summary: QI Residential - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Jacksonville Youth Academy
TrueCore Behavioral Solutions, LLC
(Contract Provider)
4501 Lannie Road
Jacksonville, Florida 32218
Review Date(s): October 10-13, 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:
Renette Crosby, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Jeff Campbell, Office of Education, Education Coordinator (Standard 2)
Abigail Galloway, AMIkids Jacksonville, Licensed Mental Health Counselor (Standard 3)
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (Interviews and
Standard 1)
LeAnn Gruentzel, Office of Accountability and Program Support, Deputy Supervisor (Standard
2)
Kristine Harshaw, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Cedric Prince, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Jacksonville Youth Academy MQI Program Code: 1293
Provider Name: TrueCore Behavioral Solutions, LLC Contract Number: 10138
Location: Duval County / Circuit 4 Number of Beds: 24
Review Date(s): October 10-13, 2023 Lead Reviewer Code: 186
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 65 (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 * Non-Applicable
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 65 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 65 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 65 (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 65 (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 Non-Applicable
5.25 Controlled Observation Non-Applicable
5.26 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 65 (Revised September 2022)
Program Overview
The Jacksonville Youth Academy is a twenty-four-bed program, for fourteen- to nineteen-year-
old males, located in Jacksonville, Florida. The program is operated by TrueCore Behavioral
Solutions, LLC, through a contract with the Department. The program provides services
including Substance Abuse Overlay Services (SAOS). In addition, the program fosters each
youth by providing Impact of Crime, Cannabis Youth Treatment, anger management, and Living
in Balance. Additional treatment services provided include individual, family, and group therapy
sessions, recreation therapy, and restorative justice programming. Program administration is
comprised of a facility administrator, an assistant facility administrator, a staff development
specialist, a human resources generalist, and an administrative assistant. Case management
services are provided by a transition services manager and two case managers. Mental health
staff at the program include the clinical director, who also serves as the designated mental
health clinician authority (DMHCA), one licensed therapist, one non-licensed therapist, two pro
re nata (PRN) licensed mental health therapists, and one recreational therapist. Medical
services are offered seven days a week from 7:00 a.m. to 7:00 p.m. and are provided by a
health services administrator and one registered nurse. Educational services are provided by
the Duval County School Board. The layout of the program includes one building which contains
the dormitory, kitchen, cafeteria, medical unit, case management, mental health, and
administrative offices. Additionally, there are three portable buildings which serve as the
education classrooms and one portable building which serves as an indoor recreation room.
The program has forty-seven operating security cameras providing coverage. At the time of the
annual compliance review, the program had four vacant positions including one staff mentor,
one registered nurse, and two youth specialists.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 65 (Revised September 2022)
Strengths and Innovative Approaches
• The youth at the program started a football team, working diligently to better their
teamwork capabilities.
• The program hosts youth and staff games to further build on the sense of community
while increasing the overall sense of job satisfaction for the staff who invest so much
time and energy into the youth.
• Youth are able to participate in community restorative justice activities while at the
program, such as trash pickup at the National Cemetery, beach clean-up, the Eastside
back to school give away, the Heart and Breast Cancer Awareness Walks.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 65 (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 to ensure background screening is conducted for all
staff, volunteers, mentors, and interns with access to youth or confidential youth records. The
program had fifteen newly hired staff since the last annual compliance review. Each staff had an
eligible background screening completed prior to their hire date. Staff records documented a
criminal history report was reviewed prior to hire for each staff. None of the staff indicated a
break in service which required a new background screening. Seven of the fifteen staff were
applicable for a pre-employment assessment tool and all seven received a passing score. All
newly hired staff were added to the program’s Clearinghouse roster. The program completed
and submitted the Annual Affidavit of Compliance with Level 2 Screening Standards to the
Department’s Background Screening Unit (BSU) on December 12, 2022, meeting the annual
requirement. The teachers who are employed by the Duval County School Board received an
Annual Affidavit of Compliance with Level 2 Screening Standards on December 12, 2022.
Documentation was reviewed and confirmed the hiring authority reviews the Department’s
Central Communications Center (CCC) Personal Involvement History Report, Staff Verification
System (SVS) module, and the Florida Department of Law Enforcement (FDLE) Automated
Training Management System (ATMS) prior to hire.
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 which address the five-year background rescreening
process. A background rescreening is required every five years from the initial date of
employment. A review of the program’s staff roster indicated three staff were eligible for five-
year rescreenings. All three rescreening/resubmissions were completed as required and not
more than twelve months prior to the staff’s five-year anniversary date.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 65 (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 staff adhere to a code of conduct as evidenced by thirteen reviewed staff
personnel records. Each staff signed a receipt indicating they received the program’s code of
conduct. Within the staff’s training records, each indicated a training on Florida Reporting of
Child Abuse requirements. Observations were made throughout the program showing the
Florida Abuse Hotline and the Department’s Central Communications Center (CCC) numbers
were posted and available to staff and youth. The program has a written policy and procedures
on the abuse reporting process. The procedures indicate for CCC reportable incidents, when the
facility administrator (FA) is notified of any incident, it is determined if the incident is CCC
reportable. The FA will obtain necessary information and contact the CCC within the two-hour
time frame. Updates will be made as necessary. Youth eighteen years of age or older are
permitted to contact the CCC upon request to report incidents of abuse and neglect. The FA is
primarily the reporting person; however, any staff is able to make a CCC report as well. 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. Youth are provided with a private space to make
their report. The program director was interviewed concerning the Trauma Responsive and
Caring Environment (TRACE) self-assessment. The program’s assessment was completed in
February 2023. Five youth were interviewed, all advised feeling safe at the program. All five
youth know the process for reporting abuse and none of the five have been stopped from
reporting. Five staff were interviewed, all staff knew the process for reporting abuse and are
allowed to assist youth with making a call. None of the five have ever observed another staff
using profanity when speaking with youth. An interview with the FA confirmed the process for
adherence to the code of conduct to include staff termination. There were no allegations of
abuse reported during the annual compliance review period.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 65 (Revised September 2022)
1.04 Management Response to Allegations (Critical) Non-Applicable
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had no allegations of physical, psychological, or emotional abuse in the program
during the annual compliance review period; therefore, this indicator is rated non-applicable.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program had a total of six reports made to the Department’s Central Communications
Center (CCC) during the annual compliance review period. A review of internal incidents and
grievances was conducted, as a result no additional calls to the CCC were warranted. A sample
of five CCC reports was reviewed for completion requirements. All five documented calls were
made to the CCC within the two-hour required time frame. A review of the program’s master
control logbooks showed all three reviewed applicable incidents were documented. The
program has not experienced an increase of reportable incidents to the CCC since the last
annual compliance review period.
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 four Protective Action Response Right Interactions model (PAR/RI) incidents
during the annual compliance review period, each of which was reviewed for completion
requirements. All four reports were completed by the end of the staff’s workday. Each report
included statements from all staff involved. None of the reports indicated use of mechanical
restraints. None of the four reports indicated youth injury. A PAR/RI certified instructor reviewed
and signed off on all reports. All four reports showed the program administrator or designee
reviewed the reports within seventy-two hours of the incident. A copy of the PAR/RI Report was
placed in the program’s centralized file after administration or designee signed the report. The
PAR/RI summaries are submitted monthly to the Department’s residential program operations.
One monthly summary was missing from the PAR/RI binder maintained in the program. The
program’s PAR/RI plan was updated on January 6, 2023, and approved by the Department
January 12, 2023. There was a total of four PAR/RI incidents for the annual compliance review
period. This was not an increase of five or more since the last annual compliance review. The
program’s PAR/RI rate for the last quarter was 0.49, which is below the statewide Residential
PAR/RI rate of 1.35. The facility administrator was interviewed and advised PAR/RI Reports are
reviewed in the morning management meeting and reported for tracking in the morning meeting
database. The assistant facility administrator (AFA) of operations conducts a video review of the
incident to ensure proper PAR/RI procedures were followed, there was no use of excessive
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 65 (Revised September 2022)
force, and the PAR/RI was a necessary level of response. Monthly, the PAR/RI summary report
is completed and reviewed for trends and submitted the Department for tracking. Five staff were
interviewed, three of the staff advised never having utilized PAR/RI, and two advised they
attempt to speak with youth prior to utilization.
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.
Five staff training records were reviewed for pre-service training requirements. Four of the five
staff completed their 120 hours of pre-service training within 180 days of employment. One
reviewed staff was still within the first 180 days of hire. All five records included essential skills
completed prior to contact with youth. Four records included documentation of staff receiving
forty hours of Protective Action Response Right Interactions model (PAR/RI) training, one staff
was in PAR/RI training during the annual compliance review week. All of the five training
records included documentation of active shooter preparedness, adolescent development and
behavior, balanced approach to restorative justice, the Department’s Central Communications
Center (CCC) incident reporting, civil rights, communication, confidentiality/health insurance
portability and accountability act (HIPPA), diversity, Department legacy, equal employment
opportunity, gang awareness, human trafficking intervention, infection control/bloodborne
pathogens, information security awareness, the Department’s Juvenile Justice Information
Systems, quality report writing, safety, security, and supervision of youth, sexual harassment,
and trauma responsive practices. All five staff received training on the grievance process,
infection control, exposure control plan, behavior management system, and the intended and
safe use of tools. All instructors were qualified to provide the delivered trainings and the
trainings documented in the Department’s Learning Management System (SkillPro).
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
Five staff training records were reviewed to include two supervisory staff. All five staff had
completed all the mandatory training topics as required. All five staff had more than the required
twenty-four hours of annual training. Two supervisory records were reviewed. The trainings
completed were more than the required eight hours of training in coaching, leadership, and
personal accountability. All in-service trainings were documented in the Department’s Learning
Management System (SkillPro). All instructors were qualified to deliver the training provided.
The program has an in-service training plan which was submitted to the Department’s regional
director on December 22, 2022. The program has a training calendar, which is updated as
changes occur.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 65 (Revised September 2022)
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures in place including the training requirements of the
grievance process. The program’s grievance process has three phases, informal, formal, and
appeal. The boxes for “Let’s Talk” and grievance forms are located on the dorm and are
checked daily by the assistant facility administrator (AFA). In a formal interview with the facility
administrator (FA) it was reported the AFA investigates each grievance and renders a decision
in writing. Should the decision be in support of the youth’s grievance, the AFA will determine
actions to rectify the situation, and obtain the youth's signature and date on the grievance form
to indicate their agreement with the decision. If the decision does not support the youth’s
grievance, it will be immediately forwarded to the FA. If the outcome of the FA or designee's
review is agreeable to the youth, both sign and date the grievance form to indicate their
agreement. If the youth is not agreeable with the decision, the youth signs and dates the
grievance to indicate the decision was discussed with them. If the youth refuses to sign the
grievance, the FA will make a note “the youth refused to sign” directly on the grievance form.
Five youth were interviewed, and all knew the location of the grievance forms and were able to
describe the grievance process. Five staff were interviewed and all were able to explain the
grievance process. The FA was interviewed and advised the process is to encourage youth to
resolve questions, disputes, and complaints through informal communication with program staff.
A formal, written grievance may be filed with the AFA at any time. The program had one
grievance filed during the annual compliance review period which was resolved during the
formal phase of the grievance process, did not require an appeal to the FA, and was completed
within the required time frame.
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 had two staff providing delinquency interventions during the annual compliance
review period, each of whom were reviewed for interventions and facilitator training
requirements. Both staff had the required education and experience necessary for working with
juvenile offenders. The staff’s education and work experience were considered by the program
when determining staff delivery of intervention services. Both staff received appropriate training
for the group being facilitated. A review of the program’s schedule was completed, and all non-
primary groups are included in the daily program schedule. Non-primary groups were conducted
as included in the program’s contract table to include Living in Balance. Cannabis Youth
Treatment and Impact of Crime (IOC) are the program’s primary services; therefore, they are
not applicable for review of interventions. The sign-in sheets for the non-primary groups were
reviewed and verified groups were provided as required and in accordance with the daily
schedule. The facility administrator was interviewed and advised the program utilizes Thinking
for a Change Problem-Solving curriculum with both cognitive restructuring and social skills
interventions. The identified youth participate three times a week as outlined on their weekly
schedule. The designated mental health clinical authority (DMHCA) was interviewed and
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Office of Accountability and Program Support Page 15 of 65 (Revised September 2022)
reported the program provides many evidence-based groups and promising practice groups
such as Cannabis Youth Treatment, Living in Balance, IOC, and group treatment for substance
abuse.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a policy and procedures which ensure interventions or instruction
focusing on developing life and social skill competencies in youth are provided. The program’s
identified life skills group is Living in Balance, which is a primary service; therefore, group
documentation was not reviewed for the annual compliance review period. The program
provides health education training for the youth along with life skills which include learning how
to complete taxes and participate in job interviews. Five youth were interviewed. Four of five
youth stated they completed life skills activities such as mock job interviews, résumé writing,
and completing tax returns. One youth stated they do not participate in life skills because they
have a job waiting for them once they complete the program; however, the program indicated all
youth participate in life skills as part of different group curricula. Five youth denied participating
in gender specific groups. An interview with the facility administrator confirmed youth are
required to participate in all groups to progress through the program. The program follows the
Young Men's Work, gender responsive philosophy. The program provides youth with personal
items which allow gender expression, to include meeting the needs of youth who identify as the
opposite gender. An interview with designated mental health clinician authority (DMHCA)
confirmed the program provides Living in Balance and substance abuse groups three times a
week, Cannabis Youth Treatment once a week, and Impact of Crime and restorative justice
twice a week. The DMHCA indicated youth are provided an opportunity to practice skills they
learned in group during their recreation time, school, and any time they interact with peers, staff,
and family.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s contract identifies Impact of Crime (IOC), which is a promising practice, as the
required restorative justice service provided to youth. IOC is a primary service; therefore, group
documentation was not reviewed. All youth are also provided with restorative justice activities
such as community service projects. An interview with the facility administrator confirmed youth
are able to participate in a variety of restorative justice groups and projects such as IOC, school
backpack giveaways, community cleaning, hosting a car wash, and helping set up for car shows
or cancer walks. All youth are permitted to participate in restorative projects. If a youth has any
victims, they are requested to write apology letters to the victims. Five youth were interviewed
about restorative justice groups and activities. Four of five youth stated they participated in IOC
and learned about how their behaviors affect their victims and families. All five youth indicated
they participated in community service projects in the program and community. All five youth
confirmed they have practiced new skills learned in groups such as breathing exercises,
thinking before speaking, speaking respectfully even when they are angry, and avoiding
negative situations and peers. An interview with the designated mental health clinician authority
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(DMHCA) indicated the program provides groups to consist of Living in Balance, substance
abuse groups, and other group treatment.
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 outline how alerts are identified, documented,
updated, and communicated to staff. Three youth were identified with alerts which required the
youth to be placed on the alert system. All three youth had alerts entered as specified in the
program’s written procedures. Nine alerts were reviewed in five youth records. All nine alerts
included the alert type, and the name and title of staff entering, removing, or updating the alerts.
One alert was applicable for being included in the program’s logbook, and the alert was found in
the logbook. The remaining eight alerts were entered into the Department’s Juvenile Justice
Information System (JJIS) prior to the youth being admitted to the program, and all eight alerts
were reviewed and entered in the program’s internal alert system upon admission, as required.
An interview with the program’s facility administrator (FA) concluded the program has a
formalized procedure in place with the healthcare staff to review the important medical issues
pertaining to the youth at the program. The FA stated the program utilizes an internal alert
system to include an alert roster and alert board which details all applicable youth alerts. Any
change in a youth's alert status is updated on the board and documented in the shift logbook.
The outgoing shift supervisor will brief the incoming shift of any new or changed alerts. In
addition, any new or updated alerts are discussed during morning management meetings. The
FA also explained the internal alerts are reviewed daily and updated as appropriate. Each
department administrator is responsible for managing alerts applicable to their department. The
internal communication board displays current, open, applicable alerts and is updated as
needed. Internal alert trackers are also maintained for each department. All internal alert
trackers are reviewed on a weekly basis during morning management team for fidelity
monitoring. Five staff were interviewed regarding how they are informed of youth alerts. Two
staff indicated they are informed of alerts through the alert log in master control, one staff stated
alerts are listed in the logbooks. Three staff indicated staff are informed of alerts verbally or
through email.
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1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains an Individual Healthcare Record (IHCR) and an individual case
management record for each youth. Five youth individual case management records were
reviewed, and each contained the youth’s name, Department identification number (DJJID),
date of birth, county of residence, and committing offense. Each record included sections for
legal information, demographic and chronological information, correspondence, case
management and treatment team activities, and miscellaneous information. All youth records
are labeled “Confidential” and are secured in locked cabinets, which are also labeled
“Confidential” in the medical and case management offices.
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 policy and procedures in place to ensure the program has a community
support group or advisory board meeting at least every ninety to 120 days. There was
documentation of the facility administrator (FA) soliciting active involvement from law
enforcement, judiciary community, community partners, business community, school board or
district, faith community, a parent/guardian of a former youth involved in the juvenile justice
system, a victim advocate, and the LGBTQI+ community. The program holds meetings virtually
through Microsoft Teams, which was confirmed by a review of sign-in sheets and agendas from
quarterly advisory board meetings. None of the meetings were cancelled or rescheduled. An
interview with the FA confirmed meetings are held quarterly and include a review of an agenda
detailing program updates and community advisory board member updates. Following each
meeting, meeting minutes are shared with all board members to provide information to
members 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. One
community advisory board member responded to a request for an interview. The business
community board member stated they participated in one of the meetings by bringing the “Stop
the Gun Violence” campaign to the program in 2023.
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 in place to ensure a system for evaluating staff, at
least annually, based on established performance standards. Each staff receives an evaluation
after their ninety-day introductory period and annually thereafter. A review of five position
descriptions confirmed each staff’s performance standards were clearly identified. A review of
five staff personnel records confirmed each staff received an annual performance evaluation on
established performance standards. The performance standards matched the position
description for each staff. A review of the contract confirmed contractually required positions
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were maintained and performed as outlined with the exception of one registered nurse position
vacant at the time of the annual compliance review; however, medical hours outlined in contract
are covered. The facility administrator (FA) confirmed the evaluation process as annually,
unless the staff is a new hire, in which they receive an evaluation at ninety days. Five staff were
interviewed and four staff stated yearly evaluations occur and one stated they received a ninety-
day evaluation. Four of the staff advised communication is good and one stated very good
within the program.
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.
A review of the program’s contract revealed seventeen special contract conditions, all of which
were being met, as evidenced by documentation or observation by the annual compliance
review team. Special contract conditions being met at this time are drills conducted three times
a month, making funding available for transportation and lodging for families of youth in need of
assistance to visit, cardiopulmonary resuscitation (CPR) and first-aid training for youth,
providing youth with a transition portfolio, funding for youth scholarships and staff continuing
education, youth clothing and hairstyles which are fitting for the community, substance abuse
groups, biannual staff training, and contracting of a certified behavior analyst and addiction
specialist. An interview with the facility administrator confirmed substance abuse, Impact of
Crime (IOC), career and technical education services are provided to the youth. Five youth were
interviewed. All five-youth confirmed they had completed, or were participating in, Cannabis
Youth Treatment, anger management, IOC, or Living in Balance.
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.
There was evidence of the program implementing career and technical education services. The
program offers Occupational Safety and Health Act (OSHA-10), Ready to Work, ServSafe,
cardiopulmonary resuscitation (CPR) and first-aid, and soft skills classes. During the annual
compliance review period, eleven youth were certified in ServSafe, twelve youth were certified
in Florida Ready to Work, two youth were certified in OSHA-10, and nineteen youth were
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certified in CPR and first-aid. Times and days vary for vocational services. The transitional
service manager works with youth on OSHA-10 after youth’s groups are complete for the day,
Florida Ready to Work was first completed on the weekend. Other services are offered Tuesday
and Thursday in the evening as evidenced by a review of sign-in sheets and the program
schedule. The program has two staff who provide career and technical education services. Both
staff are qualified to provide the services offered based on their education. The career and
technical education programs are appropriate for the age of the youth, the abilities and goals,
length of stay, and classification of the youth in the program. Five youth were interviewed
regarding their participation in career and technical education services. All five youth confirmed
they had completed and/or were currently participating in career and technical education
services. An interview with the facility administrator confirmed the program provides OSHA-10
certification, Florida Ready to Work, first-aid/CPR, and ServSafe. Youth are also provided with
the opportunity to complete job applications, obtain a state identification, and fill out job
applications online prior to release.
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 utilizes the LAURIS electronic records system to run specific reports which give a
programmatic snapshot on data points and demographic trends. Department heads use the
tracking features to assist in department management, as well as forecast staffing patterns and
meetings. The program uses the Department’s Juvenile Justice Information System (JJIS) to
track trends in completion rates, recidivism rates and releases, and compared those trends to
statewide averages. Surveys are provided to staff and youth every quarter, with a minimum
sample size on each quarter. Surveys are conducted and captured by Survey Monkey, and
results are extracted and analyzed quarterly. Programs are provided feedback as well as
comparison information from other programs.
The program has implemented 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 week's data. Additionally, regional compliance managers are responsible for
establishing data integrity by conducting on-site checks to ensure the uploaded data matches
facility records and documentation. A review of documentation supported this practice.
The program’s practice in sharing this information with providers and stakeholders on a
quarterly basis is to provide monthly reports to the Department and holding a Community
Advisory Board meeting quarterly to discuss new or updated information. Reviewed
documentation supported this practice.
The program utilizes data on a daily, weekly, monthly, quarterly, and yearly basis. Information
gathered is used for policy development and programming. Data collected from the program
level is forwarded to the senior leadership level for review, then feedback is provided to the
program on an ongoing basis. Data is evaluated for both risk and protective trends as well as for
forecasting trends which can impact compliance or programming. Information is reviewed with
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staff during daily management meetings and monthly all staff meetings, and trends are reviewed
for possible policy changes. Revised policies and survey results are discussed with facility
administrators during their monthly one-to-one meetings with senior leadership and then with all
staff during monthly all-staff meetings. If necessary, changes which are made programmatically
are also discussed with both staff and youth.
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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 regarding initial contact to a youth’s parent/guardian
and addressing court notification upon each youth’s admission. Five youth records were
reviewed. All five reviewed records documented the program notified the youth’s
parent/guardian by telephone within twenty-four hours of admission. Each of the five reviewed
records included documentation indicating the program notified the parent/guardian, the youth’s
juvenile probation officer (JPO), and the court in writing within forty-eight hours of the youth’s
admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures regarding youth orientation. A review of five records
found the program provided an orientation for each youth within twenty-four hours of admission.
The orientation included services available, daily schedule, expectations and responsibilities of
the youth, written information on the program’s behavior management system, access to
medical and mental health services, zero-tolerance regarding sexual misconduct, access to the
Florida Abuse Hotline or the Department’s Central Communications Center if the youth is over
eighteen years of age, and items considered contraband. The youth orientation also included
information on the performance plan process, dress code and hygiene requirements,
procedures regarding visitation, mail, and use of the telephone, expectations for release from
the program, community access, grievance procedures, emergency procedures, physical design
of the facility with a tour, and assignment to a living dormitory. Each reviewed record
documented a signed checklist acknowledging the youth received an orientation packet,
including a copy of the youth handbook. A youth admission was observed during the annual
compliance review week which verified orientation is completed on the day of admission and
included all elements in the program’s policy. Five interviewed youth stated they received an
orientation to the program within twenty-four hours of admission which included program rules,
procedures, schedules, and all other pertinent information.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures which address obtaining written consent of youth who
are eighteen years of age or older. Five youth records were reviewed, and none were applicable
for written consent of youth over the age of eighteen before providing or discussing information
with the parent/guardian. Only two youth were applicable for written consent of youth over the
age of eighteen during the annual compliance review period. Both applicable youth records
contained consent forms signed by the youth allowing the program to share, with the
parent/guardian, any information related to the youth's physical or mental health screening,
assessment, or treatment.
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’s policy and procedures outlined the classification process and included a
classification system which promotes safety and security, as well as effective delivery of
treatment services, based on determination of each youth’s individual needs and risk factors.
The factors included physical characteristics of the youth, age, maturity level, identified special
needs, history of violence, gang affiliation, criminal behavior, sexual aggression or vulnerability
to victimization, criminal behavior, and human trafficking history. The policy also addresses
when reassessment is warranted based upon changes in the youth’s supervision status, new
and updated alerts, relevant information available to the treatment team, and/or behavioral
concerns. Five youth records were reviewed. Each youth record had an initial classification
completed on the same day of admission to the program. The initial classification forms included
all required elements. Documentation confirmed a new screening for Vulnerability to
Victimization and Sexually Aggressive Behavior (VSAB) was completed for each youth. All five
youth were classified for the purpose of assigning them to a living area, sleeping room, and
youth group or staff mentor. The case manager conducts a risk assessment during the intake
process for each youth and reviews alerts for any issues affecting classification. Three of the
five records reviewed included a reassessment requiring re-classification for increase in
privileges or freedom of movement, assignment to work projects or activities involving tools or
instruments which may be used as potential weapons or means of escape, and prior to an
anticipated off campus activity. An interview with the facility administrator verified all youth are
assessed during admission where the youth’s information, alerts, and perception of vulnerability
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along with the VSAB results are reviewed by administration staff to choose the appropriate room
for youth.
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 addressing gang identification which includes
notification to law enforcement. The program assesses each youth at intake for suspected gang
involvement. Five youth records were reviewed, and none were applicable for youth suspected
of gang involvement. Only one youth was applicable for gang identification and notification of
law enforcement during the annual compliance review period. The program notified local law
enforcement, prior to the seven-day notification, as well as education staff of youth’s gang
involvement. The youth was identified as having gang involvement prior to admission to the
program by their juvenile probation officer, who entered the alert into the Department’s Juvenile
Justice Information System (JJIS). The program maintains an internal alert list for all youth,
including gang affiliation.
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 to ensure youth who are identified as or are
suspected gang members are provided intervention services and activities. Five youth records
were reviewed, and none were applicable for youth gang involvement and association. Only one
youth was applicable regarding gang identification during the annual compliance review period.
The youth’s Individualized Performance Plan (IPP) included gang prevention and intervention
strategies. The program utilizes the Gangs: 50 Stories of Fractured Lives gang curriculum for
gang awareness and intervention. Reviewed sign-in sheets confirmed groups were delivered as
designed. The program provided additional groups such as Impact of Crime (IOC) curriculum to
bring gang prevention and awareness to each youth in the program. As written in the program’s
policy and procedures, the case managers work with the youth to develop a plan to disaffiliate
with gang activity. An interview with the facility administrator confirmed the program includes a
gang prevention goal on the performance plan and provides various materials to educate youth
on the risks of gang involvement.
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2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
Five youth records were reviewed for Residential Assessment for Youth (RAY) assessments.
Each record contained an initial RAY assessment completed within thirty days of the youth’s
admission to the program. All initial RAY assessments were completed and maintained in the
Department’s Juvenile Justice Information System (JJIS). Two of the five reviewed records were
applicable for a RAY Reassessment. Documentation maintained in each youth’s record
supported each RAY Reassessment was completed within ninety-days of the initial RAY. The
program maintained all reassessments in each youth’s 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.
Five youth records were reviewed for a Youth Needs Assessment Summary (YNAS). All five
YNAS were completed within thirty days of the youth’s admission to the program. Reviewed
documentation supported each YNAS was documented in the Department’s Juvenile Justice
Information System (JJIS).
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
Five youth records were reviewed for Individualized Performance Plan (IPP) development. All
five records contained an IPP completed within thirty days of the youth’s admission to the
program and after the initial Residential Assessment for Youth (RAY) assessment and Youth
Needs Assessment Summary (YNAS). Each IPP was developed and signed by the treatment
leader, youth, administrative representative, living unit representative, treatment staff,
education, and all parties who have significant responsibility in goal completion. Reviewed
documentation confirmed a copy of the IPP was sent to each of the youth’s parent/guardian
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along with a signature page to return. Two of the three parents/guardians signed the signature
sheet and sent back to the program, which was maintained with the IPP in the youth’s record.
All five reviewed IPPs documented the youth’s top three criminogenic needs and individualized
goals based upon the prioritized needs reflecting the risk and protective factors identified in the
assessment process. Each youth’s IPP included specific delinquency interventions with
measurable outcomes, which will decrease criminogenic risk factors and promote strengths,
skills, and support reducing the likelihood of the youth reoffending. All five IPPs included court-
ordered sanctions, which can be initiated and/or completed while the youth is in the program,
transition activates targeted for the last sixty days, the youth’s responsibilities to accomplish
each goal, and staff responsibilities to enable the youth to complete the goals. All five reviewed
records documented a transmittal letter and a copy of the plan was sent to the committing court,
parent/guardian, and juvenile probation officer (JPO) within ten working days of the IPP being
completed. Five interviewed youth reported they participated in the development of their IPP,
were provided a copy, and were able to verbalize their current goals.
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.
Five youth records were reviewed and four were applicable for IPP revisions. Two IPPs were
revised based on the Residential Assessment for Youth (RAY) Reassessment results, four IPP
revisions were based on demonstrated progress toward completing each goal, and one IPP
revision was based on demonstrated lack of progress toward completing goals. Reviewed
practice indicated the multi-disciplinary treatment team met formally approximately every thirty
days to discuss each youth’s IPP and document the youth’s demonstrated progress toward
completing each goal. In the event a youth demonstrated lack of progress toward completing a
goal, this would be discussed during a special treatment team meeting and modifications would
be made to the youth’s IPP. Two of the five reviewed records were applicable for youth in
transition. Documentation showed each IPP was revised to facilitate transition activities during
the last sixty days of the youth’s stay in the program.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
Five youth records were reviewed and two were applicable for performance summaries. One
additional closed file was reviewed for performance summaries. Each applicable youth record
documented a performance summary was completed within the required ninety-day time frame
following the signing of the Individualized Performance Plan (IPP) as well as prior to release. All
summaries included the youth’s status on each IPP goal, youth’s overall treatment progress
based on their treatment plan, and the youth’s academic status, including performance and
behaviors in school. In addition, the youth’s behavior, interactions with peers and staff, overall
behavior adjustment, and the youth’s adjustment to the program was included in the
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performance summary. None of the reviewed performance summaries included the level of
motivation and readiness for change; however, the level was seen noted in each of the youth’s
performance plan reviews and were discussed during treatment team. Reviewed performance
summaries supported each applicable youth was provided the opportunity to review and add
comments prior to signing and received a copy. Reviewed documentation supported each
completed summary was signed by the treatment team leader, facility administrator or designee,
and the youth. Reviewed records documented the original completed performance summary
was filed in each applicable youth record and was sent to the youth’s committing court, juvenile
probation officer (JPO), and parent/guardian within ten working days. A review of three closed
youth records supported an original release summary, along with justification for release and
Pre-Release Notification (PRN), was sent to each youth’s assigned JPO. All three release
summaries and PRNs were sent at least forty-five days prior to the planned release date and a
signed copy was retained in the youth’s closed record. None of the releases were objected by
the court. Reviewed documentation in each closed record verified, once the PRN was approved,
the program provided written notification to the youth’s parent/guardian regarding the planned
release and completed an exit Residential Assessment for Youth (RAY). The reviewed youth
were not applicable for the sexually violent predator program (SVPP). None of the reviewed
closed records were applicable for a Victim Notification of Release letter.
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 which address the encouragement of parent/guardian
involvement in the case management process. Five reviewed records verified the program
encouraged and facilitated the involvement of each youth’s parent/guardian in the assessment
process, performance planning and development, progress reviews, and transition planning.
The program provides all parents/guardians advanced notice of the scheduled formal treatment
team meetings and conferences with dates and times. Each letter also indicated if the
parent/guardian could not attend by telephone or video conference on the day of the meeting,
they may participate by providing verbal or written input prior to the meeting. Parents/guardians
participate in the youth case management services through treatment team meetings, weekly
telephone calls, visitation, and family therapy. An observation of two treatment teams during the
annual compliance review week confirmed the program encouraged and tried to facilitate
parental/guardian involvement. During one treatment team, even though the parent/guardian did
not answer after trying twice, the case manager went through the process of obtaining an
interpreter through the Language Line, after being disconnected once and being transferred to
three separate interpreters, to try and facilitate the parent’s/guardian’s involvement in the
youth’s treatment process. During the second observation, the parent/guardian was involved
and commented and encouraged youth’s positive progress and improvements. The program
facilitates the parents/guardians involvement with advance invitations to assessments,
performance planning and development, progress reviews, and family days. An interview with
the facility administrator confirmed parental/guardian involvement in the case management
process is encouraged through admission calls, parental/guardian assessments, family
sessions and Parenting Wisely groups, visitation, and weekly telephone calls. Five interviewed
youth stated parents/guardians are involved with their case management through participation
in treatment team meetings, family sessions, and weekly calls.
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2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
The program maintains a policy and procedures the Individualized Performance Plan (IPP) shall
reference or incorporate the youth’s treatment or care plan. Five reviewed youth records
revealed each youth had a separate treatment and academic plan. Each IPP contained
documentation of incorporation of the plans. None of the youth were applicable for having a plan
from an outside agency.
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.
Five youth records were reviewed for treatment team meetings. Each record documented formal
treatment team reviews were conducted at least once every thirty days. Informal reviews were
held bi-weekly. The program utilized a Performance Plan Review form for both the formal and
informal treatment team meetings which included the youth’s name, date of review, meeting
attendees, comments from treatment team members, youth’s progress, and any revisions. The
treatment team leader reviewed the progress of each youth’s goals, behaviors, physical
interventions, treatment progress, and Residential Assessment for Youth (RAY) Reassessment
results. Youth are provided the opportunity to demonstrate skills acquired in the program. All
staff gave relevant input on the youth. Reviewed documentation confirmed formal treatment
team meeting attendees consisted of the youth, case management staff who act as the
treatment team leader, clinical staff, education, living unit representative, and a program
administration representative for each of the five applicable youth. Each youth’s juvenile
probation officer (JPO) and parent/guardian were invited to participate in person, by
telephone/video conference, and/or provide written input. Reviewed documentation confirmed
informal treatment team meeting attendees consisted of the youth and case management staff,
with relevant information being provided by treatment team members. An observation of two
formal treatment teams during the annual compliance review week confirmed all required staff
were present, including education, recreational therapist, and JPO, and the parent/guardian by
telephone, if they are able to be reached. A review of the treatment plans in both treatment
teams determined a youth’s anticipated release date. Five interviewed youth reported staff
review their performance through progress on performance plan goals, positive and negative
behavior, and treatment progress. Each youth reported they are given an opportunity to
demonstrate any skills they have learned in the program during treatment team.
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2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
Three closed youth records were reviewed regarding transition planning, conferences, and
Community Re-entry Team (CRT) meetings. Documentation showed all required treatment
team members, youth, parent/guardian, education staff, and juvenile probation officer (JPO)
were invited and participated in the transition conference held at least sixty days prior to the
youth’s targeted release date. All five closed youth records documented the transition
conferences were conducted and documented on the Transition Conference form which
included attendees and signatures acknowledging the transition goals and accountability of
completion. During the transition conference, participants reviewed the transition activities
outlined on each youth’s Individualized Performance Plan (IPP) or revised IPP, additional
identified transition activities, target completion dates, and each person’s responsibility for goal
completion. Each youth record contained documentation a copy of the transition plan was sent
with a request to return signature sheet to anyone not in attendance who had a responsibility for
completion of transition goals, as well as documentation a copy of the plan was sent
electronically to the JPO. Documentation in all five closed records supported the program
received an invitation to the CRT meetings. Reviewed documentation supported the program,
youth, and parent/guardian participated in the CRT meetings.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program maintains a policy and procedures for the assembling of the exit portfolio for each
youth to assist them once released back into the community. Exit portfolios are to include a
state-issued identification card, Social Security card, birth certificate, all educational
documentation, school transcripts, résumé, sample employment applications,
educational/vocational certificates earned in the program, along with a calendar of upcoming
appointments. Three closed youth records were reviewed and two youth had a completed exit
portfolio with all required elements as outlined in the policy. One youth record contained all
required elements except for the state-issued identification card, Social Security card, and birth
certificate. Reviewed documentation showed the parent/guardian was sent a notification letter
requesting the needed Social Security card and birth certificate to obtain the identification cards;
however, the program never received the needed items. All three closed youth records indicated
the exit portfolio was discussed and initiated during the transition conference and verified during
the exit conference. Documentation supported the exit portfolio was completed and given to
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each youth upon release. Documentation showed the program forwarded each youth’s JPO a
copy of the exit portfolio.
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Three closed youth records were reviewed for completion of the exit conference. Reviewed
documentation found each exit conference was conducted at least fourteen days prior to the
youth’s release and after notifying the juvenile probation officer (JPO) of the youth’s release.
Reviewed documentation supported the youth, case manager who also acted as the treatment
team leader, the facility administrator or designee, educational staff, mental health staff, and
medical staff all participated and signed the exit conference, with the parent/guardian and JPO
participating by telephone. Transition activities and target dates were reviewed and finalized
during the exit conference. Documentation showed a copy of the exit conference was
electronically sent to each JPO and mailed to each parent/guardian. All exit conferences were
separate from the transition and Community Re-Entry Team meetings. All three of the closed
youth records showed the date of admission and release coincided with the dates entered in the
Department’s Juvenile Justice Information System (JJIS).
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to promote constructive input by youth. The program
promotes active participation through opportunities to make choices, assume meaningful roles,
including team membership and leadership roles, and give input into the rules and operation of
their residential community. The recreational therapist is to meet with the Youth Advisory Board
on a monthly basis to receive input from the youth related to recreation and leisure activities for
the upcoming month. Reviewed documentation verified the program solicited input from youth
through the monthly Youth Advisory Board meetings, monthly school youth surveys, and
quarterly youth surveys. The facility administrator interview confirmed the program’s formal
process to solicit input from youth is through the Youth Advisory Board, Let’s Talk forms,
grievance forms, youth surveys, and meetings with administration. Five interviewed youth stated
they and other youth provide input regarding what happens at the program through the youth
advisory board and daily meetings.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures to provide career education based on age and
appropriateness for the educational abilities of the youth in the program. The program provides
Type 2 career education development. The interview with the lead teacher indicated the youth
participate in career education by learning job skills and writing resumes and are also allowed to
research future career paths. An interview with the facility administrator (FA) indicated the
program provides career education programming through the education department. The career
education program is appropriate based on the youth’s age, assessed educational abilities, and
goals of the youth. They also provide certifications in first-aid, cardiopulmonary resuscitation
(CPR), and ServSafe. Three closed case management youth records were reviewed. All three
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records included a completed employment application and résumé. The three reviewed records
had an appointment with the Career Source Center along with appropriate documents essential
to obtaining employment. Documentation indicated the youth's parent/guardian and juvenile
probation officer (JPO) were aware of the vocational plan for the youth. Two out of the three
reviewed records had a Department of Highway Safety and Motor Vehicles state-issued
identification card (ID). The one record missing the ID had documentation where the
parent/guardian refused to send a copy of the youth’s ID. All three reviewed records had a
career certification in first-aid/CPR, Occupational Safety and Health Administration (OSHA), and
ServSafe.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide educational access. The program provides
education services through the Duval County School District and the 250-day calendar, which is
distributed over twelve months, includes ten days used for teacher training and planning. A
review of the daily school schedule revealed the center provides three one-hundred-minute
class periods from 7:30 a.m. through 1:00 p.m. with a twenty-minute morning nourishment
period, meeting the required twenty-five hours of weekly instruction. Four of the five interviewed
youth reported there is no or little interruption to the school day. One youth indicated
interruptions happen, but not frequently. The interview with the lead teacher indicated all the
youth receive credit for a completed course. They also reported the school schedule is adhered
to. A review of five randomly selected days in the logbook indicated education classes started
and ended on time. Observations of the program video for three days verified school started and
ended on time.
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 education transition plan to be
developed upon each youth’s admission. Three closed youth case management records were
reviewed. All three youth records included an individual education transition plan developed
upon entry, including the youth’s post-release goals, meeting the required elements. Each of the
three records contained an exit plan indicating the case manager, parent/guardian, and youth
were all aware of the plan. Included in each record was an Electronic Educational Exit Plan
(EEEP) which identified the next educational placement information and input from the post-
release school district representative. Four of the five interviewed youth reported the program
was preparing them very well or well when it came to high school, high school equivalency
diploma (GED), vocational school, employment, and/or college. One youth reported the teacher
was mean. Four of the five interviewed youth reported they participated in the development of
their education transition plan.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program has a licensed mental health counselor (LMHC) who serves as the designated
mental health clinician authority (DMHCA). The DMHCA has a clear and active license in the
State of Florida, which expires on March 31, 2025. The DMHCA is on-site at the program forty
hours each week, Monday through Friday, and is on call twenty-four hours a day for clinical
emergencies. The program has a licensed clinical social worker (LCSW) on staff who serves as
the back-up DMHCA. The LCSW has a clear and active license in the State of Florida, which
expires on March 31, 2025. An interview with the DMHCA verified their role in oversight and
supervision to the mental health professionals at the program. The DMHCA reported their role
includes conducting group and individual counseling sessions as needed, completing reviews,
tracking monthly fidelity monitoring, providing groups weekly, and providing caseload coverage
as needed. The DMHCA reported maintaining constant contact with clinical staff through weekly
supervision, e-mail communication, and an open-door policy for staff.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures for assuring mental health and substance abuse
services are provided by individuals with appropriate qualifications. The program’s mental health
staff is composed of the designated mental health clinician authority (DMHCA) who is a licensed
mental health counselor (LMHC), one licensed clinical social worker (LCSW) under Chapter
491, one non-licensed therapist, and two pro re nata (PRN) licensed mental health counselors
(LMHCs). The LMHC’s license was verified and found to be clear and active, in the State of
Florida as indicated on the Florida Department of Health website. The current license expires
March 31, 2025. The LCSW’s license was verified and found to be clear and active, in the State
of Florida as indicated on the Florida Department of Health website. The current license expires
March 31, 2025. The program has two PRN LMHCs with clear and active licenses expiring on
March 31, 2023. Each of the licenses were renewed and are set to expire on March 31, 2025.
The program’s clinical staff have the required qualifications as outlined in contract and Florida
Administrative Code. The program has an active Chapter 397 license with the Department of
Children and Families (DCF) to provide substance abuse services for adolescents signed on
September 28, 2024.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has one non-licensed, master’s-level mental health staff working under a full-time
licensed mental health counselor (LMHC) who was filling the role of the designated mental
health clinician authority (DMHCA). There were no clinical vacancies at the time of the annual
compliance review. The non-licensed therapist holds a master’s-level degree from an accredited
university. The non-licensed master’s-level therapist, full-time licensed clinical social worker
(LCSW), and full-time LMHC all carry a caseload under the required fifteen youth limit. The
program’s DMHCA is responsible for providing face-to-face clinical supervision to the non-
licensed clinical staff. Reviewed Clinical Supervision Logs since the last annual compliance
review found the DMHCA conducted the required weekly face-to-face supervision with the non-
licensed clinical staff any week the non-licensed staff provided services to youth. Reviewed
documentation supported the weekly supervision was documented on a form which included all
information as outlined on the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. The reviewed
documentation found the completed Clinical Supervision Logs included a review of case history,
caseload directions, review of fidelity checks, clinical service instructions, documented
strengths, findings, trends, problem areas, situational concerns, and training. The master’s-level
non-licensed therapist had not yet completed the required twenty-hours and supervised
experience in assessing suicide risk, mental health crisis intervention, and emergency mental
health services but the therapist did not complete any Assessments of Suicide Risk (ASRs)
during the annual compliance review period. All non-licensed substance abuse clinical staff who
provided substance abuse services completed training in accordance with administrative rule.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program maintains a policy and procedures for mental health and substance abuse
services which address a standardized screening process including review of commitment
packet information, reports and records, and administering the Massachusetts Youth Screening
Inventory, Second Version (MAYSI-2) in the Department’s Juvenile Justice Information System
(JJIS). Services also include staff training in mental health and substance abuse issues, a
standardized process for referral of youth identified as in need of further mental health and/or
substance abuse evaluation to a proper profession, or when immediate attention is needed, to a
hospital or Baker Act or Marchman Act receiving facility. It is the program’s practice to complete
an Assessment of Suicide Risk (ASR) on all intake youth regardless of the MAYSI-2 outcome to
notify the facility administrator (FA) or designated mental health clinician authority (DMHCA) of
the youth’s risk factors. A review of five youth mental health and substance abuse records found
the program completed a MAYSI-2 for four out of the five youth upon admission. One youth had
a MAYSI-2 completed three months after intake. Each MAYSI-2 was completed in full in JJIS in
a confidential manner. Four of the five reviewed MAYSI-2s resulted in the youth requiring a
referral for further evaluation. The program’s practice is to conduct further evaluation on each
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youth admitted regardless of the MAYSI-2 results. Each youth received a new Mental Health
and Substance Abuse Comprehensive Evaluation In-Depth Assessment and an ASR regardless
of MAYSI-2 screening results. The ASR was completed within twenty-four hours for each
reviewed youth. All five records documented staff conducting the mental health and substance
abuse admission screening reviewed each youth’s commitment packet information and records
for existing documentation of mental health and substance abuse problems. All staff
administrating the MAYSI-2 were trained according to their records available in the
Department’s Learning Management System (SkillPro). An informal interview with the FA
confirmed the clinical department assesses all youth by completing ASRs and MAYSI-2s.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a policy and procedures to address the provision of mental health and
substance abuse assessments/evaluations. The program’s practice is to complete a new
combined Mental Health and Substance Abuse Comprehensive Evaluation In-Depth
Assessment within thirty-days of each youth’s admission. A review of five youth mental health
and substance abuse records confirmed each youth received a new Mental Health and
Substance Abuse Comprehensive Evaluation In-Depth Assessment within thirty days of
admission. Four out of five evaluations were completed by a licensed mental health counselor
(LMHC) and one evaluation was completed by a non-licensed mental health therapist. The
evaluation completed by the non-licensed mental health therapist was signed by the LMHC
within ten calendar days after the evaluation was conducted. All five reviewed evaluations
included identifying data, reason for the evaluation, relevant background including home
environment and family functioning, history of physical abuse, sexual abuse, neglect, witnessing
violence, and other forms of trauma, behavioral functioning, physical health, mental health, and
substance abuse history, and education functioning. The evaluations also included behavioral
observations, Mental Status Examinations, procedures administered and method of
assessment, discussion of findings, patterns of alcohol and other drug use, impact of substance
use on major life areas, risk factors for substance abuse diagnostic impressions/formulation
including a Diagnostic and Statistical Manual, Fifth Edition (DSM-V) diagnosis, and
recommendations. In all youth records, signed consents were observed for substance abuse
treatment.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures in place outlining the program’s mental health and
substance abuse services. Four of the five Initial Mental Health Treatment Plans were
developed within seven days of the onset of treatment, the remaining plan was twelve days late.
All five were documented on a form containing all elements of the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form and signed by the mental health and substance
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abuse clinical staff who completed the form, who was also a licensed mental health counselor
(LMHC). All treatment team members who participated in the development of the plan and the
youth, signed the plan. The parent/guardian also signed as allowed, the plan was mailed out for
signature, or the parent/guardian participated by telephone. The Initial Treatment Plan included
the youth’s psychiatric needs in all five applicable records and a psychiatric evaluation was to
be completed as it is the program’s policy. The Individualized Treatment Plan was developed for
the youth within thirty days of admission in four of five records. One Individualized Treatment
Plan was completed eight days late. All five of the Individualized Treatment Plans were
developed on a form which contains all the elements of the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan form. The Individualized Treatment Plans were signed
by the mental health and substance abuse clinical staff completing the plan. Four out of five of
the Individualized Treatment Plans were completed by the LMHC. One of the Individualized
Treatment Plans was signed by a non-licensed staff and the plan was reviewed and signed by
the LMHC within ten days of completion. In all reviewed records the Individualized Treatment
Plan was signed by all treatment team members who participated in the development of the
plan and each youth. The parent/guardian also signed the plan as allowed, the plan was mailed
out for signature, or the parent/guardian participated by telephone in all records. In two of five
records the Individualized Treatment Plan included psychiatric services to include a psychiatric
evaluation as two of the youth were on medication at the time they were admitted to the
program. The remaining three youth did not require inclusion of psychiatric services. There were
four youth applicable for treatment plan reviews as one youth was not yet due for a review. In all
four applicable records the Individualized Treatment Plan reviews were completed using a form
which contains all the elements of the Department’s Individualized Mental Health/Substance
Abuse Treatment Plan Review form. Individualized Treatment Plan reviews were completed
every thirty days, as required, in the four applicable records. Services outlined within all five of
the youth’s Individualized Treatment Plans included individual counseling bi-weekly for thirty
minutes. Two of the five Individualized Treatment Plans included group counseling four times a
week for sixty minutes and three of the Individualized Treatment Plans included group
counseling seven days a week for sixty minutes. All five records included family therapy once
monthly for thirty minutes. Psychiatric evaluations were included for all five of the youth.
Medication management was included for two of the five youth. Services were individualized for
each youth. A review of video footage indicated each of the three reviewed groups were being
conducted for the required length of time and consisted of no more than fifteen youth in a group
within the last thirty days.
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3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program has a policy and procedures addressing treatment and discharge planning. A
review of five youth mental health and substance abuse records verified each youth was
assigned to a treatment team upon arrival to the program comprised of the youth,
administration, the residential living unit, and all other staff responsible for delinquency
intervention and treatment services. Documentation reflected the youth, program administration,
residential living unit, education, medical staff, mental health/substance abuse staff, and
parent/guardian participated in the treatment team meetings in all records. In each of the five
reviewed records, youth were determined to be in need of substance abuse treatment and
received individual, group, and family counseling provided by a licensed qualified professional in
accordance with their Initial or Individualized Substance Abuse Treatment Plan. Reviewed
documentation validated each youth had a properly executed Authority for Evaluation and
Treatment (AET) form or release of records for youth eighteen years of age or older. Each
youth’s record contained a signed Youth Consent for Substance Abuse Treatment form and a
signed Youth Consent for Release of Substance Abuse Treatment Records form. Each youth’s
mental health treatment and substance abuse treatment notes were documented on the
program’s form containing all the elements of the Department’s Counseling/Therapy Progress
Note form. In all five reviewed records, individual psychotherapy or counseling occurred in a
one-on-one capacity between a youth with a mental health disorder and a mental health clinical
staff professional. Therapeutic activities designed to address specific skill deficits or
maladaptive behaviors and promote skill development and improved functioning of youth with
mental disorders were present in all records reviewed. In all five reviewed records, progress
notes demonstrated youth received services as stipulated in their treatment plan. Discharge
plans from three closed youth mental health and substance abuse records were reviewed. In all
records, the program utilized the Department’s Mental Health/Substance Abuse Treatment
Discharge Summary form. No records were applicable for being released while still on suicide
risk. The youth discharge summaries in all records documented the services needed for daily
maintenance of the positive improvement in behavioral, emotional, and social skills made by
each youth while in treatment. A review of documentation revealed the discharge plans were
discussed with each youth, their parent/guardian, and their juvenile probation officer during the
exit conference and a copy was provided to all.
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3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program has a contract to provide Substance Abuse Treatment Overlay Services (SAOS)
to all youth admitted into the program. A review of five youth mental health and substance
abuse records revealed all youth received SAOS. Each record contained weekly progress notes
documenting services received for the week and each youth's progress toward mental health
and substance abuse goals. A review of the weekly progress notes revealed each youth
received groups daily as well as individual and family therapy on a monthly basis. Group
sessions were limited to no more than fifteen youth. A review revealed youth with co-occurring
mental health disorders receive mental health treatment. The interview with the designated
mental health clinician authority (DMHCA) and facility administrator (FA) confirmed each youth
received daily groups in SAOS. Individual treatment plans and monthly treatment plan reviews
revealed ongoing SAOS are provided. The program is licensed under Chapter 397 and a
“qualified professional” is on-site at least five days a week. A licensed psychiatrist provides
psychiatric evaluations and medication management as well as participates in treatment
planning. A review of the five youth mental health and substance abuse records indicated the
DMHCA completed evaluations of the youth and provided substance abuse treatment for the
youth to include urinalysis drug testing with appropriate clinical intervention and sanctions
should youth test positive. Sign-in sheets confirmed substance abuse clinical staff are on-site
seven days a week. Counselor caseloads are limited to no more than ten youth for substance
abuse treatment services or sixteen youth for substance abuse treatment overlay services.
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 policy and procedures to address the psychiatric services provided to the
youth. The program maintains an independent contractor agreement with a licensed psychiatrist
to oversee the psychiatric services and supervise the treatment of youth who are prescribed
psychotropic medications. The psychiatrist is scheduled to be on-site every other week for eight
hours and provides medication evaluation and on-going monitoring of psychiatric medications.
The psychiatrist’s license expires on January 31, 2025. The psychiatrist is available for
emergency consultation twenty-four hours a day, seven days a week. A review of the
attendance logs since the last annual compliance review validated the psychiatrist has been
providing on-site services bi-weekly. Confirmed through an informal interview with the
psychiatrist, the psychiatrist provides psychiatric evaluations for all youth who are admitted to
the facility as well as medication management while on-site once every two weeks. The
psychiatrist briefs a representative of the treatment team regarding the psychiatric status of
each youth receiving psychiatric services who is scheduled to have a treatment team review.
Formal reviews occur face-to-face every two weeks and telephonically as needed to review any
youth with medical issues. Any psychiatric recommendations are incorporated into the mental
health clinical staff’s evaluations of the youth as well as their Individualized Mental Health or
Substance Abuse Treatment Plan. Each reviewed attendance log documented the psychiatrist’s
sign-in and sign-out times were accompanied with their signature. The program does not utilize
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a psychiatric advanced practice registered nurse (APRN). The psychiatrist has a backup
clinician to provide coverage while on vacation or leave; however, no back-up coverage was
required since the last annual compliance review. A review of the back-up psychiatrist’s license
confirmed it was a clear and active medical doctor (MD) licensure in the State of Florida with an
expiration date of January 31, 2024. It is the practice of the program to provide a psychiatric
evaluation to all youth admitted. Five youth mental health and substance abuse records were
reviewed. Each youth’s Initial Diagnostic Psychiatric Interview was completed within fourteen
days of admission and included history of the youth, Mental Status Examination, diagnosis
which was consistent with the youth’s treatment plan, treatment recommendations, prescribed
medications, explanation of the need for psychotropic medication, targeted symptoms, initial
treatment goals, potential side effects, risks and benefits of taking the medication, and
frequency of medication monitoring. All five initial psychiatric evaluations were completed on the
Department’s Clinical Psychotropic Progress Note (CPPN) and were clearly identified as initial
psychiatric interviews. Two youth entered the program while on medications and were
prescribed medications after the initial interview took place. Both applicable reviewed youth
records indicated each youth received the prescribed psychotropic medications, each
documented monthly face-to-face medication monitoring reviews, and the corresponding
CPPNs were completed, signed, and dated by the psychiatrist including identifying youth
information, diagnosis, target symptoms of each medication, evaluation and description of effect
of prescribed medication on target symptoms, as well as prescribed psychotropic medication
dosage and quantity. Documented on the CPPN was the side effects of the medication, the
youth’s adherence to the medication regimen, height, weight, blood pressure, any laboratory
findings if applicable, and whether telephone contact was made to the parent/guardian. None of
the youth prescribed psychotropic medications required the monthly monitoring of Tardive
Dyskinesia and reviewed documentation supported the nursing staff documented this on the
CPPN.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a policy and procedures to address the provision of suicide prevention
planning and detailing suicide prevention procedures. The written plan includes identification
and assessment of youth at risk of suicide, staff training which includes six hours annually,
suicide precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, a review process of suicide attempts, and a mortality review process.
The review for suicide attempts and mortality includes circumstances surrounding the event,
facility procedures relevant to the incident, all relevant training received by involved staff,
pertinent medical and mental health services involving the victim, possible precipitating factors,
recommendations for changes in policy, training, physical plan, medical, or mental health
services, and operational procedures. The suicide prevention plan is reviewed annually and was
reviewed on February 9, 2023 by the licensed mental health counselor (LMHC).
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Office of Accountability and Program Support Page 38 of 65 (Revised September 2022)
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.
Three records were applicable for suicide prevention services, each of which were reviewed.
Two of the three youth were screened upon admission to the program and one youth was
screened after a staff observed the youth making self-harm threats. All three youth were placed
on precautionary observation and had an initial Assessment of Suicide Risk (ASR) completed
within twenty-four hours by licensed staff. All three youth were placed on constant supervision
until the ASR could be completed. All three of the assessed youth were found not at risk of
suicide and were immediately stepped down to standard supervision. The parents/guardians of
all three youth were notified, and notification was documented on the ASR. Staff provided
supportive services to all youth placed on precautionary observation. A Follow-up ASR was not
needed in all three records reviewed as all three youth were stepped down to standard
observation after the initial ASR was completed. The youth had documentation on the ASR,
where the licensed mental health professional conferred with the facility administrator or
designee, prior to finalizing the supervision level. The discontinuation of close supervision was
documented in accordance with the program’s suicide prevention plan in all three records. All
three ASRs were completed by the licensed mental health counselor (LMHC) and the
documentation of the actual date and time the LMHC conferred with the program director or
designee was recorded on the ASR. A suicide alert was entered into the Department’s Juvenile
Justice Information System (JJIS) regarding the youth placed on precautionary observation and
closed according to the ASR recommendations. Logbooks were reviewed and indicated the
appropriate entries were made for the suicide precaution decisions. While on precautionary
observation, the youth were allowed to participate in select activities with other youth in
designated safe housing and safe observation areas of the program. The program had a new
camera system installed; therefore, no camera footage of the time the three youth were placed
on precautionary observation was able to be reviewed to ensure proper supervision was
maintained. Five staff were interviewed, and each staff reported if a youth expresses suicidal
thoughts, direct care staff are responsible for notifying mental health staff. Two interviewed staff
reported direct care staff are responsible for maintaining constant sight and sound and two staff
stated being responsible for documenting supervision. One staff reported direct care staff are
responsible for notifying the assistant facility administrator (AFA) and facility administrator (FA),
while one staff stated responsibility for starting precautionary observation logs and notifying the
supervisor. One staff reported they are responsible for reporting to the FA. No staff reported
direct care staff are responsible for searching youth and room for sharp objects or placing youth
in a locked room.
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Office of Accountability and Program Support Page 39 of 65 (Revised September 2022)
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a suicide prevention plan outlining staff supervision and
documentation requirements during precautionary observation (PO) status. Three records were
applicable for Precautionary Observation Logs, each of which were reviewed. All three records
indicated the Suicide Precaution Observation Logs were maintained for the duration the youth
were on suicide precautions and the appropriate level of supervision and observation of the
youth’s behavior were documented in real-time and not exceeding thirty-minute intervals.
Warning signs on the Suicide Precaution Observation Logs and notification to the facility
administrator or mental health clinical staff were documented when appropriate. Suicide
Precaution Observation Logs were reviewed and signed by each shift supervisor and mental
health clinical staff. All three Suicide Precaution Observation Logs documented safe housing
requirements.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a policy and procedures to address suicide prevention training. A review
of five pre-service and five in-service training records confirmed each staff completed two hours
of suicide prevention training in the Department’s Learning Management System (SkillPro) and
four hours of instructor-led training. The program has two fully equipped suicide response kits
which include a knife-for-life, wire cutters, and needle nose pliers. One kit is in master control,
and one is in the medical office. Both kits were co-located with the first-aid kits. A review of the
program’s suicide drills confirmed the program completed the required quarterly drill on each
shift. All mock mental health drills in response to a suicide attempt and/or incident of serious
self-injury were simulated, and no youth were used in the simulations. The program provided
semi-annual training on emergency response procedures which included “mock” training in
emergency response to a suicide attempt or incident of serious self-inflicted injury, as confirmed
by a review of drills and an interview with the facility administrator (FA). Staff who were not
present during a quarterly drill had the opportunity to review each drill scenario and procedures
in an effort to understand the process and receive the necessary training to respond to an
incident of a suicide attempt or incident of serious self-inflicted injury in the facility. Five staff
were interviewed. All five staff reported the knife-for-life, wire cutters, and needle nose pliers
(suicide response kits) are located in master control. Four out of five staff reported it is located
in medical. Three out of five interviewed staff reported medical emergency and suicide drills are
conducted monthly. Two out of five staff reported they believed drills were done weekly.
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Office of Accountability and Program Support Page 40 of 65 (Revised September 2022)
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a policy and procedures to address mental health crisis intervention
services. The policy and procedures include a notification and alert system, means of referral,
including youth self-referral, communication, supervision, documentation, and a review process.
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 policy and procedures addressing Crisis Assessments which was reviewed,
signed, dated, and approved by the designated mental health clinician authority (DMHCA) on
February 9, 2023. The program’s policy and procedures address the completion of a Crisis
Assessment, which includes the use of the Department’s Crisis Assessment form. None of the
reviewed youth treatment records were applicable for a Crisis Assessment and the program did
not have any Crisis Assessments completed during the annual compliance review period.
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 policy and procedures related to the emergency mental health and
substance abuse services. The program’s policy included procedures for 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 under Chapter 394 Florida Statutes, transport for emergency substance abuse
assessment and treatment under Chapter 397, documentation, training, and review.
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3.17 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a policy and procedures to address the safety planning process for each
youth. A review of five youth mental health records was conducted in reference to a
safety planning process for each youth. Reviewed documentation found the program developed
a safety plan form which includes warning signs, youth baseline behavior as gathered from
collateral contacts, youth’s history, evaluation, crisis recognition, jointly developed coping
strategies to include people and healthy environments as defined by the youth, intervention
strategies preferred by the youth, and a debriefing process. The safety plans have an initial and
a review planning process. Four of the five reviewed safety plans were completed within
fourteen days upon admission. One of the reviewed safety plans were completed six days late.
All the safety plans were jointly prepared by the youth, parent/guardian or family member, case
manager, and clinical staff. The safety plans incorporated any recommendations from previous
or current clinical assessments and/or screening instruments and incorporates trauma
responsive practices. Four of the five reviewed youth records had safety plan reviews updated
as necessary at least every thirty days. One of the youths’ updates was two days late, but all
other reviews were within thirty days of the previous review. The youth’s safety plans were
maintained in a centralized binder in master control and is accessible to all staff as well as
copies maintained in each youth’s Individual Healthcare Record. Five youth were interviewed.
Four youth reported they contributed to their safety plan and one youth reported they did not
know what a safety plan is. Five staff were interviewed, and all five reported safety plans are
located in master control. One staff reported they are also located in clinical records. Two out of
five staff reported they do not know the process for reviewing safety plans and one staff
reported it is not something they do. One staff reported once a youth is evaluated, safety plans
are created and placed in the logbook for staff to review and one staff stated staff can look at
them whenever they want, staff should look at them when a new youth is admitted and regularly
thereafter. One staff reported they have not reviewed safety plans and one staff reported it has
been a year since they reviewed one. Two out of five staff reported they reviewed safety plans
last week and one staff reported they reviewed them last month. An informal interview with the
facility administrator confirmed the safety plans are updated monthly.
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Office of Accountability and Program Support Page 42 of 65 (Revised September 2022)
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 contracts with a licensed physician who serves as the designated health authority
(DHA). The DHA has a clear and active license in the State of Florida, expiring January 30,
2024, with specialty training in family practice, and a past disciplinary action on their record from
1989. The DHA does not utilize an advanced practice registered nurse (APRN) or physician’s
assistant (PA). The program’s contract with the Department specifies the DHA is to be on-site at
least two hours each week or more as the clinical needs of the youth dictate. A review of the
DHA sign-in sheets for the annual compliance review period found the DHA was on-site for the
required time frame. The program has a back-up DHA who is a licensed physician with a clear
and active license in the State of Florida expiring January 31, 2024; however, the back-up DHA
was not utilized during the annual compliance review period. The program did not utilize tele-
medicine during the annual compliance review period. The DHA reviewed and approved all
health-related facility operating procedures (FOPs) for the program. The DHA was interviewed
and reported their role in the program is to conduct Comprehensive Physical Assessments
(CPAs) of youth upon admission and annually thereafter, conduct periodic evaluations every
sixty days for youth on medication or with chronic conditions, and follow-up on sick calls as
needed. The DHA reported they are on-site two hours a week and available by telephone
twenty-four hours a day. The DHA and nursing staff meet weekly to discuss any medical issues
at the facility.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program’s contract with the Department outlines the requirements for a health services
administrator (HSA) and two additional full-time registered nurses (RNs) to provide 120 hours of
nursing coverage a week. A review of the program’s staff roster and vacancy report found at the
time of the annual compliance review, the program had one full-time RN who serves as the HSA
and one licensed practical nurse (LPN) providing services at the program. The regional RN
director assisted in providing coverage during the annual compliance review period as well. A
full-time RN position was vacant for less than thirty days at the time of the annual compliance
review; however, all required nursing hours have been met by the nursing staff at the program.
A review of licenses for the two nursing staff providing services at the program found each had
a clear and active license in the State of Florida, which both expire April 2024, and current
certifications in cardiopulmonary resuscitation (CPR).
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Office of Accountability and Program Support Page 43 of 65 (Revised September 2022)
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 at the program. The designated health authority (DHA) was solely responsible for
creation and approval of all health-related FOPs and nursing protocols and signed an annual
review of each on January 19, 2023. The psychiatrist reviewed applicable FOPs on January 19,
2023. The facility administrator (FA) documented their review of FOPs and protocols on
December 21, 2022. Each of the nursing staff providing services at the program signed and
dated an annual signature page for the FOPs and nursing protocols on October 3, 2023. Each
newly hired nursing staff received a comprehensive orientation to healthcare services at the
program upon hire.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) authorizing treatment of youth in the program’s custody. Five
Individual Healthcare Records (IHCRs) were reviewed, and all were applicable for an AET.
Each of the applicable IHCRs contained a valid AET which was stamped as a copy and signed
by all required parties. None of the youth were over the age of eighteen or in the custody of the
Department of Children and Families (DCF). The nursing staff was interviewed and reported the
current policy for obtaining a new or current AET was unknown. If a youth is over the age of
eighteen, the nursing staff reported the youth would sign a release of information form.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is notified of any
changes in the youth’s condition and to document informed consent for youth healthcare. Five
youth Individual Healthcare Records (IHCRs) were reviewed for parental notifications and two
were applicable for requiring consent or notification for medical treatment. Two of the IHCRs
documented the program received consent from the youth’s parent/guardian for all new
medications, over-the-counter medications beyond those covered by the Authority for
Evaluation and Treatment (AET), or new psychotropic medications prior to administration.
Witness signatures were found for consent for psychotropic medication as required. All
applicable youth IHCRs documented the program sent the required Department form to provide
written notification to the parents/guardians. Each of the five reviewed IHCRs documented the
program received and verified the youth’s vaccination records on the date of admission. None of
the youth were applicable for requiring new vaccinations or requesting religious exemption. The
nursing staff was interviewed and confirmed the program’s process for notifying
parents/guardians of medical treatment by telephone and in writing. The nursing staff reported
vaccination records are obtained through Florida Shots, the youth’s commitment packet, or
youth’s prior medical record within twenty-four hours of admission.
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Office of Accountability and Program Support Page 44 of 65 (Revised September 2022)
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures regarding youth healthcare admission screening and
rescreening each time the physical custody of the youth changes. Five youth Individual
Healthcare Records (IHCRs) were reviewed, and each contained a Facility Entry Physical
Health Screening (FEPHS) form completed by a registered nurse (RN) on the day of the youth’s
admission. None of the youth were applicable for a change in custody greater than twenty-four
hours. The nursing staff was interviewed and verified FEPHS forms are completed by RNs and
if they were completed by non-healthcare staff, would be reviewed by a RN.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures ensuring all youth admitted to the program are
provided an orientation to healthcare services. Five youth Individual Healthcare Records
(IHCRs) were reviewed and each contained documentation the youth was oriented to
healthcare services at the program upon admission. Each youth’s orientation included all
required topics and was documented on the Health Education form and an orientation sheet
which listed all reviewed topics and was signed and dated by the youth.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to notify the designated health authority (DHA) or
designee, by telephone or verbally, of each youth’s arrival at the program and provide
immediate notification when any youth admitted to the program requires emergency care. Five
youth Individual Healthcare Records (IHCRs) were reviewed and three were applicable for a
documented chronic condition upon admission. The designated health authority (DHA) was
notified upon admission for each of the five youth regardless of the youth’s status. The DHA
notification was documented in each youth’s IHCR in the Chronological Progress Notes. None
of the youth were found to be in need of emergency care at admission. The nursing staff was
interviewed and confirmed the program notifies the DHA on all new youth admissions
regardless of their healthcare condition.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures ensuring the Department’s Health-Related History
(HRH) form is completed prior to the Comprehensive Physical Assessment (CPA) and
healthcare needs are identified. Five youth Individual Healthcare Records (IHCRs) were
reviewed and each contained a HRH completed by a registered nurse (RN) on the day of
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admission and prior to completion of the CPA as evidenced by the date and signatures on both
the HRH and CPA. There was documentation on each youth’s CPA the designated health
authority (DHA) reviewed the HRH. The nursing staff was interviewed and reported the
healthcare staff are responsible for completing the HRH upon admission and as needed
thereafter.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the acute and chronic healthcare needs of
the youth are addressed by completing a Comprehensive Physical Assessment (CPA) within
seven days of youth admission. Five youth Individual Healthcare Records (IHCRs) were
reviewed and each contained a new CPA completed by the designated health authority (DHA)
within seven days of admission on the Department form. Each CPA was completed in its
entirety as required and any parts of the exam deferred by the physician were documented as
such. In addition, each of the youth refused parts of the exam and a refusal form was found in
the youth’s IHCR. The program is an all-male program; therefore, none of the youth were
applicable for a gynecological exam. All of the five youth’s Department Problem List were
updated as required. Each of the five youth had a Tuberculosis Skin Test (TST) documented in
the IHCR within the last year with their results found on the Infectious and Communicable
Disease (ICD) form. Nursing staff were interviewed and reported all youth receive a CPA within
seven days of admission and annually thereafter. The nursing staff also verified the process for
ensuring each youth has a valid TST within the last year, as well verified youth are screened for
sexually transmitted infections upon request.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures for the completion of sexually transmitted infection
(STI) and human immunodeficiency virus (HIV) testing. The policy reflected HIV test results may
only be disclosed to the youth and entities approved by Florida Administrative Code. Five youth
Individual Healthcare Records (IHCRs) were reviewed and each documented the youth was
clinically screened for STIs. One of the five youth was referred to the designated health
authority (DHA) for testing on the required Department form; however, the youth refused the
testing which was documented on a refusal form maintained in the youth’s IHCR. There was
documentation in each of the five IHCRs the youth were offered counseling and testing for HIV.
Two of the youth signed the Department form indicating they did not consent to HIV testing.
Three of the youth did consent to HIV testing as indicated by their signatures on the required
Department form. Testing was conducted for one of the three youth and their results maintained
in sealed envelopes marked as confidential in the youth’s IHCR. One of the three envelopes
was signed by the DHA indicating their review, the remaining two were placed on the waiting list
to receive testing and had not received testing at the time of the annual compliance review. A
review of each youth’s Health Education form found one of the applicable three youth received
pre and post-test counseling by the certified HIV counselor. The program utilizes an outside
provider who is a certified HIV counselor to provide all counseling and testing. The nursing staff
were interviewed and verified the program’s practice for STI and HIV testing. Five youth were
interviewed, and each reported they could receive HIV testing if requested.
Florida Department of Juvenile Justice Residential Annual Compliance Report
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4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures addressing the program’s sick call process. None of
the youth presented with a similar sick call complaint three or more times within a two-week
period. All five youth had a sick call request addressed by the registered nurse (RN). Each of
the Sick Call Request forms were filed in each youth’s Individual Healthcare Record (IHCR) in
reverse chronological order. Each sick call was on the youth’s Sick Call Index and Sick Call
Referral Log. None of the youth were in restricted housing of any kind. A review of the
program’s contract and the activity schedule found the program is conducting sick call twice a
day, seven days a week, at the required times. The sick call hours are listed on the activity
schedule which is posted throughout the program and on the medical clinic door. A program
tour found Sick Call Request forms are stocked on the youth dorm with a corresponding locked
box for them to submit the request in. An interview with the nursing staff confirmed the
program’s sick call process and hours. Five staff were interviewed, and each reported the RN
reviews sick call requests. Each of the five staff reported the nurse conducts the sick call and
one staff also reported the DHA can conduct sick call. Five youth were interviewed, and four
youth reported they are seen within one day of submitting a sick call, the remaining youth
reported they are seen immediately. A sick call was unable to be observed during the annual
compliance review due to none being requested.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures regarding the provision of episodic and emergency
care. Five youth Individual Healthcare Records (IHCRs) were reviewed and two were applicable
for episodic care encounters. The program did not have additional youth with episodic care
encounters during the annual compliance review period. Both of the episodic care events were
rendered by a registered nurse (RN) and documented in subjective, objective, assessment, and
plan (SOAP) format. The program had nine first-aid kits located in the medical clinic, kitchen,
maintenance office, in a backpack in master control, in the two classrooms, and a kit for three
vehicles, which are maintained in master control when not on a transport. The nursing staff
documented weekly checks of the first-aid kits for all designated health authority (DHA)-
approved contents throughout the annual compliance review period. A review of three first-aid
kits, the kits in medical and for two vehicles, found each contained all up-to-date DHA-approved
items. The kit in medical had additional items not approved by the DHA; however, the program
reported this is due to the kit being the main medical first-aid kit and requiring additional items.
The program has one automated external defibrillator (AED) maintained in the administration
hallway with the AED procedures. The nursing staff documented monthly checks of the AED
throughout the annual compliance review period. The RN conducted a self-test of the AED, and
it was found to be in good working order. The batteries expire April 2025 and were last replaced
April 2023. The pads expire April 2025 and were last replaced in April 2023. The program has
back-up batteries and pads for when the current ones expire. A review of medical drills for the
annual compliance review period found the program conducted both announced and
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Office of Accountability and Program Support Page 47 of 65 (Revised September 2022)
unannounced medical drills monthly on all three shifts without exception to ensure all direct care
staff had an opportunity to participate. Multiple drills throughout the year on each shift included
the practice of cardiopulmonary resuscitation (CPR)/AED. Each drill simulated a medical
scenario, and the drill forms included all required elements. The program has a list of
emergency numbers, including the Poison Control Center, which is inaccessible to youth. The
program maintains a list of non-healthcare staff authorized to assist youth with medication
administration in the event healthcare staff are not on-site and documentation was provided
each of the authorized staff had the required training administered by a RN. Each of the
healthcare staff currently providing services at the program have current CPR/AED
certifications. The nursing staff were interviewed and confirmed the program’s practice for
conducting medical drills and monitoring first-aid kits and the AED. Five staff were interviewed,
and each reported any staff can call 9-1-1 in the event of an emergency. Five youth were
interviewed, and each reported they can see a doctor if needed. An episodic care event did not
occur during the annual compliance review to be observed.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures to ensure for timely referrals and coordination of
medical services to an off-site healthcare provider. A review of five Individual Healthcare
Records (IHCRs) found one of the five were applicable for off-site care. The program did not
have any additional examples of off-site care for review. In the one applicable IHCR, there was
an indication the youth required off-site first-aid or emergency care. The Department’s Summary
of Off-Site Care Consultation Report form was utilized and filed in the youth’s IHCR. One
applicable IHCR had documentation of the parent/guardian notification efforts. The DHA
reviewed and signed all off-site care findings, instructions, and information for the applicable
IHCR. There was evidence indicating the referrals were tracked and youth received appropriate
follow-up care as documented in the IHCR. The registered nurse (RN) confirmed the youth are
tracked utilizing the episodic log and calendar.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure any youth admitted to the program who
have chronic conditions receive regularly scheduled evaluations and any as-needed follow-up
care. Five youth Individual Healthcare Records (IHCRs) were reviewed and three were
applicable for a chronic condition documented on their Facility Entry Physical Health Screening
(FEPHS) form. One youth was taking medication on an ongoing basis. Two of the three
applicable youth were classified with Medical Grade two to four, and the remaining youth with a
chronic condition was classified as a five due to being prescribed psychotropic medication. Each
of the youth treated on an ongoing basis were added to the program’s chronic condition log.
Each of the three youth received periodic evaluations documented in the Chronological
Progress Notes at least every ninety days in accordance with the program’s contract with the
Department and prior to the renewal of any medications, if applicable. None of the evaluations
were completed off-site. None of the youth were applicable for being on anti-tuberculosis
medication or prenatal care. None of the youth had an indication of lapses in care. The facility
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administrator was interviewed and reported administration meets daily with the medical
department to review any youth medical issues. The nursing staff and designated health
authority (DHA) were interviewed and confirmed periodic evaluations are conducted every sixty
days and tracked on the program’s chronic condition tracker.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a policy and procedures to ensure the accurate and safe administration of
youth medications. A review of five youth Facility Entry Physical Health Screening (FEPHS)
forms found one youth was taking medication at the time of admission. The youth medications
were verified prior to the youth being admitted into the program, and the prescription notification
was documented in the youth’s Chronological Progress Notes. The designated health authority
(DHA), and when applicable the psychiatrist, was contacted to obtain an order to resume the
specified medications prescribed prior to admission for each youth. A review of the five youth
IHCRs found one youth was applicable for current medications to be continued, discontinued,
changed, or for new medications to be ordered. The applicable youth’s IHCR included a
Practitioner Order form indicating the DHA, or psychiatrist, ordered the prescription for the
youth. None of the youth were in restricted housing of any kind. All of the youth were applicable
for over-the-counter medications (OTCs) which were administered according to approved
protocols. The Department Medication Administration Record (MAR) was used to document all
medications and treatments for all reviewed IHCRs. The MAR clearly indicated start and stop
dates of each youth’s medications. In all applicable IHCRs, the staff initialed each administered
medication entry. There were no undocumented explanations for lapses or errors in medication
administration for any of the reviewed IHCRs. The registered nurse (RN) documented side-
effects monitoring weekly on the MAR for all five reviewed IHCRs. The MAR contained all
required elements. The youth initialed each provided medication entry. There were no youth
applicable for parenteral medications. There were no standing orders, emergency orders, or pro
re nata (PRN) orders for psychotropic medications. A medication pass was observed. The youth
were escorted by the direct care staff and approached the nurse individually. The medical
provider identified themself and confirmed the reason the youth was present. The medical
provider prepared the medication and verified the youth’s allergies and alert status. The medical
provider and youth initialed the MAR, and the medical provider observed to ensure the
medication was swallowed. The Six Rights of Medication Delivery/Administration were
maintained in each of the youth observed. Five youth were interviewed, and all five advised a
nurse provides medication and could explain the process. Five staff were interviewed, all five
advised a nurse provides the medication. An interview with the nurse advised the nurse
provides medication two times a day. All youth medications are reviewed upon admission and
listed on the Prescription Medication form. All medications must have an intact pharmacy label
with the youth’s name and pertinent information.
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4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures to ensure medical equipment classified as
sharps/medications are secure and inventoried utilizing a routine perpetual inventory. A review
of the medical equipment classified as sharps confirmed the items were securely stored and
inventoried utilizing a routine perpetual inventory descending count. All medications were
identified and secured in a locked medication cart designated for storage of medications. The
medication cart was secured, clean, and organized with stock items separate from youth-
specific medications. The program had no controlled medication during the annual compliance
review week. All medications were stored in a separate, secured area, inaccessible to the youth.
Observations were conducted of inventory counts of three over-the-counter (OTC) medications
and three sharps. All inventories were correct with no discrepancies. An interview with nursing
staff verified the program’s inventory and disposal of unused medication process. The RN
reported in the event of a discrepancy, they would notify the facility administrator, health
services administrator (HSA), and regional nursing director and conduct an investigation into the
cause of the discrepancy.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a policy and procedures for infection control which include an exposure
control plan and are written in accordance with Occupational Safety and Health Administration
(OSHA) and Center for Disease Control and Prevention (CDC) guidelines. The infection control
policy was last reviewed and signed by the designated health authority (DHA) on January 19,
2023. The infection control procedures include all required elements and specify staff have
access to protective equipment and Hepatitis B immunizations. The program maintains a
separate file for any instances of facility or occupational exposure, which is kept for a period of
ten years; however, the program has not had an exposure incident during the annual
compliance review period. The exposure control plan was written in accordance with OSHA
standards and was last reviewed and signed by the designated health authority (DHA) on
January 19, 2023, and facility administrator on December 21, 2022. The plan includes a process
for needle stick post-exposure evaluation. The program has not had any instances of infectious
diseases or quarantining/hospitalization of at least ten percent of youth and/or staff which
needed to be reported to all required parties during the annual compliance review period. The
facility administrator and nursing staff were interviewed and verified the infection control policy
and exposure control plan are maintained in master control, accessible to all staff. The nursing
staff also reported training in infection and exposure control is conducted for all youth upon
admission and all staff during pre-service training and annually thereafter.
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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 maintains a policy and procedures requiring all program staff to promote safety
and security by maintaining active supervision of youth to include interacting positively with
youth, engaging youth in a full schedule of constructive activities, closely observing behavior of
youth, and consistently applying the program’s behavior management system (BMS). The
provider defines active supervision as the effective and efficient supervision which includes
positive contact, positive reinforcement, structured activities, and random/predictable movement
providing suitable and timely response to the everyday needs of the youth and an immediate
response to emergencies while maintaining the safety and security of the program. The
program has a daily youth activity schedule which was posted throughout it. The program staff
are required to account for the whereabouts of youth under their supervision and ensure staff-
to-youth ratios are compliant with contract requirements. The program’s contract requires staff-
to-youth ratios to be one-to-eight during awake hours and one to-twelve during sleep hours. The
ratio for off-site activities, transportation, and visitation is one staff to five youth. Observations of
staff supervision for four days during the annual compliance review week included classroom
activities, youth searches, line movement, school breaks, youth headcounts, youth participating
in group and individual counseling, meal and snack time, and outdoor/indoor recreation
activities. Daily observations during the annual compliance review week verified staff-to-youth
ratios were maintained, as required. During all activities and/or movement, observations showed
staff were strategically positioned to ensure proper supervision of youth and to ensure there
were no physical obstructions in their view of the youth. Observations of interactions between
program staff and youth reflected the interactions were positive and consistent with the
program’s BMS. Informal interviews with three staff verified the staff were aware of the number
of youth they were currently supervising and the program census. A review of video footage for
three separate days verified staff observed youth while in their sleeping rooms. Four of five
interviewed staff were able to explain the process for rectifying youth counts. One staff was not
aware of the procedure.
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 describing the collaborative behavior management
system (BMS) which promotes safety, respect, and fairness, promotes and protects youth
rights, includes positive and negative consequences, includes constructive disciplinary actions
as well as opportunities for reinforcement, recognition of accomplishments in a four to one ratio,
promotes socially acceptable means for youth to meet their needs, a process for explaining to
youth the reasons for any sanctioning, gives the youth the opportunity to explain their behavior,
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opportunities for staff and youth to discuss the impact of behavior on others, reasonable
reparations of harm caused to others, discussions of alternative behaviors, promotes positive
dialogue and peaceful conflict resolution, and minimizes separation of youth from population. A
review of the BMS reflects each of the appropriate parties were involved (including education) in
the development, implementation, and on-going maintenance of the BMS. There is a standing
agreement between the program and the school related to the BMS in which the regional
training coordinator provides training to all education staff in the jointly combined BMS plan. The
program’s policy and procedures include a protocol where staff are provided feedback regarding
the implementation of the BMS, which was supported by five staff interviews.
Five youth case management records were reviewed, and all five confirmed youth orientation
included a review of the program’s BMS, and each contained an acknowledgement form signed
by the youth. Five position descriptions were reviewed and confirmed each includes
implementation of the program’s BMS. Five interviewed staff and corresponding staff training
records indicated they were trained in the program’s BMS. The BMS details are posted
throughout the program, on the living unit and provided in the youth handbook. The behavior
management system does not include increased length of stay, denial of a youth’s basic rights
or services, promotion of group discipline, punishment of youth by other youth, or disciplinary
confinement. Staff and youth interactions were observed for adherence to the BMS, to include
negative consequences and positive rewards, and consequences were in direct relation to the
seriousness of the inappropriate behavior. The program’s BMS includes a process wherein staff
explain to the youth the reason for any sanction imposed, the youth is given an opportunity to
explain their behavior, and the staff and youth discuss the behavior’s impact on others,
reasonable reparations for harm caused to others and alternative acceptable behaviors. The
program offers a variety of incentives to include canteen, off-campus outings, food from outside
restaurants, and games.
The facility administrator reported the BMS is compiled of a series of levels. The youth complete
each level by earning daily points to earn positive days in the program. Earning positive days
allows youth to participate in the nightly incentive. If a youth has a behavioral infraction, they will
not earn points for the task, and after so many deducted points they will not earn enough points
to make the positive day and progress towards the next level. Additionally, youth can require a
special treatment team referral for more serious behavioral violations. The youth will meet with
their treatment team to provide feedback and share their input, and together the team will
determine an appropriate consequence. Youth have the opportunity to utilize their earned points
in canteen, where youth can purchase snacks and drinks. The program utilizes a daily tracker to
manage each youth's progress and as means of communication with the staff and youth of
where the youth is at in the program. Staff are evaluated from commendable to unacceptable in
participation in the maintenance of the therapeutic milieu of the living unit and enforcement of
the BMS. Performance evaluations are completed at ninety days of employment or promotion,
and annually. Ongoing informal fidelity is conducted by management to ensure any issues with
BMS implementation are addressed timely to avoid systemic issues, and re-training is
conducted, as needed.
Five youth were interviewed, and all youth stated the BMS is good. The five interviewed youth
listed some of the consequences for negative behavior as being early bedtime, privilege
restrictions, and level freezes. Rewards were reported to include daily and weekly incentives,
including canteen, pizza parties, water slides, and Fun Fridays. Each of the five youth were able
to explain the difference between each level and how youth move from one to the next. All five
youth reported youth are not allowed to punish other youth, and four stated staff use rewards
the same. One youth said staff do not give the rewards.
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Five staff were interviewed, and all staff indicated they received training in the BMS. Four of five
staff indicated the BMS operates on points, one was aware of levels, and two staff indicated
rewards and consequences were handed out in a four to one ratio. All five staff reported they do
not take anything away from the youth as a punishment for their behavior. The staff collectively
reported youth are rewarded with canteen, treats, snacks, and off-campus outings. Staff also
report youth are informed of the consequences and are they able to explain their behavior
immediately with staff, during the behavior reporting process, where a youth may document
their response to an infraction, and during emergency treatment teams. Five staff reported they
are given feedback on their implementation of the BMS from their supervisors immediately, in
meetings, and in evaluations.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
An observation of ten-minute checks was conducted during the week of the annual compliance
review. The observation was completed utilizing video footage compared to written
documentation of ten-minute checks. The program has a new closed-circuit surveillance system
with forty-seven cameras, all of which are operational. The program’s camera system stores
video recordings for thirty days, although at the time of the annual compliance review, there
were only seven days of recordings on the new systems. A sample of three days was reviewed
for the night shift while youth were sleeping, at one-hour intervals. The review verified staff
conducted checks at least every ten minutes, documenting the times accurately on the ten-
minute check log, as well as initialing each check and signing the form. Ten-minute checks
documentation matched the actual footage reviewed. Staff were observed looking into each
room with a flashlight to ensure the safety of the youth. Five staff were interviewed, and four of
five indicated checks are done every eight minutes and one was not aware, reporting it is
because they do not work the night shift.
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5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program’s policy and procedures ensure youth are accounted for at all times through a
system of physically counting youth at various times throughout the day. The program’s policy
requires the program to conduct and document youth counts minimally every two hours, at the
beginning of each shift, after each outdoor activity, and during emergency situations. The
program maintains a chronological record of events as they occur. The program tracks daily
census information, including the total daily census count, new admissions, releases or direct
discharges, transfers, and youth temporarily away from the program. Staff are required to know
the exact number and location of all youth for whom they are assigned to supervise at all times.
The policy dictates the master control operator maintains a running count to ensure all youth are
properly accounted for, whether on or off facility grounds. Observations of program counts were
conducted. In each instance, master control called for the head count over the radio system and
asked all movement to stop. After a brief pause, master control called each area of the facility
and asked for the number of youth in the area. If the count is reconciled, all movement is
allowed to resume. According to the program’s logbooks, master control maintains an ongoing
count of all youth and youth movement. Counts were documented at least every two hours, at
the beginning of each shift, after each outdoor activity, and during emergency situations.
Documentation in program logbooks included total daily census, head counts, any youth
movement, new admissions or releases, transfers, and youth away from the facility.
Five interviewed staff indicated counts are conducted every two hours and after movement.
Staff reported emergency counts are conducted after a drill, following power outages, any time a
youth cannot be located, or any deviation from the normal schedule. When asked about the
daily census, all five staff knew the census for the program the day of the interview.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a chronological record of events in the master control’s logbook. The
logbooks are bound with numbered pages and contain fields for events to be documented. The
logbooks were in good shape and not missing any pages; however, a small percentage of
pages were re-attached by staples. Logbooks were legible and all entries made in ink with no
erasures or white-out areas. Errors were struck through with a single line and initialed by the
staff correcting the error. All entries included the dates and times of the events, with the names
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of the staff and youth involved, brief descriptions of the events, and the names and signatures of
the staff making the entries. Incoming staff signed and dated the logbook to document it had
been reviewed and/or to confirm they were verbally briefed about its contents. A shift briefing
was unable to be observed in person; however, video observations and an informal interview
with the shift supervisor indicated the contents of the previous two shifts are discussed by
supervisors and staff at this time. The activity schedule and logbook documented minimal
interference of educational instruction, classes and recreation are held as required, and the
logbooks reflect youth arrive and depart school on time. Each logbook documented emergency
situations, incidents, special instructions for supervision of youth, population counts, perimeter
and security checks, transports, law enforcement visits, admissions, releases, and any
information relating to escapes or attempted escapes. A review of the program logbooks
reflected internal incidents were reported to the Department’s Central Communications Center
(CCC), with some exceptions, youth injuries were not initially reportable, but were reported
when injury was determined to be more serious; and in two instances, off-site staff arrests were
not noted in the logbook when they were reported by the provider to the CCC.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
A review of the program’s policy and procedures on key control confirmed it includes the control
and use of keys to include key assignment and usage, inventory and tracking of keys, secure
storage of keys, procedures addressing missing or lost keys, and reporting and replacement of
damaged keys. Observations of the key control system indicated the master control operator
maintains the distribution, collection, and documentation of keys. The key inventory was
reviewed and confirmed the inventory matches the actual key rings in use. Keys are stored in a
locked box in the master control room and all keys remained secure when not in use. The
locked storage box is not easily accessible while locked. Permanent issued keys must be
authorized in writing by the facility administrator (FA) and must sign a Permanent Key
Assignment Sheet acknowledging receipt of the keys and proper procedures for control of keys.
Positions eligible for a permanent key include the FA, assistant facility administrator (AFA),
clinical director, health service administrator, and human resource manager. Each position had
a signed form on file. Provisions for restricted keys were observed and are accessible to
physical plant manager, therapists, case managers, kitchen staff, nurses, the administrative
assistant, AFA, and FA. There were no damaged keys observed; however, policy indicates they
are to be reported to the shift supervisor and returned to the physical plant manager who is
responsible for discarding them, issuing the replacement key, and updating the appropriate
inventories. There were no Department’s Central Communication Center (CCC) incidents or
Program Monitoring and Management (PMM) deficiencies related to key control concerns. An
informal interview with the master control designee indicated keys are tracked and reconciled
using a central key log which indicates the date, time, who the keys were issued to, what type
and number of keys, assignment of a radio, search of person, securing of personal keys, and
what time the keys and radio are returned. Five sets of keys from the key box were compared to
the key inventory with no deficiencies noted. Observations of three staff’s keys determined their
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assigned keys were consistent with the key log. Each staff was aware of the number of keys on
their assigned keys as well as what each key was for. Five staff were interviewed. Three of the
five staff indicated staff keys are given to master control upon entry, personal keys are securely
stored, visitor personal keys are given to master control upon entry, and there is a key log with a
daily tracking of keys. Two reported keys are assigned to staff, one staff stated there is an
inventory of keys, and one explained the facility is searched if keys are missing.
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 which address illegal contraband and outline all
prohibited items. The program clearly delineates those items considered contraband and youth
are provided with a youth handbook containing a list of items considered to be contraband and
the consequences associated with any found contraband as part of their admission to the
program. Staff and youth sign an acknowledgement form reflecting their understanding of the
policy. Five youth records and five staff records all contained signed forms. The program staff
are required to search the facility's grounds and the physical plant for contraband. Youth are
searched every time they move from one area of the program to another. All incoming and
outgoing mail is searched. The program maintains a log of youth room searches detailing items
found and their disposition, to include documentation in youth records when necessary. The
written policy and procedures address any staff who are found in possession of contraband will
be subject to disciplinary action up to and including dismissal. If any contraband found is illegal,
law enforcement is notified according to policy. No incidents of contraband have been reported
since the last annual compliance review. The facility logbook, incident reports, and room search
reports were reviewed and verified searches for frequency, quality, and results. An interview
with the facility administrator (FA) confirmed the program’s written policy is adhered to
concerning any contraband.
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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 control the introduction of contraband and
unauthorized items into the facility. Searches of youth are conducted prior to all movement,
before and after visitation, before and after tool usage, and when returning to the program after
being off campus. Facility searches are conducted at random, in youth rooms, and any common
area utilized by youth. An observation of searches was conducted every day in relation to youth
movement including between classrooms, the living unit, recreation, and the dining area. Youth
were treated with dignity and respect to minimize stress and embarrassment. Searches were
conducted by the appropriate number of staff and gender. Observations determined searches
were thorough and conducted as required by the Protective Action Response Right Interactions
model (PAR/RI) training manual. Five youth and five staff interviews confirmed youth are
searched prior to every movement.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has two vehicles for transportation. Documentation of the annual safety inspection
was reviewed for each vehicle, and no issues were noted. Each vehicle had current
maintenance records. Both vans were secured prior to inspection and included a fire
extinguisher, seatbelt cutter, a window punch, and the appropriate number of seatbelts. The
program has first-aid kits for each van, and they are kept in the master control office until
transport. The door to the youth passenger area cannot be opened from the inside. Five staff
and five youth were interviewed. All five staff and four of five youth indicated youth are attached
to the vehicle with a seatbelt. Four of the five staff reported youth wear handcuffs and leg
shackles when being transported off-campus. Two interviewed youth reported youth are
required to wear handcuffs or shackles. One youth had not been on a transport since arriving at
the facility. A random check of ten personal vehicles determined vehicles were locked when not
in use.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a policy and procedures to ensure the safety and security of youth and
the community when youth are transported outside of the program. A review of the program’s
policy and procedures, as well as interviews and observations, reflected staff transporting youth
are given a radio and program cellular telephone. Reviewed documentation verified all
approved drivers had a valid driver’s license. The program assigns a ratio of one staff to five
youth during transport, not including the driver. No off-site transports were conducted during the
annual compliance review week; therefore, the transportation process was unable to be
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observed. Five staff were interviewed, and three out of five verified use of a facility cellular
telephone and walkie talkies during transports. All five staff knew the vehicles have first-aid kits
and three were aware of seatbelt cutters. Two of five staff knew program vehicles contain fire
extinguishers and window punches. Four of five staff confirmed transport vehicles are searched
for contraband prior to and after each use. Each of the five staff were aware of what to do in
case of an emergency and confirmed youth are not allowed to be transported in personal
vehicles. Youth are not permitted to drive program or staff vehicles. Five youth were
interviewed, and all reported staff are driving transport vehicles safely and they have not seen
anyone place contraband in a transport vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures outlining the audit/inspection process. The physical
plant manager in conjunction with the assistant facility administrator (AFA) are responsible for
conducting weekly security audits and safety inspections. Findings are documented on the
Weekly Safety Inspection report and provided to the facility administrator (FA) for review. The
report details identification of issues and tracks the correction of the deficiencies. All efforts are
made to correct deficiencies in a timely manner, depending on the severity of the issue.
The policy and procedures meet all requirements according to Florida Administrative Code.
Weekly safety and security audit documentation was reviewed and indicated audits were
completed weekly, as required. The facility administrator reported all efforts are made to correct
deficiencies in a timely manner, dependent of the severity of the issue.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures for a tool management system which
ensures youth do not use tools or equipment as weapons or for security breaches. These
address the issuance, inventory, and control of tools and equipment. All tools, with the
exception of mops, brooms, and mop buckets, are stored in the maintenance building when not
in use. The tools in the broom closet and in the maintenance building are all marked for easy
identification and a shadow board is used for storage. Tools are inventoried prior to being
issued for work and following any work activities. Tools with sharp edges and points are
inventoried daily to include kitchen knives, which are stored in a locked cabinet inside the
kitchen and maintenance tools located inside a locked cage inside the maintenance building. A
monthly inventory of all other tools is maintained. Machetes, bowie knives, and other long blade
knives are prohibited. There were no cases of any missing tools since the last annual
compliance review; however, an informal interview with the physical plant manager indicated the
understanding of what procedures to follow in the event a tool does go missing. There were no
reports of tools broken or lost during the annual compliance review period. Logs for brooms and
mops used by youth were observed and were in compliance. Nine items from the maintenance
building were sampled and the logs for each were correct and up to date.
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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 to ensure youth use tools safely and are supervised
appropriately in order to prevent injuries to the youth, other youth, and staff. The written policy
includes supervision requirements when youth use tools, issuing tools to youth and staff
including an assessment to determine a youth’s risk to self and others, established ratios, tool
distribution and collection, and search criteria during work projects. An observation of afternoon
cleaning duty reflected the proper staff to youth ratio was maintained and youth were searched.
A review of five case management records indicated the program trains youth on the intended
and safe use of class B tools. Risk assessments were conducted for any youth permitted to
handle tools. Five youth were interviewed, and one indicated they are permitted to use mops
and brooms and the remining four stated youth cannot use tools. Four of five interviewed staff
reported youth may handle mops and brooms, and one indicated youth must pass a risk
assessment before using class B tools.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures establishing guidelines for outside contractors who
come on-site to complete repairs. When a contractor arrives on campus, they sign the visitors
sign-in log and the Written Notification and Guidelines for Outside Contractors form which lists
unauthorized items and contraband. If any unauthorized items are needed by the contractor
while in the program, approval is obtained by the facility administrator (FA) or designee. Any
tools required to be used within the program are inventoried and recorded on the
Vendor/Outside Contractor Tool Inventory List before and after the repair is completed. Three
reviewed invoices showed the vendors signed contractor agreements. The reviewed invoices
indicated vendors arrived on-site with tools which were logged on the contract agreement forms
and all equipment was inventoried before entering and leaving the program. An informal
interview with the plant manager indicated when contractors are on-site, youth are not allowed
near the work area. The plant manager stays with the contractor at all times to ensure the work
is being completed and all tools are secured. During the annual compliance review week,
contractors were observed entering the facility, being searched, logging their tools on the
contractor form, and being escorted to the work site. No youth were allowed in the area
contractors were working in and the physical plant manager remained with them the entire time
they were on campus. The contractors’ tools were checked upon leaving the program.
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 conducts 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. A review
of drill documentation reflected the program conducts Continuity of Operations Plan (COOP)
drills monthly on each shift in accordance with their COOP. All drill forms document the type of
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drill, date and time, participants, a brief scenario, and findings and recommendations. Fire
evacuation routes and egress plans were posted throughout the facility. The program has
twelve fire extinguishers and a review of inspection tags indicated they are inspected annually
by a contracted inspection service and monthly by the physical plant manager. According to the
facility administrator, COOP and fire drills are conducted monthly on each shift. Five of five
interviewed youth indicated they know what to do in case of a fire and three youth were aware
drills are completed monthly. Three of five interviewed staff indicated they had participated in
fire drills, two have participated in escape drills, and one reported a major disturbance drill.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program maintains a Department approved Disaster and Continuity of Operations Plan
(COOP) available for all staff to review, located in the program’s staff duty office and in the
facility administrator’s office. The COOP was submitted and signed by the Department’s
regional director on February 15, 2023. The combined Emergency Disaster Preparedness Plan
and COOP addresses alternative relocation sites approved by the Department’s residential
regional director. Designated equipment and supplies required for continuous operation and
services during emergency, including water, canned foods, bags with emergency equipment,
first-aid supplies, towels, blankets, and extra clothing are stored on-site in the kitchen pantry
and the maintenance building. The COOP addresses phases of a disaster plan as well as
emergency management including preparedness, response, and recovery. The COOP
addresses emergencies including fire, fire prevention, evacuations, severe weather, program
disturbances, bomb threats, hostage situations, chemical spills, flooding, and terrorist attacks. It
also includes staff roles and responsibilities, any equipment and supplies needed, information
about youth needed, alternative housing arrangements, provisions for continuity of care and
custody of youth, and provisions for public protection. The program keeps a binder in the staff
duty office with the COOP containing all required youth information, including their full name,
identification number, admission date, date of birth, gender, race, parent/guardian information,
contact information of who the youth will be residing with, who to notify in case of emergency,
juvenile probation officer information, names of the committing judge, state attorney, and public
defender, committing offense and where it occurred, notation of jurisdiction retention, victim
notification if applicable, a physical description of the youth, their overall health status, personal
physician (if known), and a photograph of the youth.
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Office of Accountability and Program Support Page 61 of 65 (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 and materials. All hazardous items or materials are stored in the
maintenance building and inside a locked storage closet inside the kitchen, both inaccessible to
youth. The physical plant manager maintains strict control of all flammable, poisonous, and toxic
items by utilizing a perpetual inventory. A review of Safety Data Sheets (SDS) compared to
samples from the inventory determined the facility has SDS maintained on-site for all materials
with no discrepancies. Inventories were compared to a sample of the actual items at the
program and no items were missing and no additional items were discovered on the inventory.
The facility administrator (FA), assistant facility administrator (AFA), supervisors, and physical
plant manager (PPM) are listed as authorized to handle flammable, poisonous, and toxic
materials, with specific designation for the FA and PPM as being the only staff allowed to
remove chemicals from storage.
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 of and supervision for
flammable, poisonous, and toxic items and materials. According to the program’s policy, youth
are prohibited from handling or accessing flammable, toxic, or caustic materials at the program.
Youth are also prohibited from cleaning, handling, or disposing of any person’s bio-hazardous
material, bodily fluids, or human waste. All flammable, poisonous, and toxic materials are stored
securely inside the maintenance building and within a locked storage closet inside the kitchen
where youth do not have access. Five youth were interviewed, and all five youth reported they
do not handle chemicals. Observations of youth cleaning the dorm confirmed this practice.
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Office of Accountability and Program Support Page 62 of 65 (Revised September 2022)
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance staff, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a policy and procedures for disposal of all flammable, toxic, caustic, and
poisonous items. According to the facility administrator (FA), hazardous items and toxic
substances or chemicals are disposed of in accordance with Occupational Safety and Health
Administration (OSHA) standards. The program can dispose of hazardous waste at the local
county landfill/hazardous waste collection center. No hazardous waste has been disposed of
during the annual compliance review period. According to the physical plant manager,
hazardous liquid waste is disposed of in accordance with the manufacturer’s Safety Data Sheet
and is stored in a hazardous materials storage area. Any liquid waste, such as dirty mop water,
is disposed of in plumbing drains and kitchen liquid waste is disposed of in the kitchen, with the
exception of grease. According to the kitchen staff and physical plant manager, used grease is
returned to the containers the grease came from and disposed of. According to the program’s
policy and procedures, in the event of a chemical spill, staff must notify master control of the
spill location, the shift supervisor and/or master control shall direct the shutdown of all air
handlers and ventilation systems as well as close all windows and doors at the direction of the
supervisor on-site or facility administrator, and, if necessary, assistance from outside the facility
shall be contacted consistent with any emergency procedures.
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Office of Accountability and Program Support Page 63 of 65 (Revised September 2022)
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.
An observation of the visitation schedule posted in the front of the facility and reviewed
documentation determined visitation is held on Sundays for two hours. Documentation reflected
all incoming and outgoing mail is searched and monitored by program staff. A review of
documentation demonstrated youth are given opportunities to communicate with their family by
telephone, mail, and during visitation. The program’s policy and telephone logs indicated
telephone calls are offered to youth on assigned days, and youth are given opportunities to
make up a call which was unanswered on their assigned day. All five interviewed youth stated
they can call their parent/guardian or write them a letter. The facility administrator stated the
program utilizes Language Line services to assist with translation for youth whose primary
language is not English. This practice was confirmed during the annual compliance review
week, as the treatment team utilized the services during the treatment team meeting for a
parent who spoke only Spanish. Four of five staff were aware of this practice, when interviewed.
One of five interviewed youth were aware of the translation services.
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Office of Accountability and Program Support Page 64 of 65 (Revised September 2022)
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program’s activity schedule reflects a variety of supervised and structured indoor and
outdoor recreation (or large muscle activity) and leisure activities are held for youth for at least
one hour daily. A review of the logbook indicated recreation was conducted for at least one hour
a day, as scheduled. The program’s documented recreation and leisure activities promote social
and cognitive skill development, creativity, teamwork, healthy competition, mental stimulation,
and physical fitness. Recreational activities are observed by staff to ensure the program takes
precautionary measures to prevent overexertion, heat stress, dehydration, frostbite,
hypothermia, and exacerbation of existing illness or physical injury, and is documented in the
facility logbook. Five youth reported they are given the opportunity to exercise, play outside, or
given down time to read a book, or play a board game. All five youth also stated physical
activities are provided for at least one hour to include basketball, football, kickball, and other
activities designed by the recreational therapist. Five interviewed staff reported youth participate
in various recreational activities for one to two hours including basketball, football, kickball, and
capture the flag.
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.26 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 65 (Revised September 2022)

report_type: QI Residential

program_name_raw: Jacksonville Youth Academy