hazardous bodily fluids, or human waste. Youth are strictly prohibited
from the maintenance area where toxic items and chemicals are stored. Observations of three
youth participating in kitchen work detail verified none of the youth were using chemicals or
cleaning products. Observations of completed projects at the co-located vocational Home
Builder’s Institute (HBI) program verified youth used paint only after receiving a risk
assessment. Six youth were interviewed, and five youth stated they did not use any chemicals
or cleaning products. One youth stated they had used paint, paint stripper, floor wax, and toilet
cleaner.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program maintains a written policy and procedures to ensure all flammable, toxic, caustic,
and poisonous items are disposed appropriately. The facility administrator (FA) or designee and
maintenance staff are responsible for the control and accountability of all caustic, toxic,
poisonous, flammable, hazardous fluids, substances, or chemicals used in the program. All
unused hazardous materials are kept in the secured storage area located outside the program
and are disposed of according to the Safety Data Sheet (SDS). In an informal interview the
physical plant manager stated the program makes every effort to use up all chemicals. If there is
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old paint, it is poured onto plastic until it dries, then it is disposed of, pursuant to the SDS
requirements. Any unused chemicals are taken to the local county waste day. The physical
plant manager stated there were no chemicals disposed of during the annual compliance review
period. Used kitchen grease and waste is stored in a large container outside the kitchen area
and is disposed of by a local vendor. All liquid waste from work details is disposed down
plumbing drains. The program’s policy states all chemical spills are to be reported to master
control and the shift supervisor. immediately An evacuation of the affected area is to be
conducted and a determination would be made by the FA whether to contact outside assistance
to contain the spill. Staff and youth are not allowed to return to the affected area until it has been
deemed safe by a qualified professional. The interviewed FA stated disposal of hazardous items
and toxic substances or chemicals are disposed of in accordance with Occupational Safety and
Health Administration standards.
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.
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5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a written policy and procedures for youth to have visitation and
communication with family members in order to re-establish family and community relationships.
Youth are informed of visitation upon admission during the orientation process. The program
encourages visitation by the parent/guardian through a welcome letter sent upon each youth’s
admission, which includes the days and time of visitation, who is allowed to visit, and the
corresponding rules of visitation. A list of authorized visitors and correspondence is maintained
in each youth’s case management record and updated as needed. A review of ten youth case
management records verified each record contained an approved correspondence, visitation,
and telephone log. Visitation is held in the administration area on Saturdays and Sundays from
9:00 a.m. to 11:30 a.m. Special visitations are also provided for those parents/guardians who
are unable to participate in the regularly scheduled visitation day. The program’s policy requires
all outgoing and incoming mail to be searched for contraband in front of the youth. The
program’s practice is to document searches on the mail log contained in the youth case
management records. The program utilizes a third-party language translation service for youth
and parents/guardians whose primary language is not English. Six youth were interviewed, and
each stated they had been provided opportunities to communicate with family members by
telephone, mail, and visitation. Six staff were interviewed, and each verified the program uses a
translation service for youth and parents/guardians whose primary language is not English. The
interviewed facility administrator stated staff have been identified which can assist in translation
to ensure the youth is safe and not experiencing any issues within the program. Positive peers
are also identified to assist in any settings such as school, group, or recreation. There is also a
language assistance hotline which the program utilizes for translation for youth and
parents/guardians whose primary language is not English.
5.23 Recreation and Leisure Activities Limited Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a written policy and procedures to ensure each youth has a variety of
recreation and leisure activities. The daily activity schedule was posted throughout the program
and included a range of supervised and structured indoor and outdoor recreation activities for at
least one hour daily for the youth. The structured activities included large muscle activities on
the schedule. A review of logbook entries indicated recreation was conducted as scheduled.
The activities selected on the schedule promote social and cognitive skill development,
creativity, teamwork, healthy competition, mental stimulation, and physical fitness. Observations
of recreation activities ensured the program takes precautionary measures to prevent
overexertion, heat stress, dehydration, frostbite, hypothermia, and exacerbation of any existing
illness or physical injury. The program’s contract requires the program to have two recreation
therapists on-site. Each recreation therapist is to have a bachelor’s degree in a related field or
work-related experience which must be approved by the Department. One recreation therapist
position has been vacant since the provider took over the contract on July 1, 2021, and the
second position has been vacant since April 4, 2023. The facility administrator (FA) reported the
operations manager has been providing large muscle recreation activities to the youth at the
program. The operations manager has work-related years of experience; however, was not
approved by the Department to provide recreation therapeutic services. A review of ten youth
records verified each youth had recreation therapy included on their Individualized Performance
Plan. Ten youth were interviewed, and each stated the program provides the opportunity for
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youth to participate in creative arts, sports, and physical fitness activities. Each youth stated
they are provided at least one hour daily to participate in recreation activities. Six staff were
interviewed, and each confirmed youth participate in large muscle activities such as football and
basketball, playing board games, playing cards, watching television, and playing video games.
5.24 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program maintains a written policy and procedures to ensure staff search and inspected
controlled observation rooms prior to placing a youth in controlled observation. The program has
a designated area to house youth who have been placed on controlled observation.
Observations of the rooms indicated the program met the measurement and construction
required by Florida Administrative Code.
EVERGLADES YOUTH ACADEMY
The program had ninety-four controlled observation placements since the last annual
compliance review. Ten Controlled Observation Reports involving program youth were
reviewed. All ten reviewed Controlled Observation Reports indicated a staff of the same gender
searched the youth and inspected the room prior to placing each youth in controlled
observation.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
The program had sixty-three controlled observation placements during the annual compliance
review period. Seven Controlled Observation Reports involving youth were reviewed. All seven
reviewed Controlled Observation Reports indicated a staff of the same gender searched the
youth and inspected the room prior to placing each youth in controlled observation.
5.25 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program maintains a written policy and procedures regarding controlled observation.
Program staff are authorized to temporarily place a youth in a controlled observation room if
there is an imminent risk of the youth harming themselves or others, or if the youth is causing
major damage to the program which may cause a security risk. If a youth is placed in controlled
observation for any of these reasons, a Controlled Observation Report is to be completed upon
the youth’s placement.
EVERGLADES YOUTH ACADEMY
The program had ninety-four controlled observation placements since the last annual
compliance review. A review of ten Controlled Observation Reports verified supervisors or
administration authorized the placement of each youth in controlled observation. None of the
reviewed reports indicated the youth exhibited behaviors indicative of a mental health crisis or
suicidal ideation. Documentation indicated youth placed in controlled observation were identified
as an imminent risk to the youth harming themselves or others, the youth was causing major
damage to the program which may have caused a security risk, or the youth was physically out-
of-control and less restrictive methods were ineffective and staff needed to quickly gain control
for program safety. All ten Controlled Observation Reports indicated staff advised youth of the
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reason for controlled observation and the and the behavioral expectations in order for the youth
to be released. All ten reviewed Controlled Observation Reports indicated medical staff
completed a Health Status Checklist for the youth in controlled observation. None of the
reviewed Health Status Checklists indicated any youth sustained an injury. Reviewed
documentation indicated three youth remained in controlled observation for longer than two
hours. All three controlled observation reports included documentation of the facility
administrator (FA) or designee’s approval for continued placement over two hours. Two youth
required approval for continued placement in controlled observation and documentation
validated the FA or designee approved the continued placement at least every two hours for the
two applicable youth.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
The program had sixty-three controlled observation placements since the last annual
compliance review. A review of seven Controlled Observation Reports validated supervisors or
administration authorized the placement of each youth in controlled observation. None of the
reviewed reports indicated the youth exhibited behaviors indicative of a mental health crisis or
had suicidal ideation. Documentation indicated youth placed in controlled observation were
identified as an imminent risk to the youth harming themself or others, the youth was causing
major damage to the program which may have caused a security risk, or the youth was
physically out-of-control and less restrictive methods were ineffective and staff needed to
quickly gain control for program safety. All seven Controlled Observation Reports indicated staff
informed the youth of the reason for placement in controlled observation and the expected
behavior in order for the youth to be released. All seven reviewed reports indicated medical staff
completed a Health Status Checklist for the youth in controlled observation. Three of the
reviewed Health Status Checklists indicated the youth had sustained an injury and healthcare
staff were notified and provided treatment. Reviewed documentation indicated four youth
remained in controlled observation for more than two hours. All four controlled observation
reports included the FA or designee’s approval for continued placement beyond two hours. Two
youth required approval for continued placement in controlled observation and documentation
confirmed the FA or designee approved the continued placement at least every two hours.
5.26 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program maintains a written policy and procedures requiring safety checks for youth on
controlled observation. A safety check is to be conducted every fifteen minutes to ensure the
youth is safe and for staff to observe the youth’s behavior. Once a determination has been
made for the youth to be released from controlled observation, the facility administrator (FA) or
designated supervisor must provide approval for the youth’s release. The release is to be
documented on the Controlled Observation Report.
EVERGLADES YOUTH ACADEMY
The program had ninety-four controlled observation placements since the last annual
compliance review. Ten Controlled Observation Reports were reviewed, and each report
indicated staff completed the first page of the report and the report was submitted to a
supervisor. Staff documented safety checks conducted at least every fifteen minutes on the
Controlled Observation Safety Check form. All ten Controlled Observation forms indicated the
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FA or designee approved the release of the youth from controlled observation based upon the
youth’s behavior. The ten reviewed reports documented the FA or designee approved the report
within fourteen days of the youth’s release from controlled observation. In each instance, staff
determined the youth did not warrant an alert after the youth was released from controlled
observation. Reviewed documentation showed the Controlled Observation Report, Health
Status Checklist, and Controlled Observation Safety Check forms were maintained in an
administrative file and in the youth’s individual case management record. The program’s
operating procedures designate the FA, assistant facility administrator (AFA), shift supervisor, or
administrator on call as they are the only staff to authorize placement in controlled observation.
Three youth were interviewed, and each stated they were sent to their room for getting into
trouble. One youth stated they were in a room for two hours with the door locked. One youth
stated they were placed in a room once for half a day, and one youth stated they were in a room
all day and staff were conducting checks.
EVERGLADES YOUTH ACADEMY - SEX OFFENDER PROGRAM
The program had sixty-three controlled observation placements since the last annual
compliance review. Seven Controlled Observation Reports were reviewed, and each report
indicated staff completed the first page of the report and submitted it to a supervisor. Staff
documented safety checks conducted at least every fifteen minutes on the Controlled
Observation Safety Check form. All seven Controlled Observation Forms indicated the FA or
designee approved the release of the youth from controlled observation based on the youth’s
behavior when the youth was no longer a threat to themself and others. All seven reviewed
reports documented the FA or designee approved the report within fourteen days of the youth’s
release from controlled observation. In each instance, staff determined the youth did not warrant
an alert after the youth was released from controlled observation. Documentation showed the
Controlled Observation Report, Health Status Checklist, and Controlled Observation Safety
Check forms were maintained in an administrative file and in the youth’s individual case
management record. The program’s operating procedures designate the FA, AFA, shift
supervisor or administrator on call as the only staff to authorize placement in controlled
observation. Three youth were interviewed, and one stated they were sent to a room once for
getting into trouble for ninety minutes. The other two youth reported not ever being placed in a
room for getting in trouble.
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report_type: QI Residential

program_name_raw: Everglades Youth Academy - SOP

rule: Indicator 2.14

rating: Limited Compliance

rule: Indicator 5.23

excerpt: Recreation and Leisure Activities