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
Tampa Residential Facility
TrueCore Behavioral Solutions, LLC.
(Contract Provider)
9508 East Columbus Drive
Tampa, Florida 33619
Review Date(s): August 8-11, 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:
Marvin Bliss, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Rob Aguis, Office of Education, Deputy Director (Standard 1)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Cindy Jones, Office of Education, West Central Education Coordinator (Standard 2)
Gustavo Mazorra, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Interviews
and Standard 5)
Qualia Turner, Department of Juvenile Justice Detention Services, Supervisor (Standard 5)
Program Name: Tampa Residential Facility MQI Program Code: 1281
Provider Name: TrueCore Behavioral Solutions, LLC Contract Number: 10098
Location: Hillsborough County / Circuit 13 Number of Beds: 74
Review Date(s): August 8-11, 2023 Lead Reviewer Code: 173
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
2.20 Educational Access*
3.02 Licensed Mental Health and Substance Abuse Clinical Staff *
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 72 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Youth Input Satisfactory
1.16 Advisory Board Satisfactory
1.17 Staff Performance Satisfactory
1.18 Recreation and Leisure Activities Satisfactory
1.19 Special Contract Conditions Satisfactory
1.20 Contract Specific Career and Technical Education Services Satisfactory
1.21 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 72 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Limited
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 72 (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 * Limited
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 72 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 72 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Satisfactory
5.25 Controlled Observation Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 72 (Revised September 2022)
Program Overview
The Tampa Residential Facility is a seventy-four bed program, for fourteen to nineteen-year-old
males, located in Tampa, Florida. The program is operated by TrueCore Behavioral Solutions,
LLC., through a contract with the Department. The program provides services including
comprehensive mental health and substance abuse services. In addition, the program fosters
each youth by providing The Council for Boys and Young Men, Young Men’s Work, Living in
Balance, Pathways to Self-Discovery and Change, Coping with Depression, Coping with Stress,
Teen Relationships, Strategies for Anger Management, The Passport Program, Thinking for a
Change, and Impact of Crime. Additional treatment services provided include group, family, and
individual therapy. Program administration is comprised of a facility administrator, assistant
facility administrator, administrative assistant, and human resources. Case management
services are provided by a director of case management, four case managers, and a transitional
services manager. Mental health staff at the program includes a director of clinical services, two
assistant directors of clinical services, four licensed therapists, four non-licensed therapists, one
recreation therapist, one certified behavioral analyst, a file clerk, and two contracted
psychiatrists. Medical services are offered 6:00 a.m. through 11:00 p.m. daily and are provided
by a health services administrator, who is a registered nurse (RN), one part-time and four full-
time RNs, and one contracted medical doctor. Educational services are provided by the
Hillsborough County School Board. The layout of the program includes an administrative
building, a kitchen with an attached cafeteria, classrooms, and three youth living unit buildings.
The program has 144 security cameras with 142 operationally providing coverage. At the time of
the annual compliance review, the program had twenty-four vacant positions including twelve
youth care worker Is, six youth care worker IIs, one master control technician, three licensed
therapists, one transporter, and one dietary associate.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 72 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures addressing pre-employment background screenings.
Forty-three applicable staff records were reviewed for background screenings. All forty-three
records reflected an eligible background screening from the Agency for Healthcare
Administration (AHCA) Clearinghouse through the Department’s Background Screening Unit
(BSU) were received. In all forty-three records reviewed, background screenings were
completed prior to the date of hire, criminal histories were reviewed, and a pre-employment
assessment tool was administered to direct care applicants. One reviewed record indicated the
staff was hired prior to the background screenings being completed. The staff record indicated
the criminal history was reviewed, and a pre-employment assessment tool was administered.
This staff was placed into pre-service training. Each of the forty-three direct care staff received a
passing score on the pre-employment assessment tool. The program’s Annual Affidavit of
Compliance with Level 2 Screening Standards was completed for the program and sent to the
BSU on December 9, 2022. The Annual Affidavit of Compliance with Level 2 Screening
Standards for education staff was completed and sent on December 9, 2022.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures ensuring staff receive a background rescreening
every five years from the initial date of employment. Nine staff at the program required a
background rescreening during the annual compliance review period. All nine staff received a
rescreening within twelve months of their five-year anniversary of the initial agency hire date.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 72 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to ensure program-related incidents, which place at
risk or have the potential to place at risk, the health, safety, or welfare of the public or of youth,
staff, visitors, the security of the facility, or the reputation of the provider are reported and
handled appropriately and in a timely fashion. According to the policy and procedures, abuse
reporting procedures include any staff who have knowledge of, or has a reasonable suspicion a
youth has been, is being, or is in danger of being abused, should immediately report it to the
Florida Abuse Hotline (for youth under the age of eighteen), or the Department’s Central
Communications Center (CCC) (for youth eighteen years of age or older). If a youth is
requesting to contact the Florida Abuse Hotline, policy states staff are to notify the staff, who will
assist the youth in making the call or contact the supervisor. The program had no incident
reports of claims against staff for physical abuse or emotional abuse. Three of the four reviewed
incidents were unsubstantiated and one was still under review at the time of the annual
compliance review. The program has had no substantiated instances of physical, psychological,
or emotional abuse since the last annual compliance review. The program completed the
Trauma Responsive and Caring Environment (TRACE) self-assessment on February 23, 2023.
The surveys were completed on March 23, 2023, and the action plan was completed on May
19, 2023. Staff adhere to a Code of Conduct, as indicated in the receipt of the employee
handbook contained in the staff personnel records. Seven reviewed pre-service training records
and seven in-service training records reflected staff received training on child abuse reporting.
The Florida Abuse Hotline and CCC telephone numbers were observed to be posted throughout
the facility. All seven interviewed youth reported they feel safe in the program. All seven youth
reported they have never been prevented from making a call to the Florida Abuse Hotline. All
seven youth reported staff are respectful when talking with youth. One of the seven youth
reported hearing staff curse around youth. Each of the seven interviewed staff were familiar with
the program’s abuse reporting procedures. All seven interviewed staff reported they have never
observed a coworker denying a youth the right to an abuse call, and all seven reported they
have not witnessed their coworker’s using profanity or threatening behavior when dealing with a
youth. The facility administrator (FA) reported youth and staff are given instructions on abuse
reporting at respective orientations, and annually thereafter for staff.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 72 (Revised September 2022)
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program maintains a policy and procedures to ensure the program takes immediate action
to address incidents of physical, psychological, and emotional abuse. The program’s
administration manages youth and staff needs and provides directions to each on how to
access the Florida Abuse Hotline. The program had four incident reports alleging physical
abuse toward a youth since the last annual compliance review. Three incidents were
unsubstantiated, and one incident was under investigation at the time of the annual compliance
review. A review of the incident reports indicated the facility administrator (FA) took immediate
action to address the concerns by removing the staff from youth contact until a determination
was made. An interview with the FA indicated the program’s management response to
allegations of abuse is all staff, volunteers, interns, or contracted staff shall immediately report
any allegations or suspicion of an incident of abuse or harassment which has occurred in the
program to the Florida Abuse Hotline and the Department’s Central Communications Center for
youth eighteen years of age or older.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a policy and procedures to ensure program-related occurrences which place
at risk, or have the potential to place at risk, the health, safety, or welfare of the public or of
youth, staff, visitors, the security of the facility, or the reputation of the program are reported and
handled appropriately and in a timely fashion. The program had thirty incidents reported to the
Department’s Central Communications Center (CCC) during the annual compliance review
period. A sample of seven incidents was reviewed. All seven incidents were reported within two
hours. Documentation in the facility logbooks was found for all seven CCC reports. The program
has experienced an increase in the number of reportable incidents to the CCC since the last
annual compliance review, from twenty-two to thirty. The facility administrator (FA) stated the
increase is due to the number of new staff and news of the possibility of changes to the
program’s contract. For CCC reportable incidents, when the FA/designee is notified of any
incident, it is determined if the incident is CCC reportable by review of the Department’s CCC
reportable incidents criteria. The FA/designee shall obtain necessary information and contact
the CCC within the two-hour time frame. Updates are made as necessary. Youth eighteen years
of age or older are permitted to contact the CCC upon request to report incidents of abuse or
neglect. The FA/administrative duty officer are primarily the reporting staff; however, any staff
can make a CCC report. For abuse reporting, all staff are mandated reporters and can contact
the Florida Abuse Hotline at any time. Youth who request to contact the Florida Abuse Hotline
are provided with the opportunity to do so immediately upon request.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 72 (Revised September 2022)
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program had ten incidents of utilizing Protective Actions Response (PAR)/Right Interactions
(RI) during the annual compliance review period. Five PAR Reports were reviewed, and all
reports were completed by the end of the staff’s shift and included statements from all staff
involved. Mechanical restraints were not utilized in any of the PAR Incidents. None of the
reports resulted in an allegation of abuse. All five reports reflected a review by a PAR/RI
certified instructor/supervisory staff and post-PAR/RI interviews were completed with the youth
involved within thirty minutes of the incident. All five reports were reviewed by the administrator
or designee within seventy-two hours of the incident. None of five reports indicated the need for
a PAR/RI medical review. The program submitted all PAR/RI incident data to the Department by
the fifteenth of every month during the annual compliance review period. The program’s PAR/RI
plan was updated and approved by the Department on January 9, 2023. The PAR/RI third
quarter rate during the annual compliance review period was 0.10 which is below the statewide
Residential PAR/RI rate of 1.22. The fourth quarter PAR/RI rate is 0.14 which is below the
statewide Residential PAR/RI rate of 1.35. According to the facility administrator, all PAR/RI
Reports are reviewed and compared to video surveillance of the incident. The facility
administrator added, the program follows up appropriately if use of PAR/RI is unwarranted or
improper. Seven pre-service and seven in-service training records indicated all staff received
PAR/RI training. An informal interview with the facility administrator indicated the program has
moved to training all staff in PAR/RI.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program has a policy and procedures ensuring all newly hired staff are sufficiently prepared
to satisfy pre-service training requirements. According to the program’s policy and procedures,
staff must complete a minimum of 120 hours of required training within the first 180 days of their
hire date. Training documentation was available for review within the Department’s Learning
Management System (SkillPro). All seven reviewed pre-service training records indicated all the
staff had the required 120 hours. Each of the seven staff completed the required training prior to
having any contact with youth to include cardiopulmonary resuscitation (CPR), first-aid,
automated external defibrillator (AED), Protective Action Response Right Interactions model,
ethics, suicide prevention, emergency procedures, child abuse reporting, and Prison Rape
Elimination Act (PREA). The program’s pre-service training plan was approved by the
Department on December 30, 2022.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 72 (Revised September 2022)
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a policy and procedures ensuring all staff maintain the necessary training to
meet the needs of the program and youth in their care. All seven reviewed in-service staff
completed the required mandatory in-service courses to include cardiopulmonary resuscitation
(CPR), first-aid, automated external defibrillator (AED), Protective Action Response Right
Interactions update, ethics, and suicide prevention. All seven in-service training records
reflected each staff completed over twenty-four hours of annual training. There were three
supervisory staff reviewed. All three had more than the required eight hours of supervisory
training in the areas of coaching, leadership, and personal accountability. All trainings were
observed to be documented in the Department’s Learning Management System (SkillPro). The
program submitted, in writing, a list of in-service training to the Department’s Office of Talent,
Leadership, and Culture and the training plan was signed on December 30, 2022. The program
has an annual training in-service training calendar, which is updated as changes occur.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures for youth to formally file complaints about conditions,
treatment, services, the actions of program staff, and other youth in violation of the youth’s
rights. Also to ensure such complaints are reviewed in a fair and timely manner, resolved to the
best interest of the youth, the program, and the Department. The program’s grievance process
includes an informal phase, including verbal dialogue and “Let’s Talk” forms, a written or formal
phase, and appeal phase, in which youth utilize the grievance form. According to the policy and
procedures, the program has seventy-two hours to handle informal and formal grievances. The
program reviews all grievances during morning management meetings and are followed-up on
within twenty-four hours. The program had two grievances filed since the last annual
compliance review. None of the grievances went to the appeal phase. The two grievances were
completed as required, meeting required time frames. The program had sixty “Let’s Talk” forms
completed since the last annual compliance review, five were reviewed and all were completed
according to policy. None of the sixty “Let’s Talk” forms were abuse related. The program
maintains a grievance binder monthly for completed grievances and “Let’s Talk” forms.
Grievance forms were observed to be available to youth on the dorms and by staff, as well as a
locked grievance box for submitting the forms. A review of seven pre-service staff training
records reflected all staff completed training on the program’s grievance procedures. Each of
the seven interviewed youth were familiar with the program’s grievance procedures. Two of
seven youth knew the phase levels. All seven youth reported they can ask for assistance in
filling out grievances and forms are available to them by asking staff. All seven interviewed staff
were familiar with the program’s grievance forms location and the procedures. According to the
facility administrator, youth have access to the grievance forms on the dorm and by asking staff.
Once the form has been completed the youth will place the form in the grievance box. The
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 72 (Revised September 2022)
grievance box is checked each morning and the grievances are reviewed in the morning
meeting. The grievance will then be given to the appropriate staff to meet with the youth within a
forty-eight hour time frame. During the informal phase the assistant facility administrator will
review the grievance, get back to the youth, and provide a written response within forty-eight
hours. In the formal phase the facility administrator will review the grievance, get back to the
youth, and provide a written response within twenty-four hours or no more than five business
days from the day the grievance was originally filed.
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 has a policy and procedures describing what type of delinquency interventions
shall be provided to the youth. A review since the last annual compliance review of intervention
group sign-in sheets indicated a total of eighteen staff facilitated various evidenced-based
groups. Each of the eighteen staff had been considered by the program, when making the
determination to deliver delinquency intervention services, according to their education and
work experience. All eighteen staff had training in all groups they facilitated. A review of the
contract indicated the program is required to conduct Impact of Crime (IOC), Thinking for a
Change (T4C), and Pathways to Self-Discovery and Change, each of which was provided by
trained therapists or case managers. A review of the activity schedule indicated the youth are
provided with structured, planned programming, or activities for at least sixty percent of awake
hours. A review of the non-primary groups including Young Men’s Work, The Council for Boys
and Young Men, and Teen Relationships was conducted and confirmed all were provided by
trained staff. The facility administrator stated the program provides IOC, T4C, and Pathways.
Group sign-in sheets were available for review and found groups were delivered, as designed
during the annual compliance review period. A review of seven youth records found all to be
participating in IOC. According to the facility administrator, all facilitators are trained to facilitate
the specialized service groups. Seven youth interviews indicated youth participate in daily
groups and are able to practice what they have learned throughout their day. The designated
mental health clinician authority (DMHCA) interview indicated the licensed mental health
professional provides clinical supervision for non-licensed mental health professionals, provides
the weekly group schedule, substance abuse treatment, and mental health treatment. The
DMHCA stated since there is no correct mix of learning styles, nor are youth learning styles
fixed, clinical services at the program are geared toward male adolescents and utilize several
modes of delivery to increase the prospects youth will respond positively to services. Written
clinical material is read aloud during each therapy group which helps youth whose dominant
style of learning is reading or listening. Role playing is performed in groups to involve youth
whose learning style is most productive when they are socially, emotionally, and physically
involved in a task. Written material is infrequently utilized in therapy groups due to the problems
which many youth in the program have with writing. When written material is used in a clinical
setting, youth who have difficulty with writing may pair up with fellow group participants to
complete the assignment. Written treatment plan objectives are converted to learning
experiences which are completed using verbal skills for these youth as well. Since some youth
learn best in a solitary manner, clinical material is often dispensed to them to complete on their
own and reviewed with their therapists during their individual sessions. Lastly, specific
curriculums are chosen for their effectiveness with reducing criminogenic risk factors. At the
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time of the annual compliance review, only licensed therapists provided substance abuse
treatment.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures which emphasize social and life skills training for
youth. These skills and intervention services address communication, interpersonal
relationships, non-violent conflict resolution, anger management, and critical thinking. Staff are
required to reinforce and model appropriate social skills. The program’s delinquency
interventions used for life skills training include the ARISE GANGS: 50 Plus Stories of Fractured
Lives, The Passport Program, Coping with Depression, Coping with Stress, The Council for
Boys and Young Men, Young Men’s Work, Pathways to Self-Discovery and Change, Thinking
for a Change (T4C), and Living in Balance. Interventions are evidence-based, a promising
practice, or practice with demonstrative effectiveness. A review of the program’s activity
schedule identified periods for groups reflecting life skills education. Samples of sign-in sheets
and group topics were reviewed and confirmed groups were being conducted with no issues.
Seven youth were asked what group/activities they participate in at the program. One youth
indicated they participate in Teen Relationships, one indicated they participated in Life Skills
group, all seven stated they participate in T4C, Impact of Crime (IOC), and Pathways. The
facility administrator indicated the Positive Performance System, living environment, clothing,
decorations, and two youth on-site have chosen pronouns which are honored to help target the
needs of a targeted gender 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 provides the Impact of Crime (IOC) curriculum which addresses restorative justice
awareness for youth and helps them develop empathy for crime victims and survivors, while
increasing personal accountability for criminal actions and harm to others. The IOC curriculum is
facilitated by the case managers of the program. The program’s activity schedule addresses
group times. Samples of sign-in sheets and topics were reviewed and confirmed groups were
being conducted as scheduled with no issues. In addition to the IOC curriculum, the program
also affords youth opportunities to complete community service hours on-site, send letters to
military personnel, complete apology letters to victims, hear from guest speakers from the
community, participate in the victim garden, student art gallery, and restorative justice games.
All seven interviewed youth confirmed they are currently participating in IOC as their restorative
justice group. The facility administrator stated each youth who enters the program is required to
participate in an IOC group. Each youth has an opportunity and is encouraged to participate in
community service projects within the program, as well as in the community. An observation of
an IOC group was completed through video surveillance during the annual compliance review
week, which matched the program’s activity schedule and required time frame.
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1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures which address and determine how youth alerts are
identified, documented, updated, and communicated to program staff. Seven youth records
were reviewed to address the program entering alerts in the Department’s Juvenile Justice
Information System (JJIS). One of the seven youth were found non-applicable for alerts and this
was confirmed in JJIS. The six applicable youth records reflected alerts were entered into JJIS,
as required. All alerts were verified prior to their entering into JJIS. Each of the six reviewed
youth alerts were applicable for, and evidenced by, being documented within the program’s
logbook. A review of the program’s internal alerts found they were consistent with alerts entered
within JJIS. All alerts requiring removal or downgrading were found to have been done so by the
appropriate staff member. The facility administrator was interviewed concerning the program’s
internal alert process, as well as the process of entering alert information into JJIS. The program
utilizes an internal alert system to include an alert roster and alert board which details all
applicable youth alerts; dietary, security, mental health, and medical. Any change in a youth's
alert status is updated on the board as well as documented in the shift logbook. The outgoing
shift supervisor briefs the incoming shift of any new/changed alerts. In addition, any
changed/new alerts are discussed during the morning management meeting. Nursing staff is
present along with program staff, security, case management, and mental health staff in the
morning meeting held daily, where alerts are discussed. The nurse interview confirmed nursing
staff are responsible for updating the JJIS alert system for medical. Seven interviewed staff
reported they are briefed on youth alerts through briefings with shift supervisors, and the internal
alert board located in administration.
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 separates the youth records into an individual management, individual healthcare,
and mental health records. All youth records are marked ‘Confidential.’ All records are
maintained in locked cabinets within the responsible program area’s office. No records were
observed to be accessible to youth. Office area doors are also marked ‘Confidential.’ A review
of seven individual management records found each record had a label which included the
youth’s name, Department identification number, date of birth, county of residence, and
committing offense. Each record includes legal information, demographic and chronological
information, correspondence, case management and treatment team activities, and
miscellaneous.
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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 joint community advisory board which is scheduled to meet on a quarterly
basis. A review of the community advisory board binder found the last quarterly advisory board
meeting was held on March 3, 2023. Board meetings are held in person and utilizing a video
conferencing software program for those members who cannot attend in person. A review of the
list of attendees, the board roster, and letters from the program found the facility administrator
(FA) has solicited involvement from a law enforcement representative, a judiciary community
representative, other community partners, a business community representative, a school board
or district representative, a faith community representative, and a LGBTQIA+ community
representative. A review of letters in the community advisory board binder confirmed the FA
recruited a victim, victim advocate, and a parent/guardian whose child was previously involved
in the juvenile justice system. Reviewed documentation reflected a representative from each
category was a member of the advisory board or had been invited to join the advisory board. An
interview was conducted with the FA who confirmed meetings are held quarterly. The FA
maintains the community advisory board requirements. Community advisory board meetings are
held quarterly and include review of an agenda detailing program updates and community
advisory board member updates. Following each meeting, the meeting minutes are shared with
all board members to inform those who may not have been present. Recruitment letters are
mailed out periodically to solicit new membership and ensure each position on the board is
properly represented. All positions are filled except for a judiciary representative. The
interviewed board member stated they have served on the board for several years and has
been attending the meetings.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures for evaluating staff, performance standards, and the
frequency of evaluations. The program’s policy indicates evaluations are to be completed
annually. A review of seven position descriptions was conducted and determined each staff
member’s performance standards were clearly identified. A sample of performance evaluations
were reviewed and determined to be completed consistent with the program’s policy. Staff are
evaluated at the ninety-day mark for first year employees and annually for all additional staff on
their established performance standards. The performance standards matched job descriptions
for each staff position reviewed. The facility administrator was interviewed, and stated the
program has a morale committee which meets monthly and plans activities for staff to
participate. The program recognizes staff with the Employee of the Month, Employee of the
Year, staff spotlight with a monetary incentive, daily snacks and drinks, staff referral program,
staff luncheons, and BBQ’s. The program conducts hiring events to hire new staff and reduce
burnout. The program hosts job fairs once a month. Seven staff were interviewed and five staff
reported they receive performance evaluations annually, one stated every six months, and two
stated monthly.
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1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s contract with the Department does not include a Memorandum of Negotiation
(MON), Summary of Negotiated Points, or Secretary letter. There are special contract conditions
not covered by the Monitoring and Quality Improvement indicators. One is the provider shall
provide a comprehensive monthly health education program in recurring cycles, so each youth
receives the benefit of all topics during their length of stay. The medical department maintains a
health education schedule which requires monthly health education groups for the entire year.
Secondly the program has a shared psychiatrist with Les Peters Academy who is required to be
on-site at least twelve hours a week, ten at Tampa Residential Facility (TRF). The psychiatrist is
meeting the required weekly hours. The psychiatrist is meeting the required weekly hours. The
third is a licensed Psychologist must be on-site weekly for eight hours. In November 2022, the
psychologist had to cancel the contract due to being required forty hours at another facility. The
program has been advertising the position weekly since November 2022. There have been
three interviews since November 2022, one has accepted the position and is currently
negotiating the contract. The fourth is the provider shall provide a business and technology
course for youth to earn a Microsoft Certification through computer mentors and the provider of
this course has stopped providing their certification. TRF has replaced the Microsoft Certification
with Forklift and Entrepreneurship and Small Business. Youth also receive cardiopulmonary
resuscitation (CPR)/first-aid certification. Nine youth have received the Forklift certification and
sixteen youth have received CPR/first-aid certifications. The fifth is the facility shall have home-
like furniture and clothing which was being met. The sixth is the facility shall maintain stock of
epinephrine auto-injectors (two boxes), regular insulin (one to two dose vile), purified protein
derivative (PPD) (one to two doses), albuterol inhalers (two), glucagon (one to two), and
glucose tablets or glucose. The program only maintains epinephrine auto-injector, insulin, and
albuterol inhalers as prescribed by the doctor; all additional items are being maintained on-site
as required. The Department’s Office of Health Services (OHS) provided input which stated the
medications should be youth specific, besides glycogen/glucose and epinephrine auto-injector,
and should not be kept as stock medication. Additionally, there should not be a specific number
of epinephrine auto-injector; however, there should be at least one on hand. OHS stated there is
not a medical need for this item to be on-site for this program type. The seventh requirement is
the program shall have a behavioral analyst on-site no less then sixteen hours weekly. The
program has three contracts with behavioral analysts who meet the required weekly hours on-
site. The eighth is to provide religious and spiritual opportunities, which the program offers
weekly. The ninth is to provide community involvement. Due to the program type, youth may not
go into the community. The program affords youth opportunities to complete community service
hours on-site, send letters to military personnel, complete apology letters to victims, provide
guest speakers from the community, participate in the victim garden, and student art gallery.
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1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
The program’s contract requires the program to provide career and technical education services
by the provider or directly provided by the local school district. The local school district in
conjunction with the program offer small business and entrepreneurship, Occupational Safety
and Health Administration (OSHA), and Warehouse Management Continuing Legal Education
(CLE) as the pre-vocational and vocational services. The informal interview with the facility
administrator supported this. Forty-five youth received certifications in entrepreneurship and
small business trainings and sixteen youth received the Warehouse Management/CLE
certifications. These classes have been built into the school schedule, so all youth participate
throughout the day. Education staff also provide My Career Shines, as well as their own
vocational pre-test and post-test for each youth. The lead teacher indicated they teach
interviewing and résumé writing skills to youth in the program. The program also provides high
school equivalency diploma (GED) and online college courses. The vocational programs are
appropriate for the ages of the youth in the program, are appropriate for the educational abilities
and goals of youth in the program, and are appropriate for the length of stay and custody
characteristics of the youth in the program. No observations of vocational activities were
observed while the annual compliance review team was on-site. The program’s education staff
provides Career and Professional Education (CAPE) courses leading to pre-apprentice
certifications and industry certifications. The career education programming includes
communication, interpersonal, and decision-making skills. Seven youth records were reviewed,
and each youth had a completed academic and career assessment, which was incorporated
into their performance plan. Seven youth were interviewed, and all said they participate in the
identified services.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a policy and procedures for reviewing and analyzing data trends to utilize in
decision-making practices. The program’s trend analysis and data-driven decision is
strengthened through an internal database and dashboard system which allows for daily data
entry by every program. This daily process and outcome information is aggregated into weekly
and monthly totals, displayed in interactive dashboards specific to each program, and provided
back to corporate as well as program management for the purposes of tracking trends and
informing risk management. The dashboards are updated every Monday with the previous
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week's data, such as the Monthly Key Performance Indicators (KPIs) tracking, including monthly
admissions, incidents, youth assaults and fights, youth restraints, family contacts, treatment
services for all groups, individual and family sessions, treatment teams, positive youth services
for community service hours and advisory boards, staff vacancies, and the Trauma Responsive
and Caring Environment (TRACE). The program shares the KPI trends in monthly staff
meetings and postings where the data trends are easily accessible by staff, educators, and
stakeholders. Information is discussed in daily meetings with administrative staff. Staff are
updated monthly in all staff meetings, quarterly advisory board meetings, and monthly corporate
senior management meetings. The findings from trend data analyses are utilized to determine
recruitment strategies, positive morale approaches, update the policy and procedures, youth
supervision techniques, restorative justice programs, and individual and family services.
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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 policy and procedures which require notification of the youth’s
parents/guardians by telephone within twenty-four hours of the youth’s admission, followed by
written notification within forty-eight hours of admission. In addition, the program must notify the
youth’s committing court, the assigned juvenile probation officer (JPO), and post-residential
services case manager, if applicable, in writing within five working days of any admission.
Seven youth case management records were reviewed, and all contained documentation which
confirmed the parent/guardian was contacted by telephone and informed of each youth’s arrival
and program information. All seven case management records contained a copy of a written
notification which was mailed to the parents/guardians on the day of intake informing the
parents/guardians of the youth’s admission. In addition, all seven records contained written
notification of intake to the JPO and committing court.
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 policy and procedures which state the program shall provide each youth an
orientation to the program’s rules, expectations, goals, and services, which is to begin on the
day of, or prior to, each youth’s admission. Seven youth case management records were
reviewed, and all contained documentation verifying the youth received an orientation on the
day of admission. The documentation contained all the elements required to be reviewed during
orientation. The program had no youth admissions during the annual compliance review week;
therefore, orientation was not observed. Seven youth were interviewed all said orientation
started withing twenty-four hours of their admission, and the orientation to the program included
program rules, procedures, and schedules. All youth were able to explain the orientation
process.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures requiring written consent of any youth eighteen years
of age or older, unless the youth is incapacitated and has a court-appointed guardian, before
providing or discussing with the parents/guardians any information related to the youth’s
physical or mental health screenings, assessments, or treatment. Three of the seven reviewed
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youth were over the age of eighteen. A review of the three applicable case management
records confirmed each contained documentation signed by the youth allowing the release of
information regarding physical or mental health screening, assessment, and/or treatment with
their parents/guardians.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a policy and procedures which outline the classification system. This system is
used for the purpose of assessing each youth admitted to a living unit, sleeping room, and
group or staff advisor. Youth are also reassessed and reclassified, if warranted, prior to
considering an increase in privileges or freedom of movement, participation in work projects, or
other activities involving tools or instruments which may be used as potential weapons or means
of escape, or participation in any off-campus activity. The procedure also requires all admitted
youth to be screened for vulnerability to victimization and sexually aggressive behavior prior to
room assignment. Room assignments by staff shall ensure a youth’s potential for victimization
or predatory risk has been reviewed. The program’s classification forms included the physical
characteristics of the youth, age, maturity level, identified special needs, history of violence,
gang affiliation, criminal behavior, sexual aggression of vulnerability to victimization, the youth’s
perception of vulnerability, any history of potential or verified human trafficking, suicide, medical,
escape, and/or security risks. Seven youth case management records were reviewed, and each
contained a copy of the admission classification form, which was completed on the day of
admission, and addressed all suspected risk factors. A review of the Department’s Juvenile
Justice Information System (JJIS) confirmed alerts were entered for any issues affecting
classification. All youth were classified for purposes of assignment to a living area, sleeping
room, and youth group or staff advisor. Any youth identified with a medical, mental health,
substance abuse, security risk factors, and/or special needs identified during or subsequent to
the classification process immediately had the appropriate alert entered into the program’s
internal alert system and JJIS. The seven reviewed youth records all contained documentation
which confirmed reassessments were completed whenever there was an increase of the youth’s
privileges, participation in work projects, or other activities involving tools or instruments which
may be used as weapons to provide a means of escape. No youth at the program participate in
off-campus activities. The facility administrator was interviewed and advised all factors are taken
into consideration during classification to ensure youth are placed in the most secured
environment which best fits their needs.
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2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures in place to gather information on youth with any
involvement in gangs and share this information with law enforcement. Seven youth case
management records were reviewed, and three youth were applicable for gang involvement.
Each of the applicable records contained documentation which confirmed notifications were
made to the local sheriff’s office. These notifications were all made prior to the seven-day notice
of the annual compliance review. Two of the three applicable youth’s residential commitment
placements were not in their home county. In both cases law enforcement in the youth’s home
county was notified of the youth’s gang affiliation. In all three applicable youth records, alerts
were updated in the Department’s Juvenile Justice Information System and the program’s
internal alert system. Information of each youth’s gang status was shared with the education
department and the youth’s juvenile probation officer.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures in place for the implementation of gang prevention
and intervention strategies. The program provides intervention strategies when youth are
identified as a criminal street gang member, are affiliated with any criminal street gang, or are at
high-risk for gang involvement. Seven youth case management records were reviewed and
three were applicable for gang affiliation/membership. The three applicable records contained
written documentation showing each youth participated in gang prevention and intervention
strategies. Each of the applicable youth had performance plans with included relevant goals and
gang intervention strategies for the youth to complete prior to release from the program. Gang
intervention strategies implemented at the program included Impact of Crime (IOC), Gang
Awareness, and Gangs: 50 Plus Stories of Fractured Lives in addition to information on how to
disaffiliate from a gang. A review of sign-in sheets verified the applicable youth were
participating in the gang intervention groups as required. The facility administrator was
interviewed and verified the program’s gang intervention strategies are IOC, Gang Awareness,
and Gangs: 50 Plus Stories of Fractured Lives.
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2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures which require the initial Residential Assessment
for Youth (RAY) be completed within thirty days of admission and reassessments be completed
at least every ninety days. The program is to ensure any additional updates or reassessments
are completed by the intervention and treatment team to effectively manage the youth’s case.
Seven youth case management records were reviewed, and all had the RAY completed within
thirty days of admission. The initial assessments were all maintained in the youth case
management record as well as in the Department’s Juvenile Justice Information System. Four of
the seven youth were applicable for reassessments. Three youth had not been in the program
for ninety days at the time of the annual compliance review. Three of the four applicable youth
had all reassessments completed within ninety days from the time the last reassessment was
completed. One youth had one reassessment completed twenty-one days late. Two youth
required additional updates and reassessments at other intervals, and both were completed as
required. All reassessments were maintained in each youth’s case management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
The program has a policy and procedures requiring the Youth Needs Assessment
Summary (YNAS) to be completed within thirty days of admission. Seven youth case
management records were reviewed, and all had the YNAS completed within the first thirty
days of each youth’s admission. All summaries were documented in the Department’s Juvenile
Justice Information System.
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2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a policy and procedures which require the intervention and treatment team,
including the youth, to meet and develop the performance plan, based on the findings of the
youth’s initial assessment, within thirty days of admission. The performance plan shall include
the target date for completion of each goal, in addition to the youth’s responsibilities to
accomplish the goal, and the program’s responsibilities to enable the youth to complete the
goal. The program shall send a transmittal letter and a copy of the plan to the youth’s
committing court, the assigned juvenile probation officer (JPO), the parents/guardians, and the
Department of Children and Families (DCF) case manager, if applicable, within ten working
days of completion of the performance plan. Seven youth case management records were
reviewed, and all records contained documentation of the individualized performance plan being
developed within thirty days of each youth’s admission. All performance plans were developed
following the youth’s initial Residential Assessment for Youth (RAY) and the Youth Needs
Assessment Summary. All members of the treatment team were present during the
development of the individualized performance plan, as indicated by their signature on the plan.
Two of the seven youth were under the care of the DCF, and the assigned caseworkers
participated in the development of the performance plan. Three youth were over the age of
eighteen; therefore, their parents/guardians did not participate in the development of the
performance plan. The four remaining youth had their parents/guardians attend by telephone,
and a copy of the signature sheet was mailed to each parent; however, none had been
returned. The signature sheets for all youth were filed in each youth case management record.
In all seven youth records reviewed, the performance plans included the individualized goals
and were based upon the prioritized needs reflecting the risk and protective factors identified
during the initial assessment process. The youth’s three top criminogenic needs, delinquency
interventions based on RAY results, with measurable outcomes which are intended to decrease
the youth’s criminogenic risk factors, promote strengths, supports to reduce the likelihood of the
youth reoffending, target court-ordered sanctions which could be completed while in the
program, transition activities targeted for the last sixty days of the youths stay, youth and
program staff responsibilities to accomplish and complete goals, and target days for completion
were included. A transmittal letter and copy of the performance plan was sent to the committing
court and the JPO within ten days of completing the plan, for all seven youth reviewed. Four of
the youth had a copy of their performance plan mailed to their parents/guardians within ten days
of completing the plan; the remaining three youth were over the age of eighteen; therefore, a
copy of the plan was not mailed to the parents/guardians, as they did not participate in the
development of the plan. A copy of the performance plan was mailed to the DCF caseworker for
one applicable youth within ten days of completing the plan. The remaining youth under the care
of DCF was over eighteen; therefore, the DCF caseworker did not participate in the
development of the plan. Seven youth were interviewed, and all knew their performance plan
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Office of Accountability and Program Support Page 26 of 72 (Revised September 2022)
goals. Five youth said they had a copy of their performance plan and two said they did not have
a copy of their performance plan.
2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
The program has a policy and procedures in place to ensure the performance plans are
reviewed monthly and revised as necessary. Seven youth case management records were
reviewed, and each contained documentation showing the performance plans were reviewed
every thirty days during each youth’s formal treatment team review. Three of the records
contained revisions due to newly acquired/revealed information which warranted revisions. All
seven records contained revisions which were a result of the youth demonstrating progress
towards completing a goal. One youth was applicable for revisions to the individualized
performance plan to facilitate transition during the last sixty days of the youth’s stay, and all
required revisions were made.
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 policy and procedures which require the treatment team to prepare a
Performance Summary at ninety-day intervals, beginning ninety-days from the signing of the
youth’s performance plan, or at shorter intervals when requested by the youth’s committing
court. The treatment team shall also prepare a Performance Summary prior to the youth’s
release, discharge, or transfer from the program. These summaries shall be distributed within
ten working days of signing. Seven youth case management records were reviewed, and all
contained documentation confirming Performance Summaries are being completed within the
required time frame. All Performance Summaries included the youth’s status on performance
plan goals, the youth’s overall treatment progress, the youth’s academic status, behavior, level
of motivation/readiness for change, interaction with peers, interaction with staff, overall behavior
adjustment to the program, and any significant positive or negative events. All seven records
indicated each youth was allowed to read and add comments to the Performance Summary
prior to signing, and verified the youth received a copy. The original Performance
Summaries are maintained in each youth’s case management record. All the Performance
Summaries were signed by the treatment team leader, staff who prepared the summary, the
facility administrator or designee, and the youth. A copy of the summaries was sent to the
committing court and the juvenile probation officer (JPO) within ten working days. Four of the
youth had summaries sent to their parents/guardians within ten days. Three did not because
they were over eighteen years of age. One youth who was under the age of eighteen and in the
care of the Department of Children and Families (DCF) had a copy of the summary sent to the
DCF caseworker within ten days. A sample of three closed youth case management records
was reviewed to ensure release summaries were being completed as required. A review of
three records confirmed the release summaries included the original summary, along with
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justification for release was sent with Pre-Release Notification (PRN) to the JPO. The release
summary and PRN were sent at lease forty-five days prior to the youth’s planned release, with a
signed copy retained in each youth’s case management record. The court did not object to the
youths’ release in any of the three closed youth case management records reviewed. Once the
release was approved, the program provided written notification to each youth’s
parents/guardians and completed a Residential Assessment for Youth. None of the closed
youth records required victim notification.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to encourage and facilitate the involvement of the
youth’s parents/guardians in the case management process. The program encourages
parents/guardians involvement in the assessment process, in the participation of the
performance plan, during progress reviews, during treatment team meetings, and during
transition planning. If the parents/guardians are unable to attend any of these meetings in
person, they are given the opportunity to participate by telephone and can provide verbal or
written input as well. A treatment team meeting for two youth was observed during the annual
compliance review week. In both instances, the parent actively participated on the telephone.
The program offers monthly family group sessions on-site or by conference call to involve the
youth's family in treatment and to provide support to the youth. The program also provides
family visitation, and the case managers and therapists encourage parents/guardians to visit
when they speak to them during treatment team meetings. The facility administrator was
interviewed and advised parents are encouraged to attend and are invited to participate in all
aspects of the youth’s treatment in the program. Seven youth were interviewed and six said
their parents/guardians are involved in their case management. One youth was over the age of
eighteen and did not involve their parent/guardian in their case management.
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 policy and procedures in place to ensure the youth’s performance plan
references or incorporates the youth’s treatment or care plan. Seven youth case management
records were reviewed, and all contained plans in addition to the performance plans, which
included academic and treatment plans. The performance plans referenced and incorporated
the additional plans for each youth. Each youth has a separate treatment plan, such as medical,
mental health, or substance abuse. Two of the seven youth were under the supervision of the
Department of Children and Families (DCF), and both had case plans through DCF, which were
coordinated with each of the applicable youths’ performance plans.
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Office of Accountability and Program Support Page 28 of 72 (Revised September 2022)
2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
The program has a policy and procedures governing treatment team meetings and their
composition. The procedures require treatment teams meet bi-weekly, alternating between
formal and informal, to review each youth’s performance, to include Residential Assessment for
Youth (RAY) results, progress on individualized performance plan goals, and positive and
negative behaviors. Seven youth case management records were reviewed for formal and
informal treatment team meetings. All youth had formal reviews conducted at least every thirty
days. The documentation for formal treatment team meetings included the youth’s name, date
of review, required attendees, comments from members, a brief synopsis of the youth’s
progress in the program, performance plan revisions, progress of the goals, any behaviors
which resulted in physical interventions, treatment progress, and RAY reassessment results. All
formal treatment team documentation was contained in each youth record reviewed.
Documentation was reviewed which confirmed informal treatment team meetings were
conducted for each youth bi-weekly each month, alternating with the formal treatment team
meetings, which result in each youth having an informal or formal treatment team meeting every
two weeks. The informal treatment team meetings documented the youth’s name, date of
review, required attendees, comments from members, a brief synopsis of the youth’s progress
in the program, performance plan revisions, progress of the goals, any behaviors which resulted
in physical interventions, treatment progress, and RAY reassessment results. In all formal and
informal treatment team meetings, each youth was provided an opportunity to demonstrate skills
acquired in the program. Each youth’s juvenile probation officer, parents/guardians for those
youth under the age of eighteen, and any other pertinent parties were invited and given the
opportunity to provide input. During the annual compliance review week, a treatment team
meeting was observed for two youth. In both instances, all required staff were present, and
there was a review of the treatment plan to determine each youth’s anticipated release date.
Seven youth were interviewed and all seven youth replied staff review youth performance to
include progress on performance plan goals, positive and negative behavior, and treatment
progress. Six youth also reported they were given an opportunity during treatment team
meetings to demonstrate any skills they have learned in the program. The remaining youth
advised he does not get mad, which is why he doesn't demonstrate learned skills.
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Office of Accountability and Program Support Page 29 of 72 (Revised September 2022)
2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a policy and procedures in place to ensure the intervention and treatment
team is planning for the youth’s successful transition to the community upon release from the
program. Three closed youth case management records were reviewed, and all had
documentation confirming each youth attended a transition conference at least sixty days prior
to the youth’s targeted release. All of the transition conferences were attended by the youth,
treatment team leader, facility administrator or designee, the youth’s juvenile probation officer
(JPO), the parents/guardians, and education staff. During the transition conference, the
participants reviewed each youth’s performance plan for transition activities, revised the
activities, if necessary, identified additional activities/services, if needed, and identified target
completion dates with persons responsible for completion. The treatment team leader obtained
dated signatures from all attendees. A copy of the plan was sent with a request for return with
signature from anyone who did not attend the meeting, and the plan was transmitted
electronically to the JPO, with the return email acknowledgement printed and filed with the plan.
Community Re-Entry Team (CRT) meetings were also conducted prior to each youth’s release.
Each closed youth record contained copies of the invitation for participation in the CRT meeting,
and each CRT meeting was attended by the youth and case manager at a minimum.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures requiring for the assembly of an exit portfolio for each
youth to assist them once released back into the community. Three closed youth case
management records were reviewed, and all contained an exit portfolio which had been
discussed and initiated for each youth during the transition conference. The exit portfolios
contained a copy of the youth’s state-issued identification card, a copy of the transition plan, a
calendar with dates, times, and locations of upcoming community appointments, a copy of the
youth’s Social Security card, a copy of each youth’s birth certificate, educational and vocational
certificates, educational records, résumé, and sample completed employment applications. All
exit portfolios were verified during each youth’s exit conference, and the documentation
indicated the exit portfolio was completed and given to the youth upon release, with the exit
portfolio information forwarded to the juvenile probation officer.
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Office of Accountability and Program Support Page 30 of 72 (Revised September 2022)
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures which require an exit conference to be conducted, in
addition to a formal or informal meeting to review the status of any goals developed during the
transition conference, and to finalize release plans. Three closed youth case management
records were reviewed, and all had an exit conference which was conducted at least fourteen
days prior to the youth’s release, and after the program notified the juvenile probation officer
(JPO) of the youth’s release. A review of the documentation confirmed the date of each
conference, signatures of the attendees, and a summary of transition goals. Each youth’s date
of admission and date of termination documented in the case record matched with the dates in
the Department’s Juvenile Justice Information System. The exit conferences were attended by
the treatment team leader, parents/guardians, education representative, JPO, and all three
youth. The exit conference was held separately from the transition and the Community Re-Entry
Team meetings for all three youth.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a formal process which promotes constructive input from youth. The program
uses the “Let’s Talk” forms, grievance procedures, daily housing meetings, and the youth
advisory board meetings as mechanisms to promote constructive input by youth. Youth advisory
board meeting agendas, minutes, notes, “Let's Talk” forms, and grievance logs were reviewed
during the annual compliance review week. The youth advisory board meetings are held
monthly at the program. Seven youth were interviewed and stated they can provide constructive
input about things which happen in the program. Three of the youth specifically said they
provide input during the youth advisory meetings. The facility administrator was interviewed and
advised youth input is obtained during the monthly youth advisory board meetings, during daily
housing meetings, surveys which are completed by youth, and during treatment team meetings.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program maintains a policy and procedures to provide for career education. The program
provides Type 3 career education offered to all youth which includes Microsoft Office and digital
technology. Also offered to all youth is the Forklift certification. Incorporated into those programs
are communication, interpersonal skills, and decision-making skills. The facility administrator’s
interview indicated the youth are offered high school equivalency diploma (GED)/college
opportunities. According to the lead educator’s interview, youth are administered a career
assessment upon entering the program. Four closed youth case management records and
education records were reviewed. All four records contained a résumé and completed job
applications. Also included in the four applicable youth records was documentation the
parents/guardians and juvenile probation officer were aware of the youth’s career and
educational service plan. Each of the four education records contained documentation indicating
the completed job applications, specific to their home locations, were uploaded through a
website which assists with employment opportunities. All records contained each youth’s local
Career Source Center’s address and hours of operation. Three of the four youth had a copy of
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Office of Accountability and Program Support Page 31 of 72 (Revised September 2022)
their State of Florida identification (ID) card, while the fourth had a note indicating the
cancellation of the Florida Licensing on Wheels (FLOW) bus was scheduled to come in order for
youth to obtain their ID cards.
2.20 Educational Access (Critical) Limited Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide educational access for the youth.
Educational services are provided through the Hillsborough County School District which
approves the 250-day school calendar. A review of the daily education schedule revealed youth
are provided with a minimum of twenty-five hours of instruction each week, incorporating six
fifty-minute class periods, as indicated on the daily school schedule provided by the lead
educator. The 250-day calendar includes 240-days of instruction, as well as ten days for training
and/or teacher planning throughout the school year. The lead educator indicated the daily
schedule is followed with minimal interruptions. Seven randomly selected logbook entries were
reviewed, covering five different months during the review cycle. All reviewed days showed the
youth were deviating from the instructional schedule by five to forty-five minutes daily. The
inconsistencies were prevalent at the beginning of the school day, as well as returning from
lunch and end of day release. There were three days of video footage reviewed for transition to
education. On all three days; July 11, July 14, and July 20, 2023, it was discovered the youth
did not transition to and from classes according to the daily schedule provided. On July 14th,
there is no video evidence the youth returned to school after lunch. The school times for these
three days were also verified with logbook reviews, which matched the video footage. With the
findings from the logbook and video reviews, the program is falling short of the weekly
requirement of 25 hours of instruction. Seven youth were interviewed, and two of the seven
indicated there were interruptions during the school day, while the remaining five said there
were no interruptions. The reasons noted for the interruptions were codes, rain, or staff dealing
with situations.
2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program maintains a policy and procedures requiring an educational transition plan to be
developed upon the youth’s admission into the program. Four closed youth case management
records were reviewed and confirmed the program’s instructional staff and the youth completed
an education transition plan upon admission. One youth entered the program as a graduate, so
they did not have an education transition plan but had transition plans pertaining to their
education and employment upon their release. The education transition plans for four applicable
youth included services and interventions based on each youth’s assessed educational needs,
post-release education plans, recommended post-release placement, and specific monitoring
responsibilities for individuals responsible for the reintegration and coordination of the provision
of support services. The development of the plan and subsequent plans such as the youth’s exit
transition plan and Electronic Educational Exit Plan (EEEP) included key members including the
youth, parents/guardians, education representative, and school district personnel responsible
for providing guidance services, for each of the four youth. Seven youth were interviewed, as
well as the lead educator, and all indicated the plans were collaboratively developed upon the
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Office of Accountability and Program Support Page 32 of 72 (Revised September 2022)
youth’s entry into the program. The seven youth also reported they felt the program was
preparing them very well for the high school equivalency diploma (GED), high school, vocational
school, employment, and/or college.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 33 of 72 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program has a full-time licensed mental health counselor (LMHC) who serves as the
designated mental health clinician authority (DMHCA) and as the clinical director. The DMHCA’s
license is clear and active in the State of Florida with an expiration date of March 31, 2025. The
DMHCA is scheduled to be on-site for twenty-five hours a week to ensure appropriate
coordination and implementation of mental health and substance abuse services were taking
place. The DMHCA serves as the program’s mental health and substance abuse authority. The
DMHCA provides at least one hour of clinical supervision per week for each unlicensed mental
health therapist, ensures compliance with overlay requirements which include mental health
treatment services, substance abuse treatment services, and major disorders dual/intensive.
The DMHCA ensures proper completion of documentation and integration of a mental health
delivery system which meets all state and federal guidelines. The DMHCA has the responsibility
for directing the program’s psychological and treatment services in technical and administrative
duties, testing, individual, group, and family therapeutic activities, research, and participation in
overall institutional programming and administration. The DMHCA is available to provide
emergency consultation services and is on call twenty-four hours each day for emergencies.
The role of the DMHCA is to provide ongoing supervision to all staff within the program. The
DMHCA provides both formal and informal assistance to all staff. In an effort to ensure the
services are being implemented, the DMHCA conducts fidelity checks of group services, chart
audits, and a review of the weekly progress notes. The DMHCA reviews monthly treatment plan
reviews to ensure the clinical team is working on identified goals with the youth. The DMHCA
also provides annual training to all staff to ensure everyone is provided with a refresher as it
pertains to suicide training, effective communication, Prison Rape Elimination Act (PREA)
needs, and how to work with traumatized youth. The DMHCA meets daily with the management
team to ensure all departments are working together and to address any needs as they arise or
to help prevent any potential complications. The program has two back-up DMHCAs who
provide coverage in the DMHCA’s absence. The back-up DMHCA’s licenses are clear and
active in the State of Florida with an expiration date of March 31, 2025. The DMHCA interview
indicated the role of the clinical director is to provide ongoing supervision to all staff within the
program. The clinical director provides both formal and informal assistance to all staff. In an
effort to ensure the services are being implemented, the clinical director conducts fidelity checks
of group services, chart audits, and a review of the weekly progress notes. The clinical director
reviews monthly treatment plan reviews to ensure the clinical team is working on identified goals
with the youth. The clinical director also provides annual training to all staff to ensure everyone
is provided with a refresher as it pertains to suicide training, effective communication, PREA
needs, and how to work with traumatized youth. The clinical director meets daily with the
management team to ensure all departments are working together and to address any needs as
they arise or to help prevent any potential complications.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 34 of 72 (Revised September 2022)
3.02 Licensed Mental Health and Substance Abuse Clinical
Limited 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 designated mental health clinician authority (DMHCA) is responsible for ensuring mental
health and substance abuse services are provided by individuals with appropriate qualifications.
The clinical supervisor ensures clinical staff working under their supervision are performing
services the staff are qualified to provide based on education, training, experiences based on
review of job description, and an informal interview with the DMHCA. The licensed mental
health and substance abuse clinical staff all possess adequate education and training to
perform the duties for which they are assigned and meet all applicable licensing or certification
requirements for their respective disciplines and Florida Administrative Code. The program is
not licensed under Chapter 397 with the Department of Children and Families to provide
substance abuse services for outpatient treatment. Substance abuse services are provided by
licensed staff within the program. During the annual compliance review period, the program had
a total of three licensed therapist vacancies.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures ensuring the facility administrator is responsible for
providing mental health and substance abuse services by individuals with appropriate
qualifications. The program has four full-time non-licensed mental health clinical staff who
provide services to the youth in the program. Each of the non-licensed mental health clinical
staff hold a master’s level degree from an accredited university or college in the field of
counseling, social work, psychology, or related human services field. The clinical staff schedules
were different to ensure the program has clinical staff present seven days a week. The
designated mental health clinician authority (DMHCA) shall ensure clinical staff working under
their supervision are performing services the staff are qualified to provide based on education,
training, and experience. An informal interview with the DMHCA confirmed 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. A review of
the Department’s Licensed Mental Health Professionals and Licensed/Certified Substance
Abuse Professional Direct Supervision Log form during the annual compliance review period
confirmed each non-licensed mental health clinical staff working under the direct supervision of
a licensed mental health professional received a minimum of one hour of on-site, face-to-face
direct group supervision and one hour of monthly direct individual supervision by a licensed
mental health professional for the purpose of overseeing and directing the mental health
services provided. Reviewed documentation confirmed direct supervision was recorded on the
Department’s Licensed Mental Health Professionals and Licensed/Certified Substance Abuse
Professional Direct Supervision Log form. The program has a designated recreational therapist.
The program’s staffing roster was reviewed, as well as the therapist’s diploma and both
confirmed the therapist met the program’s required credentials. Reviewed documentation
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Office of Accountability and Program Support Page 35 of 72 (Revised September 2022)
confirmed each non-licensed mental health clinical staff who conducted Assessments of Suicide
Risk completed twenty hours of training and supervised experience in assessing suicide risk,
mental health crisis intervention, and emergency mental health services. During the annual
compliance review period, the program had no vacancies for non-licensed therapists.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a policy and procedures to ensure each youth’s mental health and substance
abuse needs are identified through a comprehensive screening. The program ensures mental
health and substance abuse services are available to all youth who are determined to meet
clinical criteria and certified to receive such services. Mental health and substance abuse
treatment is provided on-site. Immediately upon the youth’s admission to the program, a
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) is initiated by a clinical
staff to ensure the identification of mental health and substance abuse issues requiring
immediate attention and/or further assessment. A review of seven mental health records
confirmed the screener reviewed available information to include the commitment packet and
reports and/or records for existing documentation of mental health or substance abuse
problems or history of human trafficking, for all seven youth. Each of the reviewed records
confirmed all assessments were completed on the day of admission into the program by the
licensed mental health counselor (LMHC). A review of seven records confirmed each screening
was completed in the Department’s Juvenile Justice Information System (JJIS) and
administered in a confidential manner on the day of admission. Reviewed documentation
confirmed each MAYSI-2 was completed in full and each indicated further assessment was
required. A referral was made for further evaluation or immediate attention in each record. One
of the seven reviewed records confirmed the staff determined a referral for further evaluation
was needed; however, the MAYSI-2 did not indicate a referral was necessary, and staff entered
in JJIS the information, observations, events, and/or concerns leading to the determination a
referral was needed. Six of the seven reviewed mental health records were not applicable for an
override. Two of the seven reviewed records confirmed when the MAYSI-2 or other admission
information indicated the need for an assessment, crisis intervention, or emergency services,
the facility administrator (FA) or designee was notified, and a referral was made to alert the
designated mental health clinician authority (DMHCA). Five of the seven reviewed mental health
records were not applicable. Seven reviewed records confirmed the FA ensured an Assessment
of Suicide Risk (ASR) was conducted within twenty-four hours when the MAYSI-2 category
“suicide ideation” indicated further assessment was needed or other information obtained at
intake/admission suggested suicide risk. Additionally, two of the seven reviewed case records
had concerns of suicide ideation. Five reviewed case records were not applicable. Each of the
seven youth required an ASR and comprehensive assessment. Each of the seven youth
records documented the reason for the referral on the MAYSI-2. The FA was interviewed and
stated the MAYSI-2 is completed upon intake or when a youth returns from being out of
placement and an ASR is completed upon intake or when a hit on the MAYSI-2 occurs.
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Office of Accountability and Program Support Page 36 of 72 (Revised September 2022)
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a policy and procedures which serve as the comprehensive written plan for
mental health and substance abuse services to establish the coordination of mental health and
substance abuse services for all youth. A review of seven youth mental health and substance
abuse records confirmed each youth had a new Comprehensive Mental Health and Substance
Abuse Evaluation completed by a licensed clinician within thirty calendar days of admission.
Each reviewed assessment included identifying information, the reason for evaluation, relevant
background information including home environment and family functioning, history of physical
abuse, neglect, witnessing violence and other forms of trauma, behavioral functioning, physical
health, methods of assessment, patterns of alcohol and other drug abuse, impact of alcohol and
other drug abuse on major life areas, risk factors of continued alcohol and other drug abuse,
clinical impression including a Diagnostic and Statistical Manual, Fifth Edition (DSM-V)
diagnosis, and recommendations.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures regarding mental health and substance abuse
treatment. A review of seven youth mental health and substance abuse records confirmed an
initial treatment plan was developed for all seven youth within seven days of initiation of
treatment during the day of intake. Each initial mental health and substance abuse treatment
plan was documented on the Department’s Initial Mental Health/Substance Abuse Treatment
Plan form. Each reviewed initial mental health treatment plan or initial substance abuse
treatment plan confirmed development 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 signed by the mental health clinical staff completing
the form. Each initial treatment plan was completed by a non-licensed mental health clinical staff
and signed by the licensed mental health professional within ten days, as required. The initial
treatment plans for all seven youth were signed by all treatment team members who
participated in the development of the plan. The initial treatment plans included each youth’s
psychiatric needs, including medication and frequency of monitoring by the psychiatrist. Each
individualized treatment plan was developed for the youth within thirty days of admission. Each
individualized treatment plan was developed on the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan form. All plans were signed on the same date they
were developed. Each individualized treatment plan was signed by the mental health or
substance abuse clinical staff completing the plan. Each reviewed plan confirmed the plan was
completed by a non-licensed staff, and reviewed and signed by the licensed supervisor within
ten days of completion. Each plan was signed by all treatment team members who participated
in the development of the plan. Reviewed documentation indicated each youth’s plan was
mailed to their parents/guardians for signatures. All seven individualized treatment plans
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included psychiatric services and were signed by the psychiatrist. Three youth were prescribed
psychotropic medications and each individualized treatment plan documented the youth’s
psychotropic medication and frequency of monitoring by the psychiatrist. All three youth records
contained individualized treatment plan reviews completed on a form which contained all the
information on the Department’s Individualized Mental Health/Substance Abuse Treatment Plan
Review form. Each record contained reviews which were completed at least every thirty days
following the development of the individualized treatment plan. Each individual treatment plan
contained services for each youth. Services included individual sessions, groups, family, and
psychiatric services. Each individual treatment plan included family counseling and medication
management. Individual sessions are weekly for a minimum of fifty minutes. Group therapy is
conducted daily for sixty minutes. Family therapy is conducted monthly for a minimum of fifty
minutes. Psychiatric services are conducted once during the time of intake and medication
management services are conducted once a month. Each plan documented goals and
objectives individualized for each youth. A comparison of video footage reviewed to the
logbooks and sign-in sheets confirmed groups were conducted for the required group
time/length.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program has a policy and procedures for treatment and discharge planning. Seven youth
mental health and substance abuse records were reviewed for mental health and substance
abuse treatment. Each reviewed youth was assigned a treatment team upon arrival to the
program. The 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. A review of seven youth records contained treatment team documentation, which
confirmed team members who were in attendance included the youth, program administration,
medical staff, mental health staff, substance abuse staff, if required, and parents/guardians
when possible. Seven reviewed youth were applicable for substance abuse treatment services.
Each reviewed record confirmed youth in need of substance abuse treatment received
individual, group, and/or family counseling provided by a licensed qualified professional. Four of
the seven reviewed youth who received mental health treatment had a properly executed
Authority for Evaluation and Treatment (AET) form and three of the youth were not applicable
due to being eighteen years of age or older. Each reviewed youth who received substance
abuse treatment provided consent through a signed Youth Consent for Substance Abuse
Treatment form. All mental health treatment notes or substance abuse treatment notes were
documented on the Department’s Counseling/Therapy Progress Notes form. Each of the
reviewed youth records confirmed mental health and substance abuse group therapy included
individual psychotherapy or counseling. Each youth’s progress notes confirmed youth received
services as stipulated on the treatment plan. The seven youth records were not applicable for
discharge plans; therefore, an additional three youth records were requested for review. Three
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reviewed discharge plans confirmed documentation on the Department’s Manual
Health/Substance Abuse Treatment Discharge Summary form. Each of the reviewed Mental
Health/Substance Abuse Treatment Discharge Summary forms documented the services
needed for daily maintenance of the positive improvement in behavioral, emotional, and social
skills made by the youth during treatment. Each reviewed plan confirmed the discharge plan
was discussed with the youth, parents/guardians (when applicable), and juvenile probation
officer (JPO) during the exit conference. A copy of the Mental Health/Substance Abuse
Treatment Discharge Summary form was provided to the youth, JPO, and to the
parents/guardians (as allowed).
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program has a contract to provide mental health treatment services, substance abuse
treatment services, and major disorder dual diagnosis/intensive services. The program’s
required clinical groups include Passport, Pathways, Coping with Depression, Coping with
Anxiety, Social Skills – Non-Substance Abuse youth, Teen Relationship Workbook, Substance
Abuse/Mental Health Anger Management, and Strategies for Anger Management. Seven youth
were interviewed, and all indicated they are participating in individual counseling. Six of seven
youth stated they are receiving family counseling monthly and one stated they do not receive
family counseling. Four of seven youth stated they receive individual counseling weekly, one
stated daily, one stated every two weeks, and one stated two times per week. Two of seven
interviewed staff stated only mental health clinical staff facilitate the mental health and
substance abuse groups. Five staff stated they do not facilitate mental health or substance
abuse groups. The designated mental health clinician authority (DMHCA) was interviewed and
stated there are several mental health and substance abuse treatment services which are
provided at the program. The youth are provided with individual, group, and family therapy. The
youth are provided with treatment goals addressing both mental health and substance abuse
needs. The program offers behavior management services, medication management, skills
training, and life skills training. All youth receive a treatment plan with goals and objectives
addressing identified needs which are identified through a records review, interviews with both
the youth and the guardian as well as juvenile probation officer (JPO), and through behavioral
observations. Reviewed documentation confirmed the program provides individual, group, or
family therapy at least five days a week, with an average of seven days a week. The program
provides individual, group, and/or family counseling to each youth as part of the individualized
treatment plan. Daily therapeutic activities are provided by mental health clinical staff. Youth
with co-occurring substance abuse disorders receive substance abuse services. The program
arranges for a psychologist to provide services eight hours a week from a contracted
psychologist; however, the psychologist position is still vacant and the program is currently in
negotiations to fill the position. Therapists’ caseloads are limited to no more than twelve youth
with an average of eight or nine during the annual compliance review period. Licensed providers
provide substance abuse groups and are also qualified to provide substance abuse education.
The program provides urinalysis drug testing, with positive tests followed by appropriate clinical
intervention and sanctions, individual, group, and family therapy as part of each youth’s
treatment plan. Each youth receives individual, group, or family therapy at least five time a week
and group therapy is limited to no more than fifteen participants. Each youth receives daily
therapeutic activities such as substance abuse education, relapse prevention, substance refusal
skills, and coping skills. Youth with co-occurring mental health disorders receive mental health
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treatment. The program is not licensed under Chapter 397; however, a licensed qualified
professional provides substance abuse services. The program has a licensed psychiatrist who
provides psychiatric evaluations and medication management and participates in treatment
planning. The program provides major disorders dual diagnosis/intensive services. The program
offers mental health and substance abuse evaluations, mental health and substance abuse
treatment planning, daily individual therapy for each youth for fifty minutes weekly, family
therapy once a month, daily support services to include counseling, skills training, support
groups, psycho-educational, substance abuse therapeutic activities to include substance abuse
counseling, substance refusal skills, relapse prevention, mental health crisis intervention twenty-
four hours each day/seven days a week, and daily on-site psychiatric services. The program
maintains a full-time licensed psychiatrist, at least five days a week, forty hours a week, a
master’s-level mental health clinical staff on-site seven days a week, a registered nurse on-site
daily, and on-site during each work shift to ensure appropriate administration of medication (if
required), and to provide nursing observations.
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 has a contract with a licensed medical doctor (MD) to provide psychiatric services.
The MD is certified by the American Board of Psychiatry and Neurology in child and adolescent
psychiatry. The MD’s license is clear and active, with an expiration date of January 31, 2024.
The program has two MDs they utilize who serve as the backup for the psychiatrist with a clear
and active licenses expiring on January 31, 2024, and January 31, 2025. The MDs were on-site
as required eight hours a week. Three of seven reviewed youth mental health and substance
abuse records were applicable and confirmed youth were admitted on psychotropic medication.
Four of the reviewed youth mental health and substance abuse records were not applicable.
Each youth was referred for a psychiatric interview which is the program’s practice, regardless
of medication status. The review of youth records confirmed each of the seven youth were seen
by the psychiatrist within the required time frame, which is the process for each youth admitted.
Each Initial Diagnostic Psychiatric Interview included medical, mental health, and substance
abuse history, Mental Status Examination, Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) diagnosis, and treatment recommendations. The diagnosis for
each youth was confirmed to be consistent with every treatment plan. Three reviewed youth
were prescribed medications prior to admission to the program, which included an explanation
of the need for psychotropic medication, the target symptoms, potential side effects, and the
frequency of medication. Each reviewed youth’s Initial Diagnostic Psychiatric Interview included
initial treatment goals and risks and benefits of taking medication. The program’s Initial
Diagnostic Psychiatric Evaluation form included page three of the Department’s Clinical
Psychotropic Progress Note (CPPN) form, was clearly identified as an “Initial Diagnostic
Psychiatric Interview,” and was completed for all youth evaluated. The three youth who were
prescribed new medications, adjustments to dosage were made, or medications were
discontinued, had page three of the CPPN used and all required information was properly
documented. The remaining four were not applicable for Initial Diagnostic Psychiatric Interviews.
Each form was completed in its entirety and contacts with the parents/guardians were
documented, when applicable. Three reviewed Initial Diagnostic Psychiatric Interviews
confirmed youth receiving medication, were seen for a medication review at a minimum of every
thirty days and the psychiatric evaluation was documented on a form developed by the program
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which contains all required elements within the CPPN. Four reviewed youth was not applicable.
Three of seven reviewed Initial Diagnostic Psychiatric Interviews confirmed the psychiatric
evaluation resulted in the prescription of psychotropic medication or changes to the youth’s
existing psychotropic medication, and page three of the CPPN was completed, regardless of the
forms used to document the evaluation. Four of the reviewed youth were not applicable. Each
reviewed psychiatric evaluation was conducted within six months prior to the youth’s admission
and an updated psychiatric evaluation was conducted. Three of seven reviewed Initial
Diagnostic Psychiatric Interviews documented the identifying data, diagnosis, target symptoms
of each medication, evaluation and description of effects of prescribed medication on target
symptoms when psychotropic medication is prescribed, dispensed, and administered by the
psychiatrist prescribed psychotropic medication, if any, including the name, dosage, and
quantity of the medication; normal dosage range, ordered dosage, frequency and route of
administration, reasons for changes in medication and/or dosage and side effects, 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
parents/guardians to discuss medication, signature of the psychiatrist and date of signature.
Four reviewed Initial Diagnostic Psychiatric Interviews were not applicable. Three of seven
reviewed records confirmed the psychiatrist and the nursing staff have documented monitoring
for Tardive Dyskinesia monthly as indicated on the CPPN. An interview with the designated
mental health clinician authority (DMHCA) stated the clinical and case management team meet
with the psychiatrist on a weekly basis for one hour for medication management meetings. Case
managers, clinical staff, and the clinical director also meet with the psychiatrist informally as
needed for any additional input or feedback.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a Suicide Prevention Plan detailing the program’s suicide prevention
procedures. The plan contains all the required elements outlined in Florida Administrative Code
and outlines how the program will safely assess and protect youth with elevated risk of suicide
in the least restrictive means possible. The plan includes identification and assessment of youth
at-risk of suicide, staff training, suicide precautions, level of supervision, referrals,
communication, notification, documentation, immediate staff response, review process,
circumstances surrounding the event, program procedures relevant to the incident, all relevant
training received by involved staff, pertinent medical and mental health services involving the
victim, possible precipitating factors, and recommendations. An annual review of the plan was
completed by the facility administrator on February 2, 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.
One of seven reviewed youth mental health and substance records confirmed suicide
prevention services were needed. Two additional youth mental health and substance abuse
records were provided for review. One reviewed record was determined to be at risk during
admission screening. Two reviewed records confirmed the youth was determined to be at risk
by staff observations during the admission process. Each of the reviewed Assessment of
Suicide Risk (ASR) referral forms were generated for each of the youth. The ASRs were
completed using the Department’s form. Two of three ASR forms documented the level of
supervision for youth on suicide precautions placed on one-to-one and one form documented
standard level of supervision. A review of completed ASR forms confirmed two of the three
youth were placed on precautionary observation. One youth was not applicable for
precautionary observation. Reviewed documentation confirmed mental health (MH) staff
provided supportive services for each youth. Two of three youth completed a Follow-up ASR
prior to the removal from precautionary observation. The Follow-Up ASR was documented on
the Department’s Follow-up ASR form. 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. The two youth’s close supervision was maintained until it was no longer
deemed necessary by the designated mental health clinician authority (DMHCA) or licensed
mental health professional (LMHP), and discontinuation of close supervision was documented in
the youth’s mental health and substance abuse record by a MH clinical staff. One youth was
never placed on close supervision and was not applicable. Each ASR form documented a
conference was held by the facility administrator (FA) and LMHP to reduce level of supervision.
Each ASR confirmed the discontinuation of close supervision was documented in accordance
with the program’s suicide prevention plan and all assessments were completed by a LMHP or
clinical staff under the supervision of a LMHP. Suicide alerts initiated for youth placed on suicide
precautions were entered in the Department’s Juvenile Justice Information System (JJIS) and
accurately closed following the recommendations of the ASR. Three of the reviewed ASRs
confirmed there was evidence in the program’s logbook and on the suicide risk assessment
indicating administration or supervisory staff provided instructions related to the suicide risk
assessment findings and suicide precaution decisions and while on precautionary observation,
the “at-risk” youth were allowed to participate in select activities with other youth in designated
safe housing/observation areas in the program. Three of the reviewed case records confirmed
the ASR forms were completed within twenty-four hours of screening/concerns and completed
by a licensed staff or by an appropriately trained non-licensed staff. A review of the program’s
logbook confirmed the FA or designee documented the discontinuation of close supervision for
the two applicable youth. A review of the three applicable youth records confirmed
documentation of the actual date/time the clinician conferred with the FA or designee and LMHP
was recorded on the ASR in the date/time sections. Two of three youth records reviewed
confirmed the ASR was conducted immediately for each youth. One youth was not applicable.
There was one youth placed in secure observation during the annual compliance review period.
Reviewed documentation confirmed the youth’s placement in secure observation was
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authorized by the program director or designee and DMHCA, the designated secure room was
in writing, and all was completed on the Health Status Checklist form prior to placement in
secure observation; staff of the same gender conducted a visual check of the youth to
determine if there were any observable injuries which would make placement in the secure
observation room inappropriate. The secure observation room was inspected immediately prior
to the youth’s placement to ensure it was safe and secure. The youth was placed in a secure
observation room due to “at-risk” or “suicide risk” behavior and maintained on one-to-one
supervision. The Suicide Precautions Observation Log was completed in its entirety. Within
eight hours of placement, a new Follow-up ASR was completed. The youth was removed from
secure observation within twenty-four hours, provided supportive counseling services during
secure observation, and the level reduced only after conference with the FA/designee and
LMHP. A review of the ASR or Follow-up ASR form confirmed it was reviewed by a LMHP prior
to the youth’s removal from secure observation and included documentation reflecting the
LMHP concurred with the removal of secure observation. The FA or designee’s written
authorization was obtained for youth’s removal from secure observation. Video coverage of the
youth on precautionary observation was reviewed during the week of the annual compliance
review. There were no discrepancies noted. Seven staff were interviewed, and all stated if a
youth expresses suicidal thoughts, direct care staff are to notify the mental health staff. Four
staff stated they would search youth and the room for sharp objects. Five staff stated they would
place the youth on constant sight and supervision and four staff stated they would document
their supervision of the youth. One staff stated they would notify a supervisor, one staff stated
they would notify a supervisor and then master control, one staff stated a supervisor is notified,
one staff would call a code white, and one staff stated they would make sure the youth are safe.
All seven staff indicated the suicide response kits are kept in sub control rooms on the
dormitories.
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.
One of seven reviewed youth mental health and substance abuse records confirmed youth were
placed on suicide precautionary observation. Two additional youth mental health and substance
abuse records were provided for review. All Suicide Precaution Observation Logs were
maintained for the duration each youth was on suicide precautions, and the staff documented
each youth’s behavior in real time at intervals which did not exceed thirty minutes on the
required Department form. Two of three reviewed records documented warning signs, and
notification was made to the designated mental health clinician authority and the facility
administrator/designee. One youth was not applicable. Each reviewed Suicide Precaution
Observation Log was reviewed and signed by mental health clinical staff and documented safe
housing requirements.
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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.
A total of seven pre-service and seven in-service staff training records were reviewed for
completion of six hours of annual suicide prevention training and implementation of suicide
precautions. The program has training which includes mock suicide drills which are held no less
than quarterly on each shift, for all staff who come in contact with youth including kitchen and
maintenance staff. All mock mental health drills were in response to a suicide attempt and/or
incident of serious self-injury. All drills were simulated and did not utilize program youth in the
simulated drills. Any staff who was not present during a quarterly suicide drill had the
opportunity to review drill scenario and procedures to understand the process and receive
necessary training. The program has four suicide response kits which are located in all three
sub-control rooms on the dormitories and one in master control. The facility administrator was
interviewed and confirmed mental health drills are conducted monthly. Seven staff were
interviewed, and all reported medical emergency and suicide drills are conducted monthly on
each shift.
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 has a Comprehensive Mental Health Crisis Intervention Plan. The plan ensures
the program responds 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 program. The plan
contains all the required elements outlined in Florida Administrative Code and includes
notification and alert system, means of referral including youth self-referral, communication,
supervision to include one-to-one, constant, close and standard supervision, and documentation
and review of the crisis.
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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 has a comprehensive plan for mental health and substance abuse services,
suicide prevention, crisis intervention, and emergency care. The plan addresses practices
necessary to effectively handle youth in need of a Mental Status Examination and the
completion of a crisis assessment. A review of seven youth records confirmed no youth
received a crisis assessment. The program only had two youth during the annual compliance
review period who received a crisis assessment. Reviewed documentation confirmed the date
the youth was determined to be in crisis and the date of assessment correlated. The reviewed
crisis assessments included reason for assessment, Mental Status Examination and interview,
determination of danger to self and/or others including imminence of behavior, intent of
behavior, clarity of danger, lethality of behavior, clinical impressions, supervision
recommendations, treatment recommendations, recommendations for follow-up or further
evaluation, and was conducted by a licensed mental health professional, or by a non-licensed
mental health clinical staff working under the direct supervision of a licensed mental health
professional. One of two assessments confirmed notification to parents/guardians of follow-up
treatment. One youth was not applicable for follow-up treatment services. One of two reviewed
crisis assessments confirmed a mental health alert was entered into the Department’s Juvenile
Justice Information System (JJIS) due to the youth being placed on precautions after completion
of a crisis assessment. It was determined the youth posed a safety and security risk; therefore,
the youth remained on alert until a follow-up crisis assessment and/or follow-up Mental Status
Examination was completed, and supervision was documented on the Department’s Mental
Health Alert Observation Log.
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 has a detailed Emergency Mental Health and Substance Abuse Services Plan
which addresses mental health and substance abuse emergency care. The plan contains all the
required elements outlined in Florida Administrative Code and includes the 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 a review process for each incident.
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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.
None of the seven reviewed youth mental health and substance abuse records were applicable
for a Baker and/or Marchman Act; therefore, the program provided one additional record for
review. The program reported there was only one applicable youth since the last annual
compliance review. A review of the additional record found it was applicable for Baker Act
proceedings. The youth record supported the direct care staff immediately notified mental health
staff and placed the youth on one-to-one supervision. The designated mental health clinician
authority (DMHCA), who is a licensed clinical social worker, began the Baker Act proceedings
and authorized the transport of the youth. The youth was transported by law enforcement. Upon
return to the program from the Baker Act, the youth was placed on one-to-one supervision. An
Assessment of Suicide Risk (ASR) was completed by the DMHCA, and the youth remained on
one-to-one supervision. The program did not have any Marchman Acts during the annual
compliance review period.
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.
Seven youth mental health and substance abuse records were reviewed for a safety planning
process. The program had documentation of conducting on-going safety planning for each
youth. Each of the safety plans highlighted the youth’s warning signs, behavior, crisis
recognition, jointly developed coping strategies, intervention strategies preferred by the youth,
and debriefing process. Each plan was completed within fourteen days upon completion of
admission, was jointly prepared by the youth, parents/guardians or family member, and
program’s clinical staff. Each safety plan incorporated recommendations from previous or
current clinical assessments of screening instruments and incorporated trauma responsive
practices. Each plan was reviewed, at least every thirty days, and updated as necessary
following any significant behavioral or mental health event identified by the youth’s intervention
and treatment team and reviewed by staff who have contact with the youth. Safety plans are
maintained in a binder in the sub-control room in each dormitory. Seven interviewed youth
reported they were involved in the development of their safety plan. Six of seven interviewed
staff stated safety plans are located in the sub control rooms on the dormitories and one staff
stated safety plans are located in master control. The designated mental health clinician
authority indicated safety plans are reviewed monthly, during every formal treatment team
meeting, and staff are reminded during monthly staff meetings to review safety plans.
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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 policy and procedures ensuring a designated health authority (DHA)
shall be responsible for all healthcare services provided and for the medical care of all youth at
the program. The DHA holds an active, unrestricted license under Chapter 458, Florida Statute,
and is a medical doctor with a license expiration date of January 31, 2024. The physician’s
specialty training is in internal medicine. The program does not utilize a physician’s assistant or
advanced practice registered nurse. A review of the Florida Department of Health records
confirmed the DHA had no current disciplinary cases and/or public complaints on record. The
DHA is scheduled to be on-site twice weekly for at least four hours for acute medical concerns,
emergency care, and coordination of off-site care. Reviewed Physician Weekly Clinic Logs
during the annual compliance review period validated the DHA was on-site twice weekly
according to contract. The program has a back-up physician in the event of the DHA’s absence,
who holds a clear and active license, with an expiration date of January 31, 2024; however, the
back-up DHA had not been utilized since the last annual compliance review. The DHA is
responsible for communication with program staff regarding youth medical needs and is
available for consultation twenty-four hours a day, seven days a week. All applicable facility
operating procedures were reviewed by the DHA. The program did not have any contractual
provisional language included for either telemedicine or telehealth services. The program’s
policy and procedures outline specific duties of the DHA to include conducting Comprehensive
Physical Assessments (CPA), conducting sick call and/or conducting medical evaluations, and
providing treatment based on referrals either through the program’s sick call process or episodic
care. The DHA reports being available by mobile telephone or through an answering service
when not on-site.
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 facility operating procedures for all health-related procedures and
protocols utilized. The program provides on-site nursing coverage seven days a week from 6:00
a.m. to 10:00 p.m. The program’s contract indicates the program shall have a health services
administrator (HSA), four full-time registered nurses (RNs), and one part-time RN. The provider
shall provide five and one-half nursing positions to include one full-time RN supervisor, four full-
time RNs, and one part-time RN to ensure on-site nursing coverage for sixteen hours each day,
seven days each week, for a total of two hundred hours each week. All RNs are to be licensed
in the State of Florida. The program had a total of nine RNs providing services since the last
annual compliance review. A review of the nine licensees reflected one expires April 30, 2024,
five expire July 31, 2024, and three expire on April 30, 2025. The program hired four new
nurses since the last annual compliance review. A review of the four nursing staff training
records validated training on the treatment protocols and healthcare policies and procedures on
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Office of Accountability and Program Support Page 47 of 72 (Revised September 2022)
various dates throughout the annual compliance review period. Each of the five nursing staff
who provided services at the program throughout the annual compliance review period had a
current certification in cardiopulmonary resuscitation (CPR).
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The program’s assigned designated health authority (DHA)
conducts an annual review of all health-related policies, procedures, and protocols. Reviewed
documentation supported the DHA signed all healthcare policies and procedures on July 6,
2023, the facility administrator (FA) on July 5, 2023, and the psychiatrist signed the applicable
policies and procedures on July 6, 2023. The DHA reviewed and signed all nursing protocols on
July 6, 2023. There were no noted applicable policy changes during the annual compliance
review period. An annual review of all written policy and procedures for all health-related
procedures and protocols was documented as required. The program maintains a training
requirement whereby newly employed healthcare personnel shall receive a comprehensive
clinical orientation to the Department’s healthcare policies and procedures. Reviewed
documentation confirmed nursing staff reviewed, signed, and dated a cover page indicating their
review of the FOPs, treatment protocols, and other procedures on July 12, 2023. One medical
FOP was revised on July 6, 2023. The FOP was signed by the DHA and FA, and a signature
page, with the specific policies and date of revision, was signed by nursing staff following the
revisions. Approval of treatment protocols or standing procedures were written and authorized
by the DHA and were not delegated to any other person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) for all youth admitted into the program. The AET form is signed
by the parent/guardian who has legal custody of the youth. The AET serves as informed
consent for non-invasive medical procedures which can be completed by healthcare staff or for
minor ailments requiring over-the-counter (OTC) medications. A review of seven youth
Individual Healthcare Records (IHCRs) found all contained a valid and legible copy of an AET
and the word “Copy” was clearly stamped on each AET. The program utilizes a separate form
for youth eighteen years of age or older providing consent for the release of specific information
as noted on the Release of Information Authorization for Youth Eighteen Years of Age and
Older form and to whom the information can be released and shared. Three of the seven
reviewed youth IHCRs were applicable for youth eighteen years of age or older. Documentation
supported the youth signed a Release of Information Authorization Form for Youth Eighteen
Years of Age or Older. Two of the reviewed IHCRs were applicable for a court order being filed
in the record due to the youth being in the care of the Florida Department of Children and
Families (DCF).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 48 of 72 (Revised September 2022)
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 policy and procedures ensuring the parent/guardian is informed of
significant changes in the youth’s medical and/or mental health condition and ensuring consent
is obtained when new medications and treatments are prescribed. The policy and procedures
ensure parents/guardians are afforded the right to give or withhold consent about the healthcare
provided. Procedures also ensure the parent/guardian is notified to obtain consent of new
psychotropic medications, discontinuances, or psychotropic medication adjustments. Six of the
seven reviewed youth were taking psychotropic medications and were applicable for parental
notifications for psychotropic medications, as the remaining youth turned eighteen years of age
prior to being prescribed psychotropic medications. At the time of the annual compliance review
period, six youth were applicable for having a new psychotropic medication prescribed to them,
discontinued, or had the dosage significantly changed. Documentation in six IHCRs found the
parents/guardians verbal consent was documented on page three of the Clinical Psychotropic
Progress Note (CPPN). The seventh youth was not applicable. The six IHCRs contained
documentation of staff who witnessed telephone call attempts and conversations for
psychotropic medications. In each of the seven IHCRs reviewed, the youth vaccinations were
verified within thirty days of the youth’s admission to the program. Two of the seven reviewed
youth were in the care of the Department of Children and Families (DCF). None of the seven
reviewed youth were applicable for requiring consent to be obtained prior to administering
vaccinations within thirty days of the youth’s admission. None of the youth were applicable for a
religious exemption from immunization. Immunization records are obtained from Florida Shots
at admission. The health services administrator (HSA) was interviewed and stated immunization
records are obtained on the Florida Shots database and reviewed prior to or within twenty-four
hours of admission. An interview with the HSA indicated parent/guardian verbal consent is
obtained as soon as possible after an order is written by the physician and a written notification
is sent within twenty-four hours. In an emergency, all attempts are made to verbally contact the
parents/guardians prior to a youth leaving for the emergency. The parents/guardians are also
contacted upon the youth’s return with results. Written notifications are completed upon the
youth’s return.
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 policy and procedures ensuring each youth receives a screening for
health concerns upon admission, or at a minimum, each time the physical custody of the youth
changes and they are returned or readmitted to the program. A review of seven youth Individual
Healthcare Records (IHCRs) validated each youth received an initial admission screening
utilizing the Department’s Facility Entry Physical Health Screening (FEPHS) form. The FEPHS
form was completed for each youth reviewed, by a registered nurse (RN) on the date of the
youth’s admission to the program. None of the FEPHS were completed by a direct care staff.
The RN notifies the designated health authority (DHA) with the youth’s history and applicable
identified chronic conditions and documents the notification on the DHA Notification form and in
the nursing admission chronological notes. Youth are not placed in general population until any
identified healthcare needs are deemed to not require immediate medical attention and/or a
referral for further assessment. An interview with the health services administrator (HSA)
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Office of Accountability and Program Support Page 49 of 72 (Revised September 2022)
indicated each youth is seen by a RN immediately, following the initial search, upon admission.
If there is a change in custody, a new FEPHS is completed upon the youth’s return to the
facility. The HSA stated they are notified of all new admissions through the medical alert
system. At the time of the annual compliance review there had been no youth requiring a new
FEPHS for physical change in custody.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program maintains a policy and procedures to ensure all youth are oriented on the general
process of healthcare delivery services at the program. The program’s policy outlines
orientation/admission health education shall be provided by the healthcare staff, in writing, and
during an individual session with the youth to ensure youth with identified disabilities can
understand the information provided. Seven youth Individual Healthcare Records (IHCRs) were
reviewed for healthcare orientation. Each youth received a general care orientation on the day
of admission. The program’s healthcare orientation included all required topics including access
to medical care, sick call, what constitutes an “emergency” and when to notify staff, medication
process to include side-effect monitoring, the right to refuse care and how it is documented,
what to do in the event of sexual assault or attempted sexual assault, the non-disciplinary role of
healthcare providers, and standard universal precautions. Informal interviews with youth
validated this practice. A review of the program’s written operating procedures covered the
necessary health-related topics for youth orientation to the program. Each youth received a
health education packet specifically designed for male adolescents.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to ensure the designated health authority (DHA) is
notified when youth are admitted to the program. The program’s practice is to notify the DHA of
all admissions and outline any youth with a chronic medical condition, psychotropic medication,
or medical concern by telephone, by text message, or verbally if on-site. When a youth is
admitted on prescribed psychotropic medications, the psychiatrist is also notified. Nursing staff
document the notification on the DHA Notification of Admission form. Seven youth Individual
Healthcare Records (IHCRs) were reviewed. Six reviewed youth had a known or suspected
chronic condition upon admission. None of the reviewed youth were identified as in-need of an
emergency response upon admission. Each of the six applicable youth had a referral to the
DHA and/or psychiatrist upon admission to the program. The DHA and/or psychiatrist were
notified, and documentation was found for each of the applicable youth within the chronological
progress note section of the IHCR. The nursing staff updated the Chronic Conditions Log after
the notification was completed. The interviewed health services administrator (HSA) stated
nursing staff notify the DHA by telephone, or in person if on-site, regarding youth history and
chronic conditions once the initial nursing assessments and record reviews are complete.
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Office of Accountability and Program Support Page 50 of 72 (Revised September 2022)
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 policy and procedures ensuring nursing staff shall complete the
Department’s Health-Related History (HRH) form prior to the Comprehensive Physical
Assessment (CPA). A review of seven youth Individual Healthcare Records (IHCRs) indicated
each had a completed and/or updated HRH form, within seven days of admission. Reviewed
practice supported the HRH form was completed on the day of admission for each youth. Each
of the reviewed IHCRs, indicated the HRH form was completed prior to the CPA. The HRH was
reviewed by the designated health authority (DHA). This was evidenced by a checkbox on the
CPA, indicating the HRH was reviewed for each youth. The program’s practice is to complete a
new HRH and CPA annually. An interview with the program’s health services administrator
(HSA) confirmed the practice of completing the HRH upon admission. The HSA confirmed the
program’s practice is for the DHA to complete a CPA during admission and on a yearly basis.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program maintains a policy and procedures ensuring each youth admitted shall receive
and/or shall have on record a current Comprehensive Physical Assessment (CPA) and Health-
Related History (HRH) form completed no later than seven calendar days of admission into the
program. The program maintains a written policy and procedures ensuring each youth receives
a routine healthcare screening, a physical health evaluation, and evaluation for latent or active
tuberculosis. A review of seven youth Individual Healthcare Records (IHCRs) found a new CPA
form was completed by the designated health authority (DHA), on the Department’s CPA form,
within seven days of admission for each youth. Each youth’s Medical Grade was documented
on their CPA. Each of the CPAs documented the appropriate Medical Grade for the reviewed
youth. There was no indication of any missing or incomplete elements on any of the reviewed
CPAs. None of the seven youth refused any part of the examination; therefore, a refusal form
was not needed. All sections of the CPA were completed in full utilizing an “O” and/or applicable
“X” markings. The program’s practice is for the youth not to be placed into general population
until their healthcare needs are identified and deemed not to require immediate medical
attention and/or a referral for further assessment by healthcare staff. The Department’s Problem
List was updated, as required for each youth. All seven youth had at least one verified
Tuberculosis Skin Test (TST) completed and documented within a year of their admission. Each
youth’s results were documented on their CPA and on their Infectious and Communicable
Disease form, and each youth’s test results matched on both forms. An interview with the
program’s health service administrator (HSA) reported youth are assessed at the time of
admission and the CPA is completed by the DHA during admission and on a yearly basis. In
addition to the TST purified protein derivatives (PPDs) are administered during admission and
then annually thereafter. An informal interview with nursing staff indicated there were no current
youth with symptoms suggestive of active tuberculosis (TB) and there were no youth prescribed
anti-TB medications during the annual compliance review period.
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Office of Accountability and Program Support Page 51 of 72 (Revised September 2022)
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 policy and procedures ensuring all youth entering the program are
clinically screened, evaluated, and treated, if necessary for sexually transmitted infections
(STIs) and human immunodeficiency virus (HIV). The designated health authority (DHA) makes
the decision based on the screening tool and medical evaluation to order testing for sexually
transmitted diseases/infections. A review of seven youth Individual Healthcare Records (IHCRs)
reflected each youth was identified as sexually active and was clinically screened and evaluated
for STIs utilizing the Sexually Transmitted Infections Screening form. Further evaluation wasn’t
required for any of the seven youth; therefore, an additional three IHCRs were requested and
reviewed. All three reviewed youth were referred to the DHA. Each youth’s referral was
documented on their STI form. Testing was ordered and performed for each youth. Each youth’s
IHCR included documentation of testing, screening results, clinical evaluations, and diagnoses
on the Department’s Infectious and Communicable Disease (ICD) form. The IHCR for each
youth documented testing had been ordered and performed. Testing, screening, clinical
evaluations, and diagnoses were documented accordingly on the Department’s ICD form,
excluding HIV results, and filed within the lab section of the IHCR, for all three youth. There
were no applicable youth who were out of the Department’s custody for over thirty days and/or
required a rescreening due to presenting symptoms. The program maintains a written policy and
procedures ensuring all youth at risk for HIV infection are offered counseling, testing, education,
prevention counseling, and a referral for medical treatment, as indicated. All seven youth were
offered counseling and testing. Consent forms in four applicable reviewed IHCRs reflected each
youth was provided treatment/referral for HIV. All four youth received HIV testing and consent
was documented for each. Each youth’s results were in their IHCR in a sealed envelope marked
“confidential,” consistent with Florida Administrative Code. All Four envelopes were signed by
the DHA, indicating their review. Documentation of pre-test and post-test counseling was
contained in each youth’s IHCR. Each youth’s confidentiality was protected, as their HIV
statuses were not included on the program’s internal alert system. Seven interviewed youth
stated they can ask for a HIV test. The health services administrator (HSA) was interviewed and
stated every youth is screened for STIs, regardless of their risk. If further evaluation is needed,
consent is gained from the youth, and evaluation is completed within twenty-four hours.
Screening forms and results are in each youth’s IHCR under the ICD and laboratory sections.
The HSA stated rescreening is conducted if the youth is out of the Department’s custody for
thirty or more days. HIV results are documented in the lab section of the IHCR. The results are
in an envelope marked confidential, which is reviewed by the DHA. All youth consenting for
testing are tracked on the program’s HIV Testing Tracking Log maintained by the nursing staff.
The program utilizes the DHA to provide pre and post-test counseling. The program has a
written facility operating procedure (FOP), which reflects HIV test results are only disclosed to
the youth, and those entities outlined within Florida Statute.
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Office of Accountability and Program Support Page 52 of 72 (Revised September 2022)
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 policy and procedures ensuring all youth shall be able to make sick
call requests and have their complaints treated appropriately through the sick call system. Sick
call care, including dental complaints, shall be available to all youth. The sick call process is
intended to provide care in response to complaints of illness or injury of non-emergency nature;
however, requires some form of assessment and/or decision-making by a licensed nurse and/or
licensed physician. Sick call care is provided by licensed healthcare professionals pursuant to
their scope of practice and according to protocols approved by the designated health authority
(DHA). Each youth is oriented to the program’s sick call process upon admission. Seven
Individual Healthcare Records (IHCRs) were reviewed, and two were applicable for sick calls;
therefore, one additional IHCR was requested. None of the three reviewed youth presented with
a similar sick call complaint three or more times within a two-week period. A Sick Call Request
form was completed for each of the sick call requests reviewed. Each of the reviewed Sick Call
Request forms were completed by a registered nurse (RN). Each youth’s Sick Call Request
form was filed in their IHCR in reverse chronological order. Each Sick Call Request form was
documented in accordance with Florida Administrative Code. The reviewed sick calls were
found to be recorded appropriately on the Sick Call Index. In addition, each sick call was
documented on the program’s Sick Call Referral Log. None of the reviewed youth were in
restricted housing. The dates listed on each of the Sick Call Index logs, corresponded to the
completed Sick Call Request forms located in each of the youth’s IHCRs. The program offers
youth the opportunity to make a sick call request, seven days a week. Only a licensed
healthcare staff may conduct sick call and all sick call encounters are conducted in the medical
clinic to ensure youth privacy. Sick Call Request forms are available to youth and located in the
day room areas. A review of the daily schedule, posted sick call schedule, and nurse interview
found sick call is held daily from 8:00 a.m. to 10:00 a.m., 1:00 p.m. to 3:00 p.m., and 5:00 p.m.
to 7:00 p.m., meeting the contract requirement of three times a day for two hours. Sick call
hours are posted in the cafeteria and in the medical clinic. An exam table is in the medical clinic
to utilize during sick calls. Sick Call Request forms are available to youth in the cafeteria.
Completed forms are submitted by youth into a box in the cafeteria. If there are no nursing staff
on-site, the program’s policy indicates Sick Call Request forms should be turned in to the shift
manager for review no longer than two hours after being submitted. An interview with the
program’s health services administrator (HSA) indicated youth are seen by the nurse within
twenty-four hours of submitting a Sick Call Request form; however, if the sick call request was
submitted after hours, the youth will be seen at the next sick call time. The HSA validated the
program’s practice, indicating youth with three or more repeated sick call complaints within a
two-week period, are referred to the DHA. Seven interviewed staff stated nursing staff review,
respond to, and conduct sick calls. Seven interviewed youth stated they see a nurse within one
day when a sick call is requested. A sick call observation was not completed, as no sick calls
took place during the annual compliance review week.
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Office of Accountability and Program Support Page 53 of 72 (Revised September 2022)
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program maintains a policy and procedures ensuring there is a written plan to provide
twenty-four-hour emergency medical, mental health, and dental care to youth, as needed, in
response to unexpected illnesses, accidents, or conditions requiring immediate attention or an
immediate professional assessment to determine the severity. Seven youth Individual
Healthcare Records (IHCRs) were reviewed and six were applicable for episodic care. On-site
care was provided by licensed healthcare staff for each event. Each event was documented in
the required subjective, objective, assessment, and plan (SOAP) format. All events were
documented on the Episodic Care Log, which corresponded with the on-site events observed in
the IHCRs. The program has a written facility operating procedure (FOP) which addresses
episodic and emergency care practices. An interview with the health services administrator
(HSA) confirmed episodic care is documented in nursing progress notes and on the Episodic
Care Log. If non-healthcare staff provided episodic or first-aid care, it is documented on the
Department’s Report of On-Site Health Care by Non-Health Care Staff form. Seven interviewed
staff stated they can call 9-1-1 if a youth has a medical emergency; however, they stated they
must make the call by two-way radio to master control or the shift supervisor, as there is no
telephone on the dormitories. The program has a total of five first-aid kits. There is one first-aid
kit located in master control, Charlie dormitory, Alpha dormitory, Bravo dormitory, and one is in
the transportation vehicle. The program has a specific content list for each first-aid kit. The list is
maintained in each first-aid kit and has each item noted with an expiration date. The designated
health authority (DHA) has designated the RNs to inspect the contents of the first-aid kits
monthly, or as needed, and all expiration dates are listed on the inspection forms and provided
to the healthcare staff. The program keeps all their first-aid kits in-doors to prevent deterioration.
A sample of three separate first-aid kits was observed. The reviewed contents confirmed the
first-aid kits were fully stocked, with DHA approved contents. Each first-aid kit was observed
with an inspection form marked monthly with nursing staff initials and date of inspection. The
program maintains a written policy and procedures ensuring the program-based AEDs are
properly managed. The program has four AEDs, which are in master control and in each
dormitory sub-control room. Instructions are located inside the AED cases. Reviewed
documentation found on-site nursing staff check monthly to ensure the AED batteries and pads
are operable. The green light was flashing on each AED during the annual compliance review
week and no issues were noted. The batteries were last changed on the AED in master control
September 2020, and Alpha, Bravo, and Charlie dorms February 2021. The AED batteries
expire on August 21, 2023, in master control, and Alpha, Bravo, and Charlie on February 8,
2025. The pads were last changed on the AED in master control, Alpha, Bravo, and Charlie in
February 2021. The AED pads expire in master control February 2024, and Alpha, Bravo, and
Charlie in September 2023. An interview with the HSA confirmed the locations of and expiration
dates for the AEDs. In addition, all nursing staff maintained current certifications in
cardiopulmonary resuscitation (CPR) and AED. The program has three operational shifts. A
review of the program’s emergency medical drills reflected a drill was conducted on each shift
monthly for the last twelve months. The review yielded each shift conducts emergency medical
drills at a minimum of monthly. Emergency medical drills which include the demonstration of
CPR and AED are conducted at a minimum of quarterly. The emergency medical drills
consisted of both announced and unannounced drills and were conducted at least monthly on
each shift. Emergency contact telephone numbers are in areas which are not accessible to
youth. Observations, during the annual compliance review week, made throughout the program
during the tour found postings informing staff of their right and responsibility to call 9-1-1. A
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Office of Accountability and Program Support Page 54 of 72 (Revised September 2022)
review of training sign-in sheets found all healthcare and direct-care staff, who assist in the
administration of medication, were trained by a registered nurse (RN) on the administration of
the epinephrine auto-injector. A review of seven pre-service and seven in-service staff training
records found each staff was trained in episodic, first-aid, and emergency care. An interview
with the HSA confirmed the number of five first-aid kits and their locations. The HSA confirmed
the location, where the procedures are, and who checks the AED at the program. The nursing
staff confirmed the process for conducting emergency medical drills, indicating all emergency
drills are conducted on each shift, every month. Seven interviewed youth indicated they can see
a dentist or doctor, if needed. An episodic care event was not observed during the annual
compliance review week as one did not occur.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program maintains a policy and procedures for the provision of off-site emergency and non-
emergency referrals for medical care and treatment. Evaluations conducted off-site shall be
recorded on the Department’s Summary of Off-Site Care form. The designated health authority
(DHA) reviews, signs, and dates the off-site care instructions. Seven youth Individual Healthcare
Records (IHCRs) were reviewed; however, only six were applicable for off-site first-aid or
emergency care. Reviewed documentation supported the DHA reviewed each completed
Summary of Off-Site Care form and discharge paperwork as evidenced by signature and date.
The form was filed within each of the youth’s IHCRs. Reviewed documentation supported the
parent/guardian was notified, as required. Applicable discharge documents were found to be
filed within each youth’s IHCR. All six applicable reviewed youth required follow-up testing,
referral, and/or an appointment. Each youth completed and/or were still receiving treatment and
appointments, as required for the applicable records. An interview with the program’s health
services administrator (HSA) indicated medical staff document and track all off-site care on the
program’s Off-Site Care Log. Additionally, medical staff notify and provide the DHA with the
youth’s hospital’s orders upon the youth’s return, for follow-up.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program maintains a policy and procedures ensuring youth who have been identified with a
chronic illness receive regularly scheduled evaluations and necessary follow-up treatment. The
purpose of the periodic evaluation is to ensure the youth requiring ongoing treatment or who
have experienced changes in condition or treatment regimen are adequately monitored. The
frequency of the periodic evaluation is determined by the youth’s condition, clinical needs, and
clinically appropriate medical standards. A review of seven youth Individual Healthcare Records
(IHCRs) indicated five youth were identified with a chronic condition as documented on the
Facility Entry Physical Health Screening (FEPHS) form. None of the youth were identified as
having a communicable disease. All seven youth were taking prescribed medication on an
ongoing basis; however, five youth had an identified chronic health condition, were undergoing
treatment for a physical health condition, and were classified with a Medical Grade two through
four, or a Medical Grade five for youth also taking psychotropic medications. Each youth was
placed on the program’s Chronic Illness List. A review of progress notes found each youth
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received periodic evaluations at least every ninety-days. The program maintains a tracking log
for youth with chronic conditions and evaluation dates. The tracking log indicated each youth’s
next scheduled appointment. None of the youth were applicable for taking anti-tuberculosis
medications. Each of the youth had an evaluation completed prior to a prescription renewal,
change, or expiration. Five of the seven reviewed youth were applicable for an off-site
evaluation and three of the five were for dental care only. There were no indications of lapses in
care or missed periodic evaluations in any of the reviewed records. The Department’s Problem
List for each youth was updated in accordance with Florida Administrative Code. The program’s
facility administrator (FA) was interviewed and stated they meet with healthcare staff daily. The
FA indicated medical staff review youth information prior to admission to identify any medical
issues. The designated health authority (DHA) was interviewed and stated periodic evaluations
are done every two months. The DHA stated they ensure the periodic evaluations are
completed by utilizing a tracking system. The health services administrator was interviewed and
stated youth with chronic conditions are placed on the medical tracker for monitoring and
tracking of due dates.
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 policy and procedures ensuring medical staff verify any medications
arriving with a newly admitted youth and continue all currently prescribed medications. When a
youth arrives to the program with medications or orders/prescriptions for medications, the
healthcare staff conduct a preliminary assessment and interview to determine the medication is
verified as indicated. Nursing staff complete the Facility Entry Physical Health Screening
(FEPHS) to determine medical needs. All prescribed medications are obtained from a licensed
vendor according to a contractual agreement. A review of seven youth Individual Healthcare
Records (IHCRs) indicated six youth were admitted on prescribed medications. Documentation
revealed six youth’s medications were verified prior to being admitted into the program utilizing
the Department’s Prescription Medication Verification Checklist form. Additionally, if a youth is
admitted with prescribed medications the medication is verified and documented on the
program’s Medication Verification Checklist. The remaining youth was not taking medications
upon admission. All medications for each of the six youth were observed to have a current, valid
order. Each time a medication was continued, discontinued, changed, or a new one was
ordered, the DHA placed an order on a Practitioner Order form. None of the youth were in
restricted housing during the annual compliance review period. Six of the seven youth were
applicable for over-the counter (OTC) medications not listed on the Authority for Evaluation and
Treatment (AET) form. The program utilizes a pre-printed Medication Administration Record
(MAR) to document all medication and treatment. Each of the reviewed MARs met all
requirements outlined within Florida Administrative Code. The nursing staff documented side-
effect monitoring at a minimum of weekly on each MAR. There were no instances where trained
non-healthcare staff assisted in the delivery of medications. There were no undocumented
explanations for a lapse or errors in medication administration for any of the reviewed youth.
One of the seven reviewed youth needed assistance from a non-healthcare staff on the use of
his inhaler. Three youth refused medication. Each refusal was clearly documented on the MAR,
and each IHCR included a Refusal of Treatment form for each refusal. There were no youth in
need of parenteral medication during the annual compliance review period. Four of the seven
reviewed youth were prescribed psychotropic medication upon admission, and the DHA and
psychiatrist were notified the day of admission. The psychiatrist conducted an Initial Diagnostic
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Psychiatric Interview with the youth within fourteen days of admission. All four youth received a
medication monitoring/review every thirty days, as required. There were no standing orders,
emergency treatment orders, or pro re nata (PRN) orders for psychotropic medications.
Medication pass was observed for one youth during the annual compliance review week.
Medication delivery was the sole responsibility of the nurse during the time of administration.
The youth was escorted to medication pass by direct care staff and approached the nurse
administering medication individually. Nursing staff asked the youth their name and allergies.
The nurse identified themselves, reviewed the MAR, and provided a brief overview as to why
the youth was there. The youth provided their name, date of birth, what medications they were
prescribed, and if they had any allergies. The registered nurse (RN) verified the Six Rights of
Medication Administration (right youth, right medication, right dosage, right time, right route, and
right documentation) for the youth. No medications were observed to be pre-poured. Upon
administering the youth’s medication, the RN swiped the youth’s mouth and searched under the
youth’s tongue. Both the nurse and youth initialed the MAR once the medication was ingested.
Seven youth were interviewed and stated a nurse dispenses their medication. Seven
interviewed staff stated nursing staff dispense medication. The health services administrator
(HSA) was interviewed and stated medications are verified with the records sent from the
detention center. Medications are also verified with the parents/guardians during the youth’s
admission. The HSA indicated the program utilizes a pre-printed pharmacy MAR which includes
all required elements. The HSA stated medication pass is held daily at 6:00 a.m. and 6:00 p.m.
Any non-healthcare staff who provide medications are trained by the HSA.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program maintains a policy and procedures ensuring medical equipment classified as
medications/sharps are secured and inventoried by using a routine perpetual inventory.
Narcotics and other controlled medications are securely stored in a locked box located within
the medication cart. Medications such as injectables, topicals, drops, and liquids are stored
separately. A review of sharp’s inventories since the last annual compliance review found the
program is utilizing a perpetual inventory which is completed as any sharp is utilized and
disposed or added. Weekly inventories are then completed by nursing staff. All medications
were identified and secured in a locked area designated for storage of medications in the
medical office. Prescribed medications are kept in the locked medication cart, with all over-the-
counter (OTC) medications stored in a locked cabinet in the medical clinic. Observations of
areas where items are kept confirmed each item was secured and inventoried utilizing a routine
perpetual inventory. The medication cart was observed to be clean and organized, with stock
items separate from youth specific medications. Observations found all medications securely
stored in the medical clinic and inaccessible to youth. All non-controlled medications were
stored in a separate, secure, locked medication cart. Narcotics and other controlled medications
are securely stored and double locked within the medication cart. The program has a dedicated
refrigerator for medication only; however, the program did not have any refrigerated medication
at the time of the annual compliance review. All expired or discontinued class two medications
are destroyed on-site with the pharmacist, a nurse, and the facility administrator (FA) or
designee. All other medications are returned to the pharmacy for destruction. The program
nursing staff documented the daily temperature of the refrigerator on the Temperature Log form.
Reviewed documentation supported the checks were conducted daily. The program maintains a
written policy and procedures ensuring all chemical products, medicines, and medical and
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dental instruments assigned to the medical department are securely stored, regularly
inventoried, and disposed, consistent with federal and state laws. Observations validated oral
medications were not stored with injectable or topical medications. All observed perpetual and
weekly inventories of sharps and stock over-the-counter (OTC) medications were completed as
required with no noted issues. The health services administrator (HSA) stated if there were an
inventory discrepancy, they would notify the FA, conduct a recount, check all documentation,
and conduct a search. The HSA confirmed medications are inventoried daily with a perpetual
count. Medications are locked within the medical clinic and medication administration room, and
controlled medications are secured behind two locks. The HSA confirmed the process for the
destruction of medications. The HSA stated the program utilized a consultant pharmacist who
destroys medications, audits the medication cart, and discusses issues. There was an
observation made during the annual compliance review week regarding controlled and over-the-
counter medications. The annual compliance reviewer observed three controlled medications,
three OTC medications, and three sharps and confirmed all counts matched the inventories.
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 policy and procedures ensuring there is an approved plan for
exposure control and infection control ensuring staff, youth, volunteers, and visitors are not
exposed to infectious and communicable diseases. The program’s policy and procedures
specifically address prevention, containment, treatment, and reporting requirements related to
infectious diseases. The plan is in accordance with Occupational Safety and Health
Administration (OSHA) federal regulations and the Center for Disease Control and Prevention
(CDC) guidelines. The plan also included common infectious diseases of childhood, self-limiting,
episodic contagious illnesses, viral or bacterial infectious diseases, tuberculosis, Hepatitis A, B,
and C, Human Immunodeficiency Virus (HIV), infectious diseases caused by bloodborne
pathogens, other outbreaks or epidemics caused by any other infectious agent, outbreaks of lice
or scabies, Methicillin-Resistant Staphylococcus Aureus (MRSA) and other anti-biotic resistant
micro-organisms, foodborne illnesses, bio-terrorist agents, and chemical exposures. The
program maintains procedures for staff to adhere to universal precautions and the program
provides staff with the opportunity for Hepatitis B immunizations and access to protective
equipment. The designated health authority (DHA), facility administrator, and nursing staff
reviewed and signed the infection control and exposure control plan on February 3, 2023. The
FA was interviewed and stated the Exposure Control Plan is in the facility operating procedure
(FOP) binder in master control and is reviewed with staff twice a year. An interview with the
health services administrator (HSA) confirmed the Exposure Control Plan is in the FOP binder.
The HSA stated a nursing staff conducts Exposure Control Plan training and infection control
training for staff. Infection control education is provided to each youth twice a year.
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4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures for youth supervision. The program’s contractually
required staff-to-youth ratio is one to seven during daytime and daily activities; and one to eight
during sleeping hours. Observations of daily activities were made on each of the four days
during the annual compliance review week; and observations of school, recreation, meals,
breaks, family day, and line movements validated staff were actively supervising youth in
accordance with the contractually required staff-to-youth ratio. During the week of annual
compliance review, positive interactions between staff and youth were observed and staff were
able to accurately indicate the number of youth they were supervising. The program’s policy
defines active supervision as the use of effective and efficient supervision which includes
positive contact, positive reinforcement, structured activities, and random/predictable movement
which provides suitable and timely response to the everyday needs of youth and an immediate
response to emergencies while maintaining the safety and security of the program. The program
has a schedule of activities posted in each dormitory and throughout the facility; and youth were
observed following the schedule. Close monitoring of youth behavior, changes in youth
behavior, and consistent application of the behavior management system by the program staff
were observed throughout the annual compliance review week. Video review of three different
days and for each applicable shift validated staff observed youth while they were in their rooms
sleeping. Seven staff were interviewed, and each was able to provide steps taken when a youth
count cannot be reconciled, as it relates to the staff’s program duties.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program has a policy and procedures addressing the behavior management system (BMS)
and protocols regarding feedback given to staff regarding their implementation of the BMS.
There is an agreement between the program and the school related to the BMS reflecting a joint
plan for the BMS during school. The program’s regional compliance manager provided training
to the education staff in the jointly combined BMS plan to include use of BMS during school.
The BMS is clearly written and is in the youth handbook. The BMS is also posted in the
program’s living units and throughout the facility. The program’s written BMS outlines the rules
and the positive and negative consequences for behaviors. The program’s BMS was not
changed or in the process of being changed since the last annual compliance review. The
program’s BMS includes maintaining order and security, promoting and protecting youth rights,
positive and negative consequences, constructive disciplinary actions, opportunities for positive
reinforcement, recognition of accomplishments and positive behaviors at a four-to-one ratio, and
promoting socially acceptable means for youth to meet their needs. The program’s written BMS
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includes a process for explaining to youth the reasons for any sanctions imposed and youth are
provided an opportunity to explain their behavior. The BMS provides an opportunity for staff and
youth to discuss the impact of the behavior on others, reasonable reparations for harm caused
to others, discussion of alternate behaviors, promotion of positive dialogue and peaceful conflict
resolution, and consistent implementation and treatment through oversight. The separation of
youth from population is minimized and the BMS includes a variety of rewards. The BMS is also
connected to the youth’s individual behavior plan. The program’s BMS does not include
increased length of stay, denial of basic rights or services, group punishment, punishment of
youth by other youth, or disciplinary confinement. Consistent application of the BMS by the
program staff was observed throughout the annual compliance review week. The program has a
variety of rewards/incentives to include daily incentives such as special snacks, Mega Mondays
where fast food is brought in, increased amount and quality of canteen items, and special
activities. The program’s contract does not include any special provisions for the BMS. A review
of seven youth case management records validated youth orientation included a review of the
program’s BMS and all youth signed for the receipt of the youth handbook. Seven youth were
interviewed, and each was able to describe, with examples, how consequences are received.
All youth stated staff are consistent when applying the BMS and were able to state the
frequency and types of rewards available. Each youth was also able to state the levels and
differences of the BMS. Seven pre-service and seven in-service staff training records were
reviewed, and each record reflected staff completed training in the program’s BMS. Seven staff
position descriptions were reviewed and found to contain implementation of the program’s BMS.
Seven staff were interviewed, and each indicated they received training in the BMS and was
able to explain the program’s BMS. Each interviewed staff was able to explain how the point
system is applied, frequency of rewards, and types of rewards available. All seven staff
indicated items are not taken away from youth as a consequence. During an interview, the
facility administrator indicated the program utilizes a BMS compiled of a series of levels. The
youth complete each level by earning daily points and earning points allows youth to also
participate in incentives which occur daily, weekly, and monthly.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program does not utilize room restriction; therefore, this indicator is rated non-applicable
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures to address ten-minute checks. The program had 144
cameras at the time of the annual compliance review and 142 of 144 cameras were operational.
The video recordings are stored for thirty days. The facility administrator was interviewed,
formally and informally, and confirmed the number of cameras and length of recordings stored.
The program’s practice is to conduct checks in six-minute intervals. A sample of camera
surveillance and corresponding logs were reviewed for different days and times during the last
thirty days; and all checks were conducted under the required ten-minute intervals. Reviewed
documentation validated each check was documented in real time and the staff who completed
the checks initialed the check sheet. A review of the past twelve months of ten-minute check
logs found all checks to have been documented being completed every eight to ten minutes.
Staff were observed conducting checks in a manner ensuring safety and security of youth.
Seven staff were interviewed, and each indicated checks are conducted every six minutes when
youth are placed in their room for sleeping or non-punishment reasons. Each staff was also able
to describe the process and procedures to conduct checks.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program has a policy and procedures addressing census, counts, and tracking.
Observations throughout the annual compliance review week revealed staff physically counted
youth as required at various times throughout the day. A review of the program’s logbooks
during the annual compliance review period indicated counts were conducted, as required, to
ensure program youth are always accounted for. A review, since the last annual compliance
review, of a full day for each month was conducted of the logbooks, and each day contained
documentation of total daily census counts, head counts, youth movements, youth admissions
and releases, and youth temporarily away from the program. Observations were made during
the annual compliance review week of youth counts during movements and activity/room
changes. Seven staff were interviewed, and each was able to explain how and when youth
counts are conducted including emergency counts and was aware of the current youth census.
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5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures to address logbook entries. A review of logbooks
during the annual compliance review period was conducted. Logbooks were bound with
numbered pages and all logbook entries were made in ink with no erasures or white-out areas.
There were no entries destroyed or removed and no eraser marks were observed. All entries
included the date and time of the event, the name of the staff and youth involved, brief
descriptions of the events, and the names and signatures of the staff making the entries.
Logbook entries included all required information. Reviewed documentation indicated each
incoming shift reviewed the logbook entries made during the previous shift then signed and
dated the logbook to acknowledge the information. Internal incidents reported to the Florida
Abuse Hotline and/or the Department’s Central Communications Center (CCC) were
documented in the logbook. The program maintains a logbook in master control.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures to address key control which includes key
assignment and usage, 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 keys are maintained in secured key boxes located in master
control and this area is secured and inaccessible to youth. Staff secure their personal keys in
master control within a locked cabinet. The key boxes located in master control are not easily
accessible while locked. Each set of keys has an assigned number and corresponding key ring.
A review of the key inventory matched the actual key rings in use. Keys are assigned to staff
according to the position. Keys are always locked in a cabinet when not in use. Each of seven
interviewed staff were able to explain the key control process. The facility administrator assigns
the permanent and restricted keys based on the position. An acknowledgment form for
permanent keys is completed for each permanent key assigned with signature, key number, and
return date. Restricted keys are stored in a separate locked box from non-restricted keys, and
only assigned staff can access the restricted key box. The program’s physical plant manager
replaces all damaged keys. A broken key report form is completed for each broken/damaged
key and the damaged/broken key is attached to the form. The inventory and tracking of keys
and distribution of program keys to staff were observed during the week of annual compliance
review. The key tracking and distribution processes were in accordance with the program’s key
control process. An informal interview with the master control staff validated they were aware of
the process for restricting usage of keys. A random check of three staff key rings confirmed the
keys matched the inventory and each staff was aware of the number of keys on their assigned
key ring and the function of each key. There were no reports made to the Department’s Central
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Communications Center (CCC) or deficiencies in the Department’s Program Monitoring and
Management (PMM) system this annual compliance review period regarding key control
concerns. Seven staff were interviewed, and each was able to explain the program’s key control
process.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures in place to prevent contraband from entering the
facility. The policy includes items and materials considered as contraband, as well as
exemptions, providing youth with a list of items considered as contraband, informing program
youth of the consequences if found with contraband, searching the facility and grounds, and
searching of youth, incoming mail, and outgoing mail. The policy includes the consequences if
any program staff is found in possession of contraband. The policy also includes contacting law
enforcement if any item found is considered illegal as defined in Florida Statutes, or if there is
any evidence of unlawful activities. The program did not have an incident related to contraband
during the annual compliance review period. A review of the facility logbooks and youth room
search reports for the period of the annual compliance review validated the program conducted
searches as required. An interview with the facility administrator revealed staff and visitors are
searched upon entry into the facility to prevent contraband from entering the facility. All visitors
and staff are notified of the Florida Statute related to contraband, as it is posted at the entrance
door of the facility. In addition, a list of items identified as contraband is noted within the
program’s youth and parent/guardian handbook as well as the staff handbook. Weekly room
and common area searches are completed, and findings are documented on the search log.
Any unauthorized item or illegal contraband is documented on the search log and disposed of
as required. Any findings of illegal contraband require notification and reporting to law
enforcement and the Department’s Central Communications Center (CCC).
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5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures to address searches and full body visual searches to
ensure no contraband is introduced into the facility. Seven interviewed youth reported being
searched every movement, off-campus activities, meals, visitation, and education. Each of the
seven interviewed staff stated youth are searched every movement. Visual observations were
made during the week of the annual compliance review of youth searches before and after
groups, education, vocational instructions, recreational activities, transports, and following
access to tools and equipment. During searches, youth were treated with dignity and respect to
minimize their stress and embarrassment and each observed search was conducted by the
appropriate number of staff and by a staff of the same gender as the youth. Youth searches and
instructions given to youth during searches were in accordance with the program’s policy and
procedures. The program did not have any admissions or releases during the annual
compliance review week.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a policy and procedures to address vehicles and maintenance. The program
utilizes one vehicle for youth transport. Reviewed documentation validated the vehicle had
received an annual safety inspection, and all required maintenance records were documented.
An inspection of the program vehicle was conducted and found it contained a fire extinguisher,
the appropriate number of seatbelts, and the door to the youth passenger area cannot be
opened from the inside. An approved first-aid kit is checked out of master control with the
vehicle keys for each transport, and a seatbelt cutter and window punch tool are located on the
key ring. Youth are not attached to any part of the vehicle by any means other than proper use
of a seatbelt. A check of nine randomly selected program and personal vehicles was conducted
during the week of annual compliance review; and all were locked when not in use. Seven youth
and seven staff reported, during transport youth are secured with seatbelts and
handcuffs/shackles.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures to address transportation of youth and driver
eligibility. A review of the program’s policy states a minimum of two staff to one youth is
required. The review of the program’s policy states a program cellular telephone is issued for all
transports, a staff of the same gender of the youth is present during transport, youth are never
left unsupervised in a vehicle, and youth are not permitted to drive program or staff vehicles.
Reviewed documentation revealed the program maintains an approved driver list, and ensures
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each approved driver has a valid driver license. Seven youth were interviewed, and each
indicated they feel program staff are driving transport vehicles safely, confirmed a safety screen
is in the transport vehicle, and have never observed anyone placing contraband in a transport
vehicle. Seven staff were interviewed and were aware of the program’s transportation policy and
procedures including the restriction of using a personal vehicle to transport youth, search of the
vehicle is conducted before and after a transport, and the transportation ratio is two staff to one
youth. Six of seven staff indicated the transport staff have a program cellular telephone and
provided a summary of the emergency procedure steps taken if needed; the remaining staff is
not direct care, nor conducts transports; therefore, was unsure. Each staff was able to list the
required safety equipment in the transport vehicle; however, this program utilizes transporter
positions for this task, and the interviewed transport staff was able to list all required safety
equipment in the transport vehicle. The facility administrator interview confirmed the transport
vehicles used have safety screens. During the week of annual compliance review, there was
one transport of a youth. All procedures were observed to be followed.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures outlining weekly safety and security audits including
the responsible program staff for conducting the weekly security audits and safety inspections,
the development and implementation of corrective actions warranted as a result of safety and
security deficiencies found during any inspection, an internal system to verify if the deficiencies
are corrected, and existing systems are improved or new systems are instituted as needed to
maintain compliance. The program’s policy indicated the program’s assistant facility
administrator and physical plant manager are responsible for conducting the weekly safety and
security inspections. A review of the program’s weekly safety and security audits validated the
audits for the annual compliance review period were conducted, as required. An interview with
the facility administrator (FA) confirmed the program completes weekly safety and security
inspections and findings are documented on the weekly safety inspection report and provided to
the FA for review.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures addressing the issuance, inventory, and control of
equipment and tools. The program’s policy prohibits machetes, bowie knives, or other long
blade knives. An observation during the week of the annual compliance review confirmed all
Class A and Class B tools were securely stored when not in use and all tools were marked for
easy identification. A review of the program’s tool inventory records for the annual compliance
review period showed all tools were inventoried daily and prior to being issued for work and
were inventoried following work activities. The program has a procedure for missing/lost tools
and disposal of dysfunctional tools; however, the program did not have either type of situation
during the annual compliance review period.
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5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures addressing the supervision requirements when youth
use tools including one staff to five youth ratio, issuing tools to youth and staff, assessment to
determine a youth’s risk to self and others, tool distribution, collection, and search criteria during
work projects. Reviewed documentation and video observations confirmed the program youth
only use mops and brooms and have no access to any other tools. A review of seven youth
case management records validated each youth received an assessment to determine their risk
to self and others prior to using tools. Seven youth were interviewed, and all seven indicated
they use mops and brooms and three of seven additionally stated they use paint brushes during
supervised community service. Seven staff were interviewed, and all seven indicated youth can
use mops and brooms; additionally, one staff stated youth can use a scrub brush.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures to address outside contractors which includes tools
shall never be left unattended, tools should be limited to only the required tools necessary to
perform tasks, and no tool shall be given to youth at any time. The facility administrator or
designee inspects all tools upon arrival of outside contractors and is responsible for providing
approval if such tools are required. The program’s guidelines for external work orders includes
checking of tools upon arrival and departure, searching of all vendors prior to entering the
facility, tool restriction while in the facility, missing tool follow-up, and restriction of youth from
the work area. The facility administrator is responsible, by policy, for providing
approval/permission of policy restricted items, including personal cellular telephones and
smartwatches. Three contractor project invoice documentation examples were reviewed, and
each had the contractor’s signature acknowledging the program’s policy, list of types of tools
and the final departing signatures, the amount/number of each tool written, and the sign-in and
sign-out initials of each item.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a policy and procedures to address fire, safety, and evacuation drills. A review
of the program’s Continuity of Operations Plan (COOP) revealed the program’s requirement is
to conduct monthly fire drills and monthly COOP drills on a rotating basis on each shift; to
include unannounced random fire drills monthly. A review of drill documentation for the annual
compliance review period found the program conducted monthly fire and COOP drills on each
shift. The documentation for all conducted drills contained the type of drill, date and time,
participants, brief scenario, findings, and recommendations. A tour of the facility during the
annual compliance review week found fire evacuation routes and egress plans were posted
throughout the facility. The facility has thirty-two fire extinguishers and reviewed documentation
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 72 (Revised September 2022)
reflected all fire extinguishers were inspected annually. An interview with the facility
administrator revealed COOP drills are completed monthly, across each shift. COOP drills
include disturbances, riots, threats, severe weather, evacuation, and escapes. In addition, fire
drills are conducted monthly across each shift. Each conducted drill is reviewed in the general
staff meeting. Seven staff were interviewed and asked which types of drills they participated in
during the past twelve months; six staff participated in weather and escape drills; five staff
participated in fire, chemical spill, and flooding drills. All seven staff confirmed their participation
in drills. Six of seven interviewed youth stated they were instructed on what to do in the event of
a fire and had participated in drills; the remaining youth stated they had not participated in drills
nor could they provide knowledge about fire procedures. The program was able to confirm the
youth was provided information regarding fire procedures with documentation in the case
management record. Four of seven youth indicated drills are conducted at least monthly; the
remaining three youth indicated they were not sure, or did not remember the frequency of drills.
The facility administrator’s interview confirmed COOP and fire drills are conducted at least
monthly, as the drill schedule indicated.
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 Continuity of Operations Plan (COOP) and the COOP was last
reviewed and updated on February 8, 2023, by the facility administrator, and submitted to the
Department for approval. The COOP is combined with the program’s Emergency Disaster
Preparedness Plan and the COOP was approved and signed February 16, 2023, by the
Department designee. The COOP is located in the assistant facility administrator’s (AFA’s)
office and conference room; and the plan is readily available to staff. The plan addresses
alternative relocation sites approved by the Department’s regional director and the COOP
includes all the required and relevant information for continuous operation during an emergency.
The program has food and necessary supplies available for continuous operation and services
during emergency or disaster situations. COOP supplies are maintained at the program; food
items are stored in the kitchen area and youth related items are stored within the dormitories. A
review of seven youth case management records was conducted and each contained all
required information outlined within the COOP for the critical identifying information and current
photograph of each youth. In all seven youth case management records it was found the
program maintains an administrative hard-copy record for each youth including all relevant and
critical identifying information for each youth. The facility administrator was interviewed and
confirmed the COOP is maintained in the conference room and the AFA’s office.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 72 (Revised September 2022)
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 has a policy and procedures regarding the storage and inventory of flammable,
poisonous, and toxic items. The program’s flammable, poisonous, and toxic items are stored in
a locked storage area and in locked cabinets. The area is always secured and inaccessible to
youth. The program maintains an inventory and a list of positions authorized to handle these
items. A review of the inventory and the actual items on-site revealed the inventory matched
and no items were missing, nor were any additional items not listed on the inventory observed.
Each item had an accompanying Safety Data Sheet (SDS) and the SDS was available where
the items were stored. The program maintains a list of facility positions, titles, and functions who
are authorized handle these items.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures regarding youth handling and supervision of
flammable, poisonous, and toxic items. The program maintains strict control of flammable,
poisonous, and toxic items. The policy prohibits the use, handing, or clean-up of dangerous or
hazardous chemicals by youth. The program youth do not have access to areas where
chemicals and tools are stored. The program conducts the cleaning activities in the evenings
and/or on weekends. A review of the program’s preventative maintenance checklist revealed
maintenance schedules and repairs were conducted, as required. Seven youth were
interviewed, and each youth indicated they do not use any chemicals.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a policy and procedures regarding the disposal of flammable, toxic, caustic,
and poisonous items and the program utilizes a contractor who is responsible for disposal of
these items; this contractor is scheduled when any disposal of the listed items is needed. The
program has a policy and procedures regarding chemical spill clean-up including the required
actions to be taken in the event of a chemical spill; however, there were no chemical spills at the
program since the last annual compliance review. A bio-hazardous waste contractor is utilized
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Office of Accountability and Program Support Page 69 of 72 (Revised September 2022)
for the disposal of all such waste. The facility administrator interview confirmed the program’s
policy and procedures.
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures addressing visitation and communication, youth
correspondence, and use of telephone by youth. The program’s visitation schedule is posted on
the wall in the lobby, in each dormitory, the cafeteria, and is also available in the youth and
parent/guardian handbook. The program’s visitation hours are Saturdays and Sundays from
1:30 p.m. to 3:30 p.m. A review of the visitation logs for the annual compliance review period
validated visitations were taking place according to the schedule. Telephone calls and mail
opening are conducted by the youth with their case managers. A review of seven youth case
management records confirmed each youth was given opportunities to communicate with their
family members by telephone and mail. There were no applicable youth with a history of human
trafficking; however, the program does have a policy and procedures for requesting clarification
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 72 (Revised September 2022)
from the youth’s juvenile probation officer to ensure the youth’s parents/guardians or other
family members are not under current or past investigation for human trafficking related
charges. The program can arrange video teleconferencing, or hold an alternative visitation time,
as alternative measures for youth communication with their parents/guardians. The program
utilizes third party language services for language barriers with families and youth; in addition,
the program has several bilingual staff who are utilized for language barriers as well. Each of
the seven interviewed youth stated the program has bilingual staff to assist with language
barriers. All seven interviewed staff stated several staff are bilingual in Spanish and Creole. One
of seven staff confirmed the program does have access to a language interpretation line; the
remainder of youth and staff were not able to confirm the access. This gap in resource
information was provided to the program, and the program stated this resource will be shared
again with staff and youth; however, the program also confirmed the use of bilingual staff. The
facility administrator stated the program has a language interpretation service.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program does provide a variety of recreation and leisure activities for the youth. The
program activity schedule contains at least one hour of supervised and structured indoor and
outdoor recreation and leisure activities, to include large muscle activity, for youth each day. A
review of the logbook confirmed recreation and leisure activities were conducted as scheduled.
The activity opportunities promote social and cognitive development, creativity, teamwork,
healthy competition, mental stimulation, and physical activity. The program takes precautionary
measures to prevent overexertion, heat stress, dehydration, and exacerbation of existing illness
or physical injury. The program has a recreational therapist on staff according to their
contractual agreement; and the recreational therapist and schedule of activities meet all
requirements. Seven youth mental health and substance abuse records were reviewed, and
each contained an individual treatment plan. Each youth’s individualized treatment plan
contained recreational therapy goal(s). Seven youth were interviewed, and each confirmed the
program provides/allows the opportunity to exercise, play outside, or participate in indoor free-
time activities; each youth was able to state which activities they choose to participate in. Seven
staff were also interviewed, and confirmed youth are given at least one hour of recreation or
free-time activity each day. Each staff was able to provide a list of activity opportunities the
program offers each youth.
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 has a policy and procedures for the search and inspection of the controlled
observation room. The program utilized controlled observation one time during the annual
compliance review period. The room used for controlled observation had a metal door with a
shatter-resistant window, was at least thirty-five unencumbered square feet, properly covered
vents and lighting, approved fire retardant mattress, and no electrical outlets. The controlled
observation report was reviewed, and found staff documented an inspection of the room and a
search of the youth before the youth was placed in the room, as required.
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Office of Accountability and Program Support Page 71 of 72 (Revised September 2022)
5.25 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program has a policy and procedures for controlled observation. One controlled observation
report was reviewed and found to contain documentation of the supervisory or higher-level staff
authorized placement. The youth in this incident was displaying active aggression, violent
behavior, was physically out-of-control, and staff advised the youth the reason of placement in
controlled observation and expected behavior for removal. A healthcare professional or staff of
the same gender as the youth completed the Health Status Checklist. This youth did not require
an extension which is required if placed for over the initial two hours, as the youth was only in
this status for under an hour.
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 has a policy and procedures for controlled observation safety checks and
releases, including staff designations for controlled observation. The program had a single
controlled observation incident since the last annual compliance. This controlled observation
report was reviewed and the staff making the placement completed the first page of the
controlled observation report and submitted it to a supervisor. Staff documented safety checks
at least once every ten minutes and observations of the youth’s behavior. Staff documented all
safety checks and observations on the Controlled Observation Safety Checks form. The facility
administrator (FA) or supervisor who has delegated authority, gave written approval before the
youth was released from controlled observation. The controlled observation report, Health
Status Checklist, and controlled observation safety checks were maintained in an administrative
record and in the youth’s case management record. The FA or designee reviewed and
approved the controlled observation report within fourteen days of the youth’s release from
controlled observation. All seven interviewed youth had not been placed in controlled
observation; however, one youth stated after an altercation or fight youth can be placed in
controlled observation, until there is a de-escalation in their behavior.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 72 of 72 (Revised September 2022)

report_type: QI Residential

rule: Indicator 2.20

excerpt: Educational Access (Critical)

rating: Limited Compliance

rule: Indicator 3.02