summary: QI Residential - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Crestview Youth Academy
Youth Opportunity Investments, LLC
(Contract Provider)
4449 Straightline Road
Crestview, Florida 32539
Review Date(s): October 24-27, 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:
Jessica Gibson, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Janise Best, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Lea Herring, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Shyron Johnson, Dove Academy, Assistant Program Director (Standard 5)
Kevin Lawson, Office of Accountability and Program Support, DJJ Operations Coordinator,
(Interviews)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor, (Standard 4)
Ken Myers, Office of Accountability and Program Support, Regional Monitor, (Standard 2,
education)
Cedric Prince, Office of Accountability and Program Support, Regional Monitor, (Standard 2)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor, (Standard
4)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor, (Standard
2)
Program Name: Crestview Youth Academy MQI Program Code: 1440/1441
Provider Name: Youth Opportunity Investments, LLC Contract Number: 10210
Location: Okaloosa County / Circuit 1 Number of Beds: 54
Review Date(s): October 24 - October 27, 2023 Lead Reviewer Code: 210
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 84 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
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Office of Accountability and Program Support Page 4 of 84 (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 84 (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 84 (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 84 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Satisfactory
5.25 Controlled Observation Satisfactory
5.26 Controlled Observation Safety Checks and Release Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 84 (Revised September 2022)
Program Overview
The Crestview Youth Academy is a fifty-four-bed program, separated into a secure side with
thirty beds and non-secure side with twenty-four beds serving thirteen- to eighteen-year-old
male youth, located in Crestview Florida. The program is operated by Youth Opportunity
Investments, LLC, through a contract with the Department. The program provides services
including Substance Abuse Treatment Overlay Services (SAOS) for the secure component, with
delinquency programming and treatment services. The program also provides borderline
development disability (BDD) treatment services through evidenced-based delinquency
interventions for the non-secure component of youth it serves. In addition, the program fosters
youth by providing Impact of Crime (IOC) curriculum. The program also provides Seven
Challenges, Trauma-Focused Cognitive Behavioral Therapy, Skillstreaming the Adolescent,
Teen Relationships, and Life Skills Training for youth. Program administration is comprised of a
facility administrator (FA) and two assistant FAs. Case management services are provided by
the case manager director and one case manager. Mental health staff at the program include
one clinical director, who serves as the designated mental health clinician authority (DMHCA),
an assistant clinical director, and four therapists. Medical services are provided by one full-time
registered nurse (RN) and two full-time licensed practical nurses (LPNs). The program employs
a contracted psychiatrist who provides services bi-weekly. The program also has a contract with
a medical doctor who serves as the designated health authority (DHA). The DHA is required to
be available by telephone twenty-four hours a day, seven days a week. The DHA is on-site for a
minimum of once a week for two hours. Educational services are provided by the Rader Group.
The layout of the program includes one building with two living modules, which include the youth
rooms, bathrooms, and education rooms. The administration portion is at the front of the
building, which includes medical, human resources, master control, facility administrator, and
therapy offices. The program has seventy-three operating security cameras providing coverage.
The annual compliance review showed the program had twenty-four vacant positions; fifteen
safety and security specialists (SSS), two case managers, three shift supervisors, two master
control positions, one food service worker, and one transitional service manager.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 84 (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. 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 written policy and procedures in place to address the completion of
background screenings for all newly hired staff, volunteers, interns, and mentors prior to hire. A
review of the program’s employment roster found eighteen newly hired staff applicable for an
initial background screening during the annual compliance review period. All eighteen staff had
an initial background screening completed prior to contact with youth and confidential youth
records. None of the reviewed staff background screenings required a criminal history report for
review. Three of the reviewed staff had a break in service as indicated in the Department’s Staff
Verification System (SVS), and all three staff had a new background screening completed. All
eighteen staff were applicable for a pre-employment assessment tool and all staff received a
passing score, which was documented in each staff’s personnel record. All staff were added to
the Clearinghouse employee roster. The program did not have interns, volunteers, or mentors
on-site for more than ten-hours a week who needed to be always under the supervision of a
background screened staff. An Affidavit of Compliance with Level 2 Screening Standards was
completed and sent to the Department’s Background Screening Unit (BSU) on January 2, 2023,
for both the program and the school board.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a written policy and procedures in place which require all staff to receive a
background rescreening within five years from the date of their last screening which shall
include a local law enforcement background screening and re-occur every five years. A review
of the program’s employment roster found five staff applicable for a five-year background
rescreening. Five reviewed staff received a five-year rescreening completed every five years as
calculated by the Clearinghouse Prints Expiration Date. All renewal requests were submitted to
the Department’s Background Screening Unit at least ten business days prior to the five-year
anniversary.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 84 (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’s written policy and procedures indicate the program shall promote an
environment of physical, psychological, and emotional safety. The youth shall have unhindered
access to report alleged abuse. Staff shall provide telephone access to report allegations of
abuse and at no time will a youth be prevented from self-reporting or making an abuse call.
Youth in controlled observation shall not be denied from making an abuse call; however, the call
may be delayed until the youth demonstrate calm and compliant behavior. The staff shall
immediately notify the shift supervisor, who will then notify the facility administrator. The staff will
assist in placing abuse calls, dialing the telephone number, recording date and time of call,
obtaining operator name and number, and documenting this information on the internal incident
report. The staff will also maintain sight and sound of the youth. Any youth refusal of making an
abuse call shall be documented in the facility logbook and on the internal incident report. The
facility administrator or administrator on duty shall ensure all appropriate notifications are made
and the facility administrator shall review any requests to contact the Florida Abuse Hotline and
calls made during the daily management meeting. The program had a total of two incidents
related to physical, psychological, or emotional abuse during the annual compliance review
period. One of the incidents was still under investigation at the time of the compliance review;
however, this incident was substantiated by the Department of Children and Families (DCF) for
physical injury. The second incident was found unsubstantiated. None of the incidents involved
potential human trafficking victims, child sexual exploitation, or labor trafficking. Both involved
staff signed a code of conduct as evidenced by a review of the personnel records. The Florida
Abuse Hotline and the Department’s Central Communications Center (CCC) numbers were
observed to be posted throughout the program. The program completed a Trauma Responsive
and Caring Environment (TRACE) self-assessment on May 22, 2023.
Six youth were interviewed and reported they feel safe in the program. None of the youth have
been stopped from reporting abuse and all stated the Florida Abuse Hotline number is in the
program. All youth reported they have never exchanged emails, telephone numbers, or social
media contact information with staff. Six staff were interviewed about the process for staff and
youth calling the Florida Abuse Hotline or CCC for suspected abuse. All six staff reported they
notify the supervisor and program director. All interviewed staff were able to summarize the
steps for calling in suspected abuse to the Florida Abuse Hotline or CCC. The facility
administrator was interviewed and reported the staff are trained in trauma-responsive practices
upon hire with refresher training being conducted yearly during staff meetings. The staff are also
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Office of Accountability and Program Support Page 11 of 84 (Revised September 2022)
trained to understand the youth safety plans to better understand youth triggers and ways to
respond. Safety plans are reviewed in shift briefings and monthly all-team meetings. The facility
administrator was able to summarize the program’s incident reporting process. The program
ensures the staff and youth are knowledgeable in contacting the Florida Abuse Hotline or CCC
through daily morning meetings, department head meetings, weekly townhouse meetings, and
monthly meetings.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There are evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had two incidents related to physical, psychological, and emotional abuse since
the last annual compliance review. There was evidence within each of these incidents where
management took immediate action to address the incident. For both incidents the staff were
immediately placed on no youth contact. In one of the incidents, the staff was later placed on
administrative leave during the investigations. The Department of Children and Families (DCF)
investigation found the allegations of physical injury substantiated. The program reassigned this
staff to master control supervisor and this staff has no contact with youth. This incident was still
open and under investigation with the Department of Children and Families at the time of the
annual compliance review. The facility administrator was interviewed and reported one staff had
disciplinary actions due to allegations of abuse. The management response to the allegations of
abuse included staff being trained during new hire orientation. All staff are mandated reporters
to call the Florida Abuse Hotline and the Department’s Central Communications Center (CCC).
The program has these numbers located throughout the program. The youth are also oriented
during their intake and this information is included in the youth handbook.
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 eighteen incidents reported to the Department’s Central
Communications Center (CCC) during the annual compliance review period. Five incidents were
for the non-secure program and thirteen incidents were for the secure program. Eight incidents
in total were reviewed. Seven of the eight incidents were reported to the CCC within the
required two hours. One incident was reported two months late. The facility administrator was
asked about the incident. The facility administrator reported being aware of the issue and
disciplinary action was taken on the staff involved. There were no additional internal incidents or
grievances to be reported during the annual compliance review week. The program experienced
an increase of more than five incidents during the annual compliance review period. The facility
administrator reported the program has been monitoring the incident reporting data to determine
any patterns with staff, youth, and times of the incidents. The program has also experienced
significant turnover in the safety and security staff.
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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 has a Protective Action Response Right Interactions model (PAR/RI) Plan which
was updated on January 3, 2023, and was approved by the Department on January 26, 2023.
The program had a total of thirty-six PAR/RI incidents during the annual compliance review
period; the non-secure program had twenty-one incidents and the secure program had fifteen
incidents. Five of the thirty-six incidents were reviewed. All five incidents had the required
reports completed by the end of the workday. All reports included statements from all staff
involved. None of the incidents included the use of mechanical restraints. None of the incidents
resulted in injury to youth or staff and none included allegations of abuse. All five incident
reports were reviewed by a supervisor and a PAR/RI instructor. All five incident reports were
reviewed by an administrator within seventy-two hours of the incidents. A medical review was
conducted for one of the five incidents when indicated on the post-PAR interview. All five
PAR/RI Reports were reviewed in the program’s centralized file. The program submitted all
monthly summaries as required during the annual compliance review period. The secure
program’s PAR/RI rate during the previous quarter was 1.08, which is below the statewide
PAR/RI rate of 1.35. The non-secure program’s PAR/RI rate during the previous quarter was
3.75, which is above the statewide PAR/RI rate of 1.35. The non-secure program experienced a
decrease in PAR/RI incidents from the last annual compliance review period from thirty-four to
twenty-one. The secure program experienced an increase in PAR/RI incidents during the last
annual compliance review period from three to fifteen. The facility administrator reported there
has been a significant amount of turnover among the safety and security specialists, which has
contributed to the increase in PAR/RI incidents. Additionally, the program is tracking the data for
incidents to determine any patterns with the staff, youth, and times the incidents occur. The
facility administrator was interviewed and reported PAR/RI and use of force incidents are
monitored through all-staff monthly meetings, shift briefings, and coaching sessions, as needed.
Youth who are continuously being involved in PAR/RI incidents are encouraged to provide
feedback to administration. The treatment team makes all attempts to help youth with tools on
how to be compliant in the program as it relates to treatment. Six staff were interviewed and all
six were able to appropriately summarize the program’s procedures for the use of PAR/RI.
Three of the six staff reported they had used PAR/RI techniques. All three staff were able to
summarize the procedures for the use of PAR/RI techniques.
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.
A total of nine staff were reviewed for pre-service requirements. All staff had trainings completed
and documented within the Department’s Learning Management System (SkillPro). Four of the
nine staff were still within their initial 180-days of employment. Three of these four staff had not
completed the minimum of 120-hours of pre-service training. All nine staff completed
professionalism and ethics, suicide awareness and prevention, child abuse reporting, Prison
Rape Elimination Act (PREA), active shooter preparedness, balanced approach to restorative
justice, civil rights, communication, confidentiality and Health Insurance Portability and
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Accountability Act (HIPAA), Department of Juvenile Justice History, equal employment
opportunity, gang awareness, human trafficking intervention, infection control/bloodborne
pathogens, information security awareness, Department’s Juvenile Justice Information Systems
(JJIS), quality report writing, sexual harassment, standards of conduct, and trauma responsive
practices, and Massachusetts Youth Screening Instrument, Second Version (MAYSI-2). Eight of
the nine reviewed staff completed Protective Action Response Right Interactions model
(PAR/RI) training, cardiopulmonary resuscitation (CPR), first-aid, automated external
defibrillator (AED) training, facility operating procedures, emergency procedures, adolescent
development and behavior, diversity, mental health and substance abuse, safety, security, and
supervision of youth, sexual orientation, gender identity, and expression. The remaining staff
was still in training and did not have contact with youth. Five of the nine staff had completed the
Department’s Central Communications Center incident reporting. One of the nine staff had
completed motivational interviewing (MI) training. The facility administrator provided email
documentation for review regarding MI training. Information from the Technical Assistance
supervisor stated due to the MI training being transitioned to the Office of Talent, Leadership,
and Culture, no classes are being offered. It was also documented the clinical staff are not
required to take MI training. Nine staff also completed the Vulnerability to Victimization and
Sexually Aggressive Behavior (VSAB) training. All nine staff completed training for the
grievance process and infection control. Eight of the nine staff completed training for the
exposure control plan, behavior management system, and intended and safe use of tools. Two
members of the nursing staff completed job specific training. There are also specific trainings for
key positions. Not all the newly hired staff had completed these trainings at the time of the
annual compliance review. One of the two case managers had completed the Youth Opportunity
Investments (YOI) case management training, Impact of Crime training, Residential Assessment
for Youth (RAY) training, and the JJIS Specialty training. The remaining staff was still in training
at the time of the annual compliance review. All four therapists had completed Seven
Challenges training. Two of the therapists had completed Skillstreaming the Adolescent,
Trauma Focused Cognitive Behavioral Therapy, and YOI therapist training. One therapy staff
had completed Life Skills Facilitator Training and Teen Relationships facilitator training.
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.
Nine staff were reviewed for in-service training requirements. All in-service trainings were
documented in the Department’s Learning Management System (SkillPro). Three of the nine
staff were supervisors. All nine staff completed more than the required twenty-four hours of
annual training. All nine staff completed active shooter preparedness, cardiopulmonary
resuscitation (CPR), first-aid, and automated external defibrillator (AED) training, information
security awareness, mental health and substance abuse, Protective Action Response Right
Interactions model (PAR/RI) update, professionalism, interpersonal, communication, and ethics,
sexual harassment, suicide awareness and prevention, trauma responsive practices, and Prison
Rape Elimination Act (PREA). There were four additional trainings as outlined in the program’s
contract including emergency and evacuation procedures, the Department’s Central
Communications Center (CCC) reporting, workplace violence, and iChoose System (behavior
management). All nine staff had completed all additional trainings required by contract. All three
supervisory staff completed the required eight hours additional annual training for supervisors.
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All nine staff completed all trainings required by other rules and manuals. All instructors were
qualified to deliver the trainings provided. The program’s list of in-service trainings was
approved by the Department’s regional director on November 30, 2022. The program has an
annual in-service training calendar, which was provided for review.
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 written policy and procedures for the grievance process which includes the
training requirements and the three phases of the grievance process, the informal phase, formal
phase, and the appeal phase. The informal phase process includes a youth being encouraged
to reach a resolution of issues immediately and directly through informal communication with the
program staff involved. A youth may provide an informal grievance using the “Request to
Speak” forms available to all youth. Staff shall make every reasonable effort to address the
youth’s issue. A youth may not be discouraged from filing a grievance. All informal complaints
shall be handled as expeditiously as possible. The program had one grievance during the
annual compliance review period. The program’s practice correlated with their procedures. The
grievance was responded to within the required time frame and the grievance was resolved.
The program maintains copies of the grievances for the past twelve months in a binder located
in the facility administrator’s (FAs) office. Six youth were interviewed, and all six youth reported
the grievance forms are placed throughout the program. Three youth reported there are three
phases in the grievance process and four youth reported the time frames for each phase of the
grievance. One youth reported never filing a grievance since being at the program. One youth
reported they would go to the staff or FA. One youth explained the process of filling out the
grievance form and providing it to staff. The staff are to respond within forty-eight hours. All six
youth reported they could ask for assistance in completing a grievance form. Six staff were
interviewed and were able to explain the program’s grievance process. The FA was interviewed
and reported all staff receive pre-service training on the grievance process and procedures. All
steps were explained, in detail, by the FA.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff who’s regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program’s group schedule reflects the minimum number of groups are provided a week as
required. The annual compliance review period showed the program provided groups including
IOC, Skillstreaming the Adolescent, Trauma Focused-Cognitive Behavioral Therapy, Seven
Challenges, Male Healthy Relationships, Life Skills Training, and Anger Management. Male
Healthy Relationships curriculum was recently changed to the Teen Relationships curriculum.
There was a contract amendment to reflect this change. All groups provided by the program
were primary services or clinical groups; therefore, intervention and facilitator trainings were not
applicable for this annual compliance review period. The program provided structured, planned
programming, or activities for at least sixty percent of the youth’s awake hours as evidenced by
a review of the activity schedule. The facility administrator was interviewed and reported there
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were ten therapy staff who facilitated therapy groups during the annual compliance review
period. The designated mental health clinician authority (DMHCA) was interviewed. The
DMHCA reported youth are provided therapy services seven days a week, with individual
therapy services occurring once a week for the non-secure program and two times a month for
the secure program. The program has four master’s-level therapists and two licensed mental
health counselors. All youth treatment plans include Trauma Focused Cognitive Behavioral
Therapy and Skillstreaming the Adolescent. For youth needing substance abuse treatment,
Seven Challenges groups are provided.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a written policy and procedures to determine how life and social skills groups
are provided. The program utilizes evidenced based and promising practice curricula to address
life and social skills training for the youth. These curricula include Life Skills Training LST),
Skillstreaming the Adolescent, Male Healthy Relationships, Impact of Crime, Teen
Relationships, and Seven Challenges. Each of these groups are primary services except LST,
which was only provided intermittently as a supplemental group; therefore, groups were not
applicable for review. Based upon the Residential Assessment for Youth (RAY) results, the
treatment team determines the appropriate groups for each youth. The clinical director and/or
assistant clinical director conduct internal fidelity monitoring monthly for each facilitator of the
curricula. The nursing staff also provide Life Skills Facilitator Training during orientation which
includes prevention of accidents, substance and alcohol use, overdose, sexually transmitted
disease prevention, smoking, prevention of communicable diseases, cardiovascular
health/physical fitness, HIV/AIDS, nutrition basics, dental hygiene, personal hygiene, testicular
exam, family planning, anxiety reductions, and coping with anger and depression. Six youth
were interviewed. The youth listed they participated in groups and activities including
horticulture, animal care, Florida Ready to Work, Occupational Safety and Health Administration
(OSHA), OSHA 10, and OSHA 510 certifications, cardiopulmonary resuscitation (CPR)
certification, working with maintenance staff, working in the kitchen, Teen Relationships, Seven
Challenges, crane courses, high school diploma, Impact of Crime, Life Skills Training, anger
management, and coping skills. All six youth reported they have been able to practice new skills
they learned in the groups within the program. The facility administrator (FA) was interviewed
and reported the same list of groups were provided during the annual compliance review period.
The FA also reported the youth are encouraged to use their newfound skills daily in the
program. The progress of the youth is measured in their Individualized Treatment Plans.
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
criminal actions and harm to others.
The program provides Impact of Crime (IOC) groups as a promising practice for restorative
justice groups. IOC is a primary service; therefore, was not reviewed for this annual compliance
review period. The program also provides multiple opportunities for the youth to participate in
restorative justice activities. The youth participate in IOC groups and community service
projects. The secure program youth have restored a sidewalk on the grounds of the program,
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built a garden, and have assisted in repainting the living unit doors. The non-secure program
youth feed the homeless at a local church on a regular basis and have planted fruit trees. All
restorative justice projects are documented in a binder kept in the facility administrator’s office,
which was provided for review. The restorative justice activities and groups are designed to
assist youth to accept responsibility for harm they have caused by their past criminal actions,
challenging them to recognize and modify their irresponsible thinking, teach youth about the
impact of crime on victims, their families, and communities, expose youth to victims’
perspectives through victim speakers, and provide opportunities for youth to plan and participate
in reparation activities intended to restore victims and communities. The program’s activity
schedule included restorative justice groups. The program maintains a binder for all group
documentation, which is kept in the clinical director’s office. This binder includes sign-in sheets,
fidelity monitoring forms, handouts, and worksheets the youth complete. The facility
administrator (FA) was interviewed and reported youth receive Impact of Crime group
regardless of if they have completed the curriculum before in another program. The FA also
stated the youth are also provided opportunities to participate in community service activities
such as feeding the homeless, beach clean-ups, and assisting at local schools and shelters.
The youth who are not allowed to leave the program are able to participate in restorative justice
activities through beautification projects, making care packages, writing letters to the elderly and
soldiers, and landscaping projects. The designated mental health clinician authority (DMHCA)
was interviewed and reported the youth participate in Impact of Crime groups two times a week
for sixteen weeks. The curriculum is facilitated by case management staff. Six youth were
interviewed and reported they participate in IOC groups, talk about victims, and are held
accountable for their actions.
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). At the suggestion of appropriate staff members, downgrades or
discontinuations of alerts within the Juvenile Justice Information System (JJIS) are
implemented.
The program maintains a written policy and procedures to determine how new alerts are
identified, documented, updated, and communicated to staff. The procedures are in place to
establish alert identification, documentation, how to update alerts, and how alerts are
communicated to staff. Alerts are communicated to the staff in the program through the
Department’s Juvenile Justice Information System (JJIS) alert list, the alert communication
board, shift briefings, and logbook communication. There were youth identified with alert risks
during the annual compliance review week and the youth were placed in the alert system as
specified in the program’s written procedures. Observations made during the annual compliance
review found updated alerts were posted in the kitchen area for youth with dietary restrictions
and food allergies. Ten youth records were reviewed for alerts. For the ten youth, there was a
total of thirty-nine alerts reviewed. There were no discrepancies found in reviewing the thirty-
nine alerts. The facility administrator (FA) was interviewed for the formalized procedures for
healthcare staff to review important medical issues pertaining to the youth. The FA reported the
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medical staff attend daily morning meetings and provide any information to the management
team. The medical alerts are updated and printed daily. The alerts are in master control, dietary,
medical, and the conference room. The exposure control plan is in medical and master control
and is reviewed, at least, annually. The nursing staff were interviewed and reported the nursing
department updates the medical alert system. If there is a non-licensed medical staff who
updates the medical alerts, only a licensed medical staff can close the alert. Six staff were
interviewed regarding how they are informed of medical, mental health, and security alerts. All
six staff were able to summarize how staff are made aware of alerts. Staff reported being
informed through all-staff meetings, alert boards, documentation in the nurses’ office,
documentation for allergies are in the dining hall, and in master control. The staff are notified by
the mental health staff about any issues, alerts, and youth safety plans.
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 separate youth records for case management, mental health, and
medical. The individual records included the youth’s name, the Department’s identification
number (DJJ ID), date of birth, county of residence, and committing offense. The individual
records include sections labeled legal information, demographics and chronological information,
correspondence, case management and treatment team activities, and miscellaneous. All
records were labeled “Confidential.” All official youth case records were observed to be secured
in a locked file cabinet. All filing cabinets were observed to be marked “Confidential.”
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 maintains documentation of the community advisory board meetings. These
meetings are held at least every ninety days which was confirmed through a review of the sign-
in sheets and meeting minutes. The facility administrator (FA) actively solicits active
involvement from local law enforcement, the judiciary community, the business community,
school board or district, and faith community as evidenced by emails sent to the various
agencies. The FA was successful in recruiting a victim and victim advocate. There was a
meeting schedule within the quarter the annual compliance review took place in as evidenced
by invitation emails sent to the various members. The community advisory board documentation
is maintained in a binder in the FAs office. This binder includes sign-in sheets, agendas, and
meeting minutes. The FA was interviewed about the community advisory board and reported
the community advisory board provides suggestions on how to assist the program and youth
while they are inside and outside of the program. Each member provides a different perspective.
The meetings are held quarterly. A board member was interviewed, and they reported they are
a pastor who visits the program on a regular basis, at least weekly. The individual reported the
communication with the FA is excellent and is appreciative how well information is shared. The
individual was solicited for the community advisory board after being a volunteer at the program
for many years. The individual shared the community advisory board meetings help to bring
different perspectives for the program and help the FA get different ideas for the youth. The
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individual reported an observation of the youth and staff attitude changes over time and the
culture of the program have both changed for the better.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program maintains a written policy and procedures for staff performance and evaluations.
Staff are evaluated at ninety-days and annually thereafter regarding performance based on their
job descriptions. The personnel records are reviewed annually by the corporate compliance
team, the human resources manager, and the staff. Three position descriptions were reviewed
along with performance evaluations. The three positions were the clinical director, a safety and
security specialist, and a case manager. The case manager had a ninety-day review as this
staff is new to the program and has not received an annual performance evaluation at the time
of the annual compliance review. The reviewed evaluations were completed as outlined in
policy. All performance standards matched the job descriptions for each reviewed staff. The
contract was reviewed to ensure all specific contractually required positions were maintained
and performed, as outlined in the contract. The facility administrator (FA) was interviewed about
staff turnover and staff morale. The FA reported to improve staff morale, the program provides
functions, such as cookouts, potlucks, bowling, and meals on management. Also, staff
acknowledgements have also helped in retaining staff. The FA also reported other providers
have competitive salaries which “target” staff and is a challenge when it comes to turnover. The
provider has now provided retention pay for staff to help with decreasing staff turnover. The FA
reported staff are provided ninety-day and annual evaluations. The administrative staff also
provide monthly coaching sessions or as needed. Six staff were interviewed for how effective
communication among the staff is at the program. All six staff reported communication is very
good. Additional comments made were communication is very effective, each shift is informed
with what is going on, and communication is “wonderful.” One staff suggested shift briefings
could be better. All six staff reported they receive a formal evaluation every three months.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s contract and Memorandum of Negotiation (MON) were reviewed. The MON
outlined position description language. The MON also included the additional activities of
Alcoholics Anonymous/Narcotics Anonymous (AA/NA) for youth with substance abuse issues, a
diverse media center and reading materials, the provider shall utilize a peer advisory council
and religious/spiritual opportunities, healthy leisure opportunities, community involvement
activities, and career pathways for the youth. The program provided documentation for the
special contract conditions for review. The program has a volunteer come once a month for
AA/NA meetings. Sign-in sheets and pictures were provided for review. The media center and
library were observed during the facility tour. The youth must be on certain levels within the
behavior management system to earn these privileges. The provider conducts peer advisory
council meetings two times a month. These meetings are documented and maintained in a
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binder, which was provided for review. There are regular religious and spiritual opportunities
provided to the youth, which are also documented in the program’s monthly newsletter. The
program has added additional activities to their incentive program, which includes attending
local high school football games. The youth are provided community involvement activities
through Impact of Crime restorative justice projects. These activities are documented and
maintained in a facility binder and in the monthly newsletters. The facility administrator was
interviewed and reported the program offers animal care, horticulture, forklift, cardiopulmonary
resuscitation (CPR), first-aid, safe staff, and Occupational Safety and Health Administration
(OSHA)-10 certifications for special contract conditions. Six youth were interviewed regarding
specific contract negotiated items. Three of the youth reported they had not heard of these
programs and three reported they had heard about the programs. An informal interview was
conducted with the facility administrator. It was reported the youth were not participating in
these services at the time of the annual compliance review.
1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
The program provides career and technical education services required by the contract to
include Able Trust Florida Tech High School with a horticulture program, animal care program,
career and technical services, Florida Ready to Work, forklift simulator, Information Technology
(IT) access, culinary arts, Occupational Safety and Health Administration (OSHA)-10
certification, cardiopulmonary resuscitation (CPR) and first-aid, and Florida Career and
Professional Education Act (CAPE) certifications. The provider has agreed to serve as
collaborative partners who provide Career and Technical Education (CTE) services which lead
to career pathways with youth outcomes which include industry certifications earned from the
master credentials list and may include articulation agreements which provide enrollment
opportunities into CTE programs in a local technical college. The vocational activities have been
implemented in the program and the youth have been actively participating in these programs.
The program maintains a spreadsheet for all youth who participate in CTE services. This
spreadsheet was provided for review and includes each youth’s name, which CTE services
each youth is enrolled in, and when a certification was earned by each youth. Eighty-five youth
participated in career and technical services during the annual compliance review period. Most
of the youth participated in more than one course. Forty-three youth received Florida Ready to
Work, thirty-five youth received culinary arts safe staff, forty-two youth received OSHA
certifications, thirty-one youth received forklift certifications, seventeen youth participated in
horticulture and agriculture, sixteen youth participated in science, technology, engineering, and
mathematics (STEM) courses, and sixty-seven youth were CPR/first-aid certified. The career
and technical services are built into the program’s educational schedule and were provided
according to the program’s schedule. There are specific, certified instructors who provide the
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CTE services in the program The online instructor for Career Safe and OSHA-10 courses is
qualified to instruct these courses. A teacher through the Okaloosa County Schools completes
the information technology fundamentals certification for the industry certifications. The medical
staff conduct CPR/first-aid training for the youth. The CTE programs are appropriate for the age
of youth in the program. These services are also appropriate for the abilities, goals, and length
of stay of the youth in the program. All youth were searched after participation in CTE activities.
Five of six interviewed youth reported they participate in services including OSHA, Florida
Ready to Work, CAPE certification, safe staff, CPR, and high school equivalency diploma
(GED). The youth reported they are participating in these services either every day or every
other day, until they have received their certifications. The youth were also asked about not
being able to participate in the services. The youth reported if they are unable to participate, it
would be due to internet or technical issues, other school classes, or they have completed the
technical education activities. One youth reported not participating in the programming. The
facility administrator was interviewed about the CTE services and was able to accurately
summarize all the contract specific services.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program’s practice regarding data trend analysis is monitoring and tracking the incidents
reported to the Department’s Central Communication Center (CCC) and other program
incidents throughout the year. The program maintains a binder with the documentation for data
trend analysis. The provider tracks the data for all provider programs. The binder includes CCC
and incident data collected each month. This data is broken down by time of day, shift, how
many staff, how many youth, and what activities were occurring at the time of the incident. This
information is shared through monthly reports created by corporate staff and disseminated to
the facility administrator (FA). The FA shares this information with staff through daily morning
meetings and monthly all-staff meetings. The program provided the agendas from these
meetings for review. This information is also shared with providers and stakeholders on a
quarterly basis through the community advisory board meetings. These agendas were also
provided for review. The corporate staff collect all data and create the monthly reports with the
data trends. This information is then utilized within the program to determine any patterns and
implement changes to decrease the number of incidents.
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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.
SECURE
The program has a written policy and procedures to address initial contacts to the
parents/guardians, juvenile probation officer, and committing court. Five youth case
management records were reviewed for initial contacts with parents/guardians and court
notifications. All youth records included documentation the parents/guardians were notified by
telephone within twenty-four hours of admission. All youth records included documentation the
parents/guardians were notified in writing within forty-eight hours of admission. All youth records
included documentation the courts and the juvenile probation officers (JPOs) were notified
within five working days of the youth admissions.
NONSECURE
The program has a written policy and procedures to address the initial contacts to the
parents/guardians, juvenile probation officer, and committing courts. Five youth case
management records were reviewed to verify initial contact with a parent/guardian by telephone
occurred within twenty-four hours of each youth’s admission. All five records contained
documentation indicating staff notified the parent/guardian by telephone the day of admission. In
each of the records, staff mailed a letter to parents/guardians within forty-eight hours of
admission. In each record, the staff sent letters within five working days to the assigned juvenile
probation officer (JPO) and committing court notifying them of the youth’s admission to the
program.
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.
SECURE
The program has a written policy and procedures, to address the youth orientation process. Five
youth case management records were reviewed for youth orientation documentation. All youth
records included documentation the program provided orientation the day of each admission. All
youth records included documentation, the orientation had the elements including services
available, daily schedule, expectations and responsibilities of youth, written behavioral
management system located in the youth handbook, including rules for governing conduct and
positive and negative consequences for behavior, availability of and access to medical and
mental health and substance abuse services, access to the Florida Abuse Hotline, the
Department’s Central Communications Center (CCC), program’s zero-tolerance regarding
sexual misconduct, the right to report and be free from retaliation as a result of reporting such
misconduct and the agency’s sexual misconduct response policies and procedures, special
accommodations which are available to ensure all written information about sexual misconduct
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policies, items considered contraband, performance planning processes involving the
development of goals for each youth to achieve, dress code and hygiene practices, procedures
on visitation, mail, use of telephone, expectations for release from the program, access,
grievance procedures, emergency procedures, facility tour, assignment to a living unit, room,
and treatment team, and medical topics as outlined in Florida Administrative Code. The youth
handbook was reviewed, and included all required elements. The program utilizes an orientation
checklist and a signature page for the youth and assigned case manager to sign upon
completion of the orientation. No youth were admitted to the program during the week of the
annual compliance review; therefore, a youth orientation could not be observed.
NONSECURE
The program has a written policy and procedures to address the youth orientation process. Five
reviewed youth case management records included an orientation checklist completed upon
youth admission indicating all required documents were reviewed with the youth. The program’s
orientation includes services available, daily schedule, expectations and responsibilities of
youth, a handbook which includes the program’s behavioral management system, availability
and access to medical, mental health, and substance abuse services, access to the Florida
Abuse Hotline or the Department’s Central Communications Center, the program’s zero
tolerance policy regarding sexual misconduct, special accommodations for reporting sexual
misconduct, items considered contraband, performance planning process, dress code, hygiene,
visitation, mail, and telephone procedures, expectations for release from the program,
community access, grievance procedures, emergency procedures for drills and building
evacuations, facility tour, assignment to a living unit and room, and medical topics as outlined in
Florida Administrative Code. No youth orientation was observed during the annual compliance
review due to no youth being admitted while the annual compliance review team was on-site.
Six youth were interviewed, and each indicated they received an orientation to the program
within twenty-four hours of admittance. All six youth indicated the orientation included program
rules, procedures, schedules, receipt of the youth handbook, explanations about the program,
and they were given the opportunity to speak to their case manager, the nurse, facility
administrator, and participate in an intake telephone call.
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.
SECURE
The program has a written policy and procedures to address written consent of youth eighteen
years of age or older. Five youth case management records were reviewed for written consent
of youth eighteen years of age or older. Two case management records were applicable and
one additional open case management record was provided for review. All three records
included documentation a written consent was obtained for each youth upon entering the
program, if already eighteen or if the youth turned eighteen while in the program.
NONSECURE
The program has a written policy and procedures to address written consent of youth eighteen
years of age or older. Five youth case management records were reviewed, and one was
applicable for consent of youth eighteen years of age or older. In the applicable record, written
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consent was obtained by the youth prior to providing or discussing information related to each
youth’s physical or mental health screenings, assessments, or treatments with the
parent/guardian. No consents were obtained late. There were no other youth during the annual
compliance review period applicable for consent of youth eighteen years of age or older.
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.
SECURE
The program maintains a written policy and procedures which outline the classification process
and includes 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, which addresses items outlined in Florida Administrative Code. Five youth case
management records were reviewed for classification factors, procedures, and reassessments
for an increase in activities. A program classification form was provided for review. The
program’s classification form included all required elements. All five reviewed youth records
included documentation of initial classifications being completed on the youth’s admission date.
The initial classification factors included the youth’s physical characteristics, age, maturity level,
identified special needs, including medical, mental health development, or intellectual and
physical disabilities, history of violence, gang affiliation, criminal behavior, sexual aggression or
vulnerability to victimization, the youth’s perception of vulnerability, the youth’s history of
potential or verified human trafficking, suicide risk, medical risk, escape risk, and security risk.
All five youth records included documentation the youth had medical risk factors. Four youth
had security risk factors. None of the five youth had the suspected risk factor of suicide or
escape. The Department’s Juvenile Justice Information System (JJIS) included alerts to include
any issues affecting classification. All five youth were classified for purposes of being assigned
to a living area and sleeping area. All five youth having factors identified during or after the
classification process were immediately entered into the program’s internal alert system and
JJIS. A reclassification is completed at the end of ten days for the purposes of re-assessing
security measures and at the time, an increase in the youth’s privileges to include participation
in work projects or other activities involving tools, and participation in off-campus activities is
reviewed. All five youth records included documentation the youth had an increase in privileges
or freedom of movement and although the possibility to participate in work projects and off-
campus activities were reviewed, none of the five youth were permitted to participate at the time
of their reassessments.
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NONSECURE
The program maintains a written policy and procedures which outline the classification process
and includes 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, which addresses items outlined in Florida Administrative Code. Five youth case
management records were reviewed for classification factors, procedures, and reassessments
for activities. The program’s classification forms included the youth’s physical characteristics,
age, and maturity level, identified special needs, history of violence, gang affiliation, criminal
behavior, sexual aggression or vulnerability to victimization, youth’s perception of vulnerability,
suicide risk, medical risk, escape risk, and security risk. All reviewed case management records
included documentation the youth received an initial classification on the date of admission
which included all required elements. Each classification included whether the youth had
identified or suspected risk factors of suicide risk, medical risk, escape risk, and security risk.
Documentation indicated the program reviews the Department’s Juvenile Justice Information
System (JJIS) for alerts during the classification process. All five youth case management
records included documentation the youth were reassessed for classification before an increase
in the youth’s privileges or freedom of movement, participation in work projects, activities
including tools or instruments which may be used as potential weapons or means of escape,
and participation in off-campus activities. The program’s written policy and procedures govern
reassessments and reclassification documenting 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. The program
continually updates the internal alert system which is easily accessible to program staff and
keeps them alerted about youth who are security or safety risks, to include escape risks, suicide
or other mental health issues, medical risks, sexual predatory risks, and other assaultive or
violent behavior risk.
An interview with the facility administrator confirmed youth are assessed using a Screening for
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) form upon their
admission to the program and again with any major incidents which cause suspicion a youth
may be vulnerable to victimization from others or sexual aggression. If a youth has several
indications, they would be placed in a room at the front of the hall for closer monitoring and
possibly shower separately.
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.
SECURE
The program has a written policy and procedures for screening youth entering the program to
determine if the youth is a criminal street gang member or is affiliated with any criminal street
gangs. Five youth case management records were reviewed, and none were applicable for
gang identification and notification to law enforcement. Three closed records were provided for
review. Each record included documentation local law enforcement was notified of suspected
gang activity. All three youth records included documentation the youth’s home county law
enforcement was notified of the youth’s gang affiliation prior to the Monitoring and Quality
Improvement seven-day notice. All three gang alerts were entered into the Department’s
Juvenile Justice Information System (JJIS) in a timely manner. All three youth case
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management records confirmed notifications were shared with the educational provider and the
juvenile probation officers.
NONSECURE
The program has a written policy and procedures for screening youth entering the program to
determine if the youth is a criminal street gang member or is affiliated with any criminal street
gangs. Five youth case management records were reviewed and three were applicable for gang
identification and notification of law enforcement. All three case management records included
documentation local law enforcement was notified of suspected gang activity prior to the
Monitoring of Quality Improvement seven-day notice. All three youth case management records
included documentation the youth’s home county law enforcement was notified of the youth’s
gang affiliation. All three gang alerts were promptly recorded into the Department’s Juvenile
Justice Information System (JJIS) in a timely manner. All three youth case management records
confirmed notifications were shared with the educational provider and the assigned juvenile
probation officers.
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.
SECURE
The program has a written policy and procedures for youth identified as a gang member or
associate to participate in prevention or intervention activities provided by the program. Five
youth case management records were reviewed, and none were applicable for gang prevention
and intervention activities. Three additional closed records were provided for review. All three
youth records included documentation youth were identified as a gang member or an affiliated
gang member. All three youth records included documentation the youth participated in gang
prevention and intervention strategies. All three youth records had performance plans which
included gang goals and interventions to complete prior to release from the program. The
program utilizes Impact of Crime (IOC) and monthly group sessions with the gang liaison
utilizing the ARISE – Gangs: 50+ Stories of Fractured Lives curriculum. Impact of Crime groups
are held two times a week for one hour each session. All sign-in sheets were reviewed for the
monthly gang groups. The program’s written policy and procedures addressed providing the
youth an opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang.
NONSECURE
The program has a written policy and procedures for youth identified as a gang member or
associate to participate in prevention or intervention activities provided by the program. Five
youth case management records were reviewed for gang identification, prevention, and
activities. Three youth were applicable for gang identification, prevention, and activities. All three
case management records included documentation all three youth were identified as a gang
member or an affiliated gang member. All three case management records included
documentation the youth participated in gang prevention and intervention strategies. All three
reviewed youth had performance plans which included gang goals and interventions to
complete prior to release from the program. The program utilizes Impact of Crime (IOC) and
monthly group sessions with the gang liaison utilizing the ARISE – Gangs: 50+ Stories of
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 26 of 84 (Revised September 2022)
Fractured Lives curriculum. The IOC groups are held two times a week for one hour each
session. All sign-in sheets were reviewed for IOC groups and gang awareness groups. The
program’s written policy and procedures addressed providing the youth an opportunity, if they
desire, to develop a plan to disaffiliate with a criminal street gang.
An interview with the facility administrator confirmed the program’s gang prevention and
intervention strategies. Youth are asked upon intake about any gang affiliation. If they identify
themselves or come with an open gang alert which they have been identified with, they are
placed into the program’s gang awareness group which meets one time a month. There is also
an intervention placed on the performance plan related to gang awareness. All youth are given
an opportunity to disaffiliate from their gang.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
SECURE
The program has a written policy and procedures to address the individualized needs of youth
admitted to the program through a comprehensive assessment process to include the
Residential Assessment for Youth (RAY) and the Youth Needs Assessment Summary (YNAS).
Five case management records were reviewed for the RAY assessments and reassessments.
Four out of five case management records documented the initial RAY assessments were
completed within the first thirty days of admission, while one record had documentation the RAY
was completed three days late. The initial RAY assessment was maintained in the Department’s
Juvenile Justice Information System (JJIS). Three out of five case management documented
the RAY Reassessments were completed every ninety-days after the initial assessment. Two
out of the five records had RAY Reassessments completed seven days late and one day late for
the first reassessment due; however, both records had documentation the second
reassessment was completed within the required time frame. All reassessment documentation
was maintained in the youth’s official case record. No reassessments were needed based upon
intervention and treatment team meetings.
NONSECURE
The program has a written policy and procedures to address the individualized needs of youth
admitted to the program through a comprehensive assessment process to include the
Residential Assessment for Youth (RAY) and the Youth Needs Assessment Summary (YNAS).
Five case management records were reviewed for the RAY and reassessments. Each youth
had an initial RAY completed within thirty days of admission, as required. The initial RAYs were
maintained in the Department’s Juvenile Justice Information System (JJIS). All five case
management records included documentation the RAY Reassessments were completed at least
every ninety-days after the completion of the initial assessment. All reassessment
documentation was maintained in the youth’s official case management record.
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Office of Accountability and Program Support Page 27 of 84 (Revised September 2022)
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.
SECURE
The program has a written policy and procedures to address the individualized needs of youth
admitted to the program through a comprehensive assessment process to include the
Residential Assessment for Youth (RAY) and the Youth Needs Assessment Summary (YNAS).
Five case management records were reviewed for YNAS completion. Four of the five case
management records included documentation each YNAS was completed within thirty days of
admission. One case record had documentation the YNAS was completed three days late. The
YNAS were documented in the Department’s Juvenile Justice Information System (JJIS).
NONSECURE
The program has a written policy and procedures to address the individualized needs of youth
admitted to the program through a comprehensive assessment process to include the
Residential Assessment for Youth (RAY) and the Youth Needs Assessment Summary (YNAS).
Five case management records were reviewed for YNAS completion. All five case management
records included documentation the YNAS were completed within thirty days of admission. The
YNAS were documented in the Department’s Juvenile Justice Information System (JJIS).
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
SECURE
The program has a written policy and procedures for performance plan development with the
treatment team and the youth based upon the initial assessment. Five case management
records were reviewed for performance plan development, goals, and transmittals. Four of five
youth records included documentation the initial Individualized Performance Plans were
developed within thirty days of the youths’ admission. One record had documentation the initial
Individualized Performance Plan was completed three days late. The initial performance plan
was developed after the initial Residential Assessment for Youth (RAY) was completed. The
intervention and treatment team members who were present during the development of the
Individualized Performance Plan included the intervention and treatment team leader, youth,
administrative representative, living unit representative, treatment staff, educational staff, and all
parties who have significant responsibility in goal completion. All five case management records
included documentation the signature pages were mailed to the parents/guardians with a
stamped return envelope. None of the signature pages were returned to the program; however,
the program conducted its due diligence. All five original signature sheets were attached to the
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original performance plans and were maintained in the official case management record. All
records included documentation the performance plans included the individualized goals based
upon the prioritized needs reflecting risk and protective factors identified during the initial RAY
assessment process. All five Individualized Performance Plans included the top three
criminogenic needs identified from the initial RAY assessment. All youth records had a goal of
skills where specific delinquency interventions were included, and three applicable records had
target court-ordered sanctions. Transition activities were included in the initial performance
plans. All youth records included youth responsibilities to accomplish goals, program staff
responsibilities, and target dates for goal completion. All youth records included documentation
the performance plans and transmittal letters were mailed within ten working days to the
committing courts, juvenile probation officers, and parents/guardians.
NONSECURE
The program has a written policy and procedures for performance plan development with the
treatment team and the youth based upon the initial assessment. Five case management
records were reviewed for performance plan development, goals, and transmittals. All records
included an Individualized Performance Plan developed within thirty days of the youth
admission and after the initial assessment. Each case management record included
documentation the initial Individualized Performance Plan was developed with the intervention
and treatment team leader, youth, administrative representative, living unit representative,
treatment staff, educational staff, and parties who have significant responsibility in goal
completion. All five case management records included documentation the signature sheet was
sent to the parent/guardian for signature. None of the signature pages were returned. All five of
the youths’ Individualized Performance Plans included individualized goals and prioritized needs
reflecting the risk and protective factors identified during the initial assessment process, the top
three criminogenic needs, specific delinquency interventions based upon the Residential
Assessment for Youth (RAY) results with measurable outcomes to decrease risk factors and
promote strengths, skills, and supports to reduce the likelihood of the youth reoffending, target
court-ordered sanctions, could reasonably be completed while in the program, transition
activities targeted for the last sixty days of the youth’s anticipated stay, youth’s responsibilities to
accomplish goals, program staff responsibilities to enable youth to complete goals, target dates
for goal completion, and youth recreation plans. All five case management records contained
documentation indicating a copy of the Individualized Performance Plan and letter was sent to
the committing court, juvenile probation officer, and parent/guardian within ten working days.
Six youth were interviewed and all six verified they participated in the development of their
performance plan. All youth articulated the goals included in their performance plan such as
using coping skills, participate in therapy sessions, working on school and employment, anger
management, and working on additional certifications. Four youth indicated they received a
copy of their completed performance plan. Two youth denied receiving a copy. An informal
interview was conducted with the facility administrator and the clinical director. Both verified the
program’s process is to provide a copy of the performance plan to the youth immediately after
they have reviewed and signed it.
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2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
SECURE
The program has a written policy and procedures to address performance plan revisions and
transmittals. Five youth case management records were reviewed for performance plan
revisions. All records included documentation performance plan revisions were completed when
the youth demonstrated progress toward completing a goal. No youth had newly acquired
information or demonstrated any lack of progress towards completing a goal at the time of the
annual compliance review. All five performance plans were revised when the Residential
Assessment for Youth (RAY) Reassessment results warranted.
NONSECURE
The program has a written policy and procedures to address performance plan revisions and
transmittals. Five youth case management records were reviewed for performance plan
revisions. All records included documentation performance plan revisions were completed when
the youth demonstrated progress toward completing a goal. No youth had newly
acquired/revealed information or demonstration of any lack of progress towards completing a
goal at the time of the annual compliance review. All five performance plans were revised in
accordance with the results of the Residential Assessment for Youth (RAY) Reassessment
results.
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.
SECURE
The program has a written policy and procedures for the development of performance
summaries and transmittals. Five youth case management records were reviewed for
performance summaries and transmittals. Four out of five records included documentation the
initial performance summaries were completed ninety days after the initial performance plans. In
one record, the first performance summary was completed seven days late. Three of the five
youth had updated performance summaries completed every ninety days after the initial
Performance Summary. Two of the youth did not have any further performance summaries due
at the time of the annual compliance review. All five youth performance summaries included the
status of each youth on the performance plan goals, overall treatment progress, academic
status to include credits, youth behavior, level of motivation/readiness to change, interaction
with peers, interaction with staff, overall behavior adjustment to the program, and significant
positive and negative events. None of the five youth had a performance summary with the
justification for release. All youth records included documentation the youth were allowed to
read and add comments prior to signing, the youth were provided a copy, and the original
summary was filed in each case management record. All youth records included documentation
the performance summary was signed by the treatment team leader, program director or
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designee, and youth. Documentation indicated a copy of the summary was sent within ten
working days to the committing courts, juvenile probation officers (JPO), and parents/guardians.
Three closed case management records were reviewed for release summary information. All
three closed youth records included the original performance summary with the justification for
release and the Pre-Release Notification (PRN) was sent to the assigned JPOs. The release
summary and PRN were sent at least forty-five days prior to the youth’s planned release. All
three closed case management records included documentation of signed performance
summaries and PRNs. All closed records included documentation the program provided written
notification to the youth parents/guardians regarding the planned release once the PRN was
approved. All closed records included documentation the exit Residential Assessment for Youth
(RAY) was completed upon the youths’ release from the program. None of the three youth
required victim notification of release letters. None of the three reviewed youth were applicable
for the Sexually Violent Predator Program (SVPP) screening.
NONSECURE
The program has a written policy and procedures for the development of performance
summaries and transmittals. Five youth case management records were reviewed for
performance summaries and transmittals. All five case management records included
documentation the initial performance summaries were completed ninety days after the initial
performance plans. All five youth had updated performance summaries completed every ninety
days after the initial performance summaries. All five performance summaries included the
youth status on each performance plan goal, overall treatment progress, academic status to
include credits, youth behavior, level of motivation/readiness to change, interaction with peers,
interaction with staff, overall behavior adjustment to the program, and significant positive and
negative events. One of the five youth had a performance summary with the justification for
release. All five youth case management records included documentation the youth were
allowed to read and add comments prior to signing. Each youth is given a performance plan
assignment sheet, which is attached to each performance summary and sent to the committing
court. All five youth case management records included documentation the performance
summary was sent within ten working days to the committing courts, juvenile probation officers
(JPOs), and parents/guardians. Five closed case management records were reviewed for
release summary information. All five closed case management records included the original
performance summary with the justification for release and the Pre-Release Notification (PRN)
being sent to the assigned JPOs. The release summary and PRN were sent at least forty-five
days prior to planned release. All five case management records included documentation of
signed performance summaries and PRNs. All five case management records included
documentation the program provided written notification to the youth’s parents/guardians
regarding the planned release once the PRN was approved. All five closed case management
records included documentation the exit Residential Assessment for Youth (RAY) was
completed upon the youths’ release from the program. None of the five youth required victim
notification of release letters. All five case management records included documentation these
letters were sent prior to the release of the youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 31 of 84 (Revised September 2022)
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.
SECURE
The program has a written policy and procedures to promote family involvement from the time
the youth is admitted until release from the program. The case management records included
documentation of parent/guardian involvement through invitations to the assessment process,
participation in the development of the youth’s performance plan, progress reviews, formal
treatment teams, and transition planning. If the parents/guardians were unable to attend in
person, they were invited to attend by telephone. The annual compliance review team observed
a treatment team meeting during the annual compliance review week, which confirmed
parent/guardian participation. All parents/guardians attended the treatment team meetings by
telephone. The program sends letters to the parents/guardians to notify them of when treatment
teams are scheduled and family days. The youth get monthly telephone calls with their
parents/guardians. The program also has visitation every week. On special occasions, families
are given the opportunity to participate in family therapy sessions virtually through a video
conferencing platform.
NONSECURE
The program has a written policy and procedures to promote family involvement from the time
the youth is admitted until release from the program. The five reviewed case management
records included documentation of parent/guardian involvement through invitations for the
assessment process, participation in the development of the youth performance plans, progress
reviews, formal treatment teams, and transition planning. If the parents/guardians were unable
to attend in person, they were invited to attend by telephone. The annual compliance review
team observed a treatment team meeting during the annual compliance review week, which
confirmed parent/guardian participation. The parents/guardians attended the treatment team
meetings by telephone. The program sends letters to the parents/guardians to notify them of
when treatment teams are scheduled and family days. The youth get monthly telephone calls
with their parents/guardians. The program also has visitation every week. In special occasions,
families are given the opportunity to participate in family therapy sessions virtually through a
video conferencing platform.
An interview with the facility administrator confirmed all youth parents/guardians were provided
copies of the youth performance plans and updated at least monthly in the formal treatment
teams. These updates include behaviors, grades, education status, medications, health issues,
mental health, timeline for release, and about any incidents which have taken place. The
parents/guardians were mailed out letters to inform them of the date and time of these
meetings. Six youth were interviewed, and all youth indicated their parents/guardians are
involved in their progress while at the program. Youth stated their parents/guardians participate
in treatment teams and family counseling sessions. The parents/guardians were notified through
the mail and telephone 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.
SECURE
The program has a written policy and procedures for the incorporation of other plans into the
performance plan. Five case management records of youth were reviewed for the incorporation
of other plans into the performance plans. All records included documentation the academic
plans and treatment plans were incorporated into the youth’s performance plans. None of the
five youth reviewed were applicable for requiring a behavior support plan through the
Department of Children and Families (DCF) or the Agency for Persons with Disabilities (APD).
NONSECURE
The program has a written policy and procedures to promote family involvement from the time
the youth is admitted until release from the program. Five youth case management records
were reviewed for the incorporation of other plans into the performance plans. All case
management records included documentation the education plans and treatment plans were
incorporated into the youth’s performance plans. None of the five reviewed youth were
applicable for requiring a behavior support plan through the Department of Children and
Families (DCF) or the Agency for Persons with Disabilities (APD).
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 have a treatment plan,
review their treatment plan progress.
SECURE
The program has a written policy and procedures for the multidisciplinary treatment team
meetings, formal and informal. Five case management records were reviewed for formal and
informal treatment team documentation. All records had documentation formal treatment teams
were conducted every thirty days. The treatment team forms included the youth’s name, date of
review, meeting attendees, comments from treatment team members, brief synopsis of the
youth’s progress, performance plan revisions, progress on performance plan goals, positive and
negative behaviors, treatment progress, and Residential Assessment for Youth (RAY)
Reassessments results. Two of the five youth had documentation of behaviors resulting in
physical interventions, while three did not. All formal treatment team documentation was
contained in the case management records. Five case management records were reviewed and
included documentation informal treatment teams were conducted, at least biweekly alternating
formal treatment team meetings. The informal treatment team forms included the youth’s name,
date of review, meeting attendees, comments from treatment team members, brief synopsis of
the youth’s progress in the program, performance plan revisions, progress on performance plan
goals, positive and negative behaviors, treatment progress, and RAY Reassessment results.
Two of the five youth included behaviors resulting in physical interventions and three did not
require physical intervention. All five case management records included documentation the
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youth were provided an opportunity to demonstrate skills acquired in the program. The youth’s
juvenile probation officer (JPO), parent/guardian, and any other pertinent party were all invited
and encouraged to attend treatment team meetings. All informal treatment team meeting
documentation was contained in the youth records.
NONSECURE
The program has a written policy and procedures for the multidisciplinary treatment team
meetings, formal and informal. Five case management records of youth were reviewed for
formal and informal treatment team documentation. All records had documentation formal
treatment teams were conducted every thirty days. The treatment team forms included the
youth’s name, date of review, meeting attendees, comments from treatment team members,
brief synopsis of the youth’s progress, performance plan revisions, progress on performance
plan goals, positive and negative behaviors, treatment progress, and Residential Assessment
for Youth (RAY) Reassessment results. None of the youth had behaviors which resulted in
physical interventions. All formal treatment team documentation was contained in the youth
case management record. Five case management records were reviewed and included
documentation the informal treatment teams were conducted, at least bi-weekly alternating
formal treatment team meetings. The informal treatment team forms included the youth’s name,
date of review, meeting attendees, comments from treatment team members, brief synopsis of
the youth’s progress in the program, performance plan revisions, progress on performance plan
goals, positive and negative behaviors, treatment progress, and RAY Reassessment results. All
five case management records included documentation the youth were provided an opportunity
to demonstrate skills acquired in the program. The juvenile probation officers (JPOs),
parents/guardians, and any other pertinent party were all invited and encouraged to attend
treatment team meetings. All informal treatment team meeting documentation was contained in
all youth case management records.
A treatment team meeting was observed during the annual compliance review week. The
observed treatment team confirmed all required staff were present, education staff was not
present, but information was provided to the treatment team prior to meeting. Youth progress on
performance plan goals, positive and negative behaviors, behaviors resulting in physical
interventions, and treatment progress were discussed during the observed treatment teams. All
members actively participated in the treatment team meetings. The youth were provided an
opportunity to demonstrate skills acquired in the program. The anticipated release dates were
also discussed. Six youth were interviewed, and all reported they are given the opportunity
during treatment teams to demonstrate skills they learned in the program. Youth stated staff are
always asking what the youth have learned and the youth are given an opportunity to explain
and express the skills they have learned for the month. All youth indicated staff review their
performance plans during treatment team, in addition to any positive and negative behaviors,
goals, and treatment progress.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 34 of 84 (Revised September 2022)
2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. The
transition conference stated the 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.
SECURE
The program has a written policy and procedures to address transition planning, transition
conference, and the Community Re-Entry Team (CRT). Three closed case management
records were reviewed for documentation regarding transition planning, transition conference,
and the CRT meeting. All three case management records included documentation the
transition conferences were held at least sixty days prior to the youth’s targeted release date.
The treatment team members at the transition conference included the youth, treatment team
leader, facility administrator or designee, and other team members. All youth records included
documentation the following were invited to attend assigned juvenile probation officer (JPO),
parents/guardians, education staff, and any other pertinent parties. All youth records included
documentation the team reviewed transition activities on the performance plans, revised
performance plans, when necessary, identify target completion dates, and identify persons
responsible for completion during the transition conference. All youth records included the
treatment team leader obtained attendees’ dated signatures, representing their
acknowledgement of the transition goals and accountability for completion. In all three youth
records documentation the copy of the transition plans was sent with a request for return with
signature to anyone not in attendance was not needed as all parties attended in person or by
telephone. All three transition plans were submitted electronically to the assigned JPOs. All
three youth records included documentation a CRT meeting was held prior to youth release. All
three youth and their assigned case managers attend the CRT meetings. All case management
records included documentation an invitation was sent for participation.
NONSECURE
The program has a written policy and procedures to address transition planning, transition
conference, and the Community Re-Entry Team (CRT). Three closed case management
records were reviewed for documentation with transition planning, transition conference, and the
CRT meeting. All three case management records included documentation transition
conferences were held at least sixty days prior to the youth’s targeted release date. The
treatment team members who attended the transition conference include the youth, treatment
team leader, facility administrator or designee, and other team members. All youth records
included documentation the juvenile probation officer (JPO), parents/guardians, education staff,
and any other pertinent parties were invited to attend the transition conference. All youth
records included documentation the team reviewed transition activities on the performance
plans, revised performance plans, when necessary, identify target completion dates, and
identify persons responsible for completion during the transition conference. All youth records
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included documentation the treatment team leader obtained attendees’ dated signatures,
representing their acknowledgement of the transition goals and accountability for completion. In
all three youth records, documentation the copy of the transition plans was sent with a request
for return with signature to anyone not in attendance was not needed, as all parties attended in
person or by telephone. All three transition plans were submitted electronically to the assigned
JPOs. All three youth records included documentation a CRT meeting was held prior to youth
release. All the youth and their assigned case managers attend the CRT meetings. All case
management records included documentation an invitation was sent for participation.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an exit portfolio for each youth to assist once released back into
the community.
SECURE
The program has a written policy and procedures for the exit portfolio requirements. Three
closed case management records were reviewed for exit portfolio documents. All youth records
included documentation the exit portfolios were discussed and initiated during the transition
conference. Two of the three youth records included a Department of Highway Safety and Motor
Vehicles state-issued identification card (ID). In one of the youth records, the assigned case
manager requested the documents for the ID and a birth certificate, but documents were never
sent to the program and in another record, the birth certificate was received but the youth was
younger than fourteen years of age; therefore, they were not required to have a Social Security
card. In the remaining record there was a copy the youth’s ID, birth certificate, and Social
Security card. All three records included the transition plan, calendar of dates, times, and
locations of upcoming community appointments, educational records/documents, school
transcripts, résumés, and sample employment applications. All three youth records included
documentation the exit portfolios were verified during the exit conferences. All youth records
included documentation the exit portfolios were completed and provided to the youth upon
release. All youth records included documentation the case manager forwarded the exit portfolio
to the assigned juvenile probation officer (JPO). A review of the program’s contract confirmed it
did not include additional requirements for the exit portfolio.
NONSECURE
The program has a written policy and procedures for the exit portfolio requirements. Three
closed case management records were reviewed for exit portfolio documents. All youth records
included documentation the exit portfolios were discussed and initiated during the transition
conference. Two of the three youth records included a Department of Highway Safety and Motor
Vehicles state-issued identification card (ID). Attempts were made to obtain the third ID, but it
was not received. All three records included the transition plan, calendar of dates, times, and
locations of upcoming community appointments, educational records/documents, school
transcripts, résumés, and sample employment applications. None of the youth records
contained a copy of the birth certificate or social security card. All three youth records included
documentation the exit portfolios were verified during the exit conferences. All youth records
included documentation the exit portfolios were completed and provided to the youth upon
release. All youth records included documentation the case manager forwarded the exit portfolio
to the assigned juvenile probation officer (JPO). A review of the program’s contract confirmed it
did not include additional requirements for the exit portfolio.
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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.
SECURE
The program has a written policy and procedures to ensure an exit conference is held for each
youth prior to release from the program to review the status of the transition goals, planning
established at the transition conference, and to finalize release planning and preparation for the
youth to reintegrate into the community. Three closed case management records were reviewed
for exit conference documentation. All youth records included documentation the conference
was conducted after the program notified the assigned juvenile probation officer (JPO) of the
youth’s release. All youth records included documentation the exit conference was conducted at
least fourteen days prior to release. All youth records included documentation which indicated
the date of the conference, signatures, and a summary of any pending transition goals. The
Department’s Juvenile Justice Information System (JJIS) included documentation each youths’
admission date and termination date matched what was in the youth’s case management
record. All three case management records included documentation the status of transition
activities were established at the transition conference and plans finalized for the youth’s
release were reviewed. All youth records included documentation the exit conference was
attended by the intervention and treatment team leader, parents/guardians, education
representative, JPOs, youth, and other pertinent parties. There was documentation all exit
conferences were held separately from the transition conferences and the Community Re-entry
Team meetings.
NONSECURE
The program has a written policy and procedures to ensure an exit conference for each youth is
held prior to release from the program to review the status of the transition goals, planning
established at the transition conference, and to finalize release planning and preparation for the
youth to reintegrate into the community. Three closed case management records were reviewed
for exit conference documentation. All youth records included documentation the conference
was conducted after the program notified the assigned juvenile probation officer (JPO) of
release. All youth records included documentation the exit conference was conducted at least
fourteen days prior to release. All youth records included documentation which indicated the
date of the conference, signatures, and a summary of any pending transition goals. The
Department’s Juvenile Justice Information System (JJIS) included documentation each youth’s
admission date and termination date matched what was in the youth case management record.
All three case management records included documentation the status of transition activities
was established at the transition conference and plans finalized for the youth’s release were
reviewed. All youth records included documentation the exit conference was attended by the
intervention and treatment team leader, parents/guardians, education representative, JPOs,
youth, and other pertinent parties. There was documentation all exit conferences were held
separately from the transition conferences and the Community Re-entry Team meetings.
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2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
SECURE
The program has a formal process to promote constructive input by youth admitted to the
program. The program has implemented town hall meetings, a student council, and distributes
evaluation surveys to the youth upon their exit from the program. The program’s town hall meets
on a weekly basis for one hour and the student council meets twice monthly. While in these
meetings, youth discuss various topics of concern and any issues the youth notice at the
program to brainstorm possible resolutions. Reviewed documentation included sign-in sheets,
meeting minutes, and physical copies of the youth surveys located in the youth’s closed
records.
NONSECURE
The program has a formal process to promote constructive input by youth admitted to the
program. The program has implemented town hall meetings, a student council, and distributes
evaluation surveys to the youth upon their exit from the program. The program’s town hall meets
on a weekly basis for one hour and the student council meets twice monthly. While in these
meetings, youth discuss various topics of concern and any issues the youth notice at the
program to brainstorm possible resolutions. Reviewed documentation included sign-in sheets,
meeting minutes, and physical copies of the youth surveys, which are located in each youth’s
closed case management records.
Six youth were interviewed and each youth indicated they are always able to speak with staff or
the facility administrator and assistant facility administrator. Youth also indicated grievance
forms are always available to them.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
SECURE
The career educational programming is Type 3. The program provides career and professional
educational certifications. The certifications the youth can earn are Computing Technology
Industry Association (Comp TIA), Forklift, Florida Ready to Work Soft Skills, cardiopulmonary
resuscitation (CPR), first-aid, and Occupational and Safety and Health Administration (OSHA-
10). Programming includes communication, interpersonal skills, and decision-making skills.
Youth can also earn safe staff certifications. Three youth records were reviewed and had
samples of completed employment applications, and a résumé summarizing education, work
experience, and/or career training. Two of the three youth had a Department of Highway Safety
and Motor Vehicles state-issued identification card and other appropriate documents essential
to obtaining employment. Three youth had transition service providers information provided.
Documentation indicated the youth, parent/guardian, and juvenile probation officers (JPOs)
were aware of the youth educational plans. None of the records had documentation indicating
the location and business hours of a local Career Source Center.
NONSECURE
The career educational programming is Type 2. The program has personal accountability skills
and behavior appropriate work habits for employment incorporated into the programming. The
program also offers cardiopulmonary resuscitation (CPR), first-aid, and Occupational and Safety
Florida Department of Juvenile Justice Residential Annual Compliance Report
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Administration (OSHA-10) certifications. Three youth case management records were reviewed
which included samples of completed employment applications, a résumé summarizing
education, work experience, and/or career training. Two of the three youth had a Department of
Highway Safety and Motor Vehicles state-issued identification card and other appropriate
documents essential to obtaining employment. Two of the three youth had Career Source
Center information. Documentation indicated the youth’s parent/guardian and juvenile probation
officer (JPO) were aware of the youth educational plans.
The interview with the lead educator indicated the educational transition plan was shared during
a treatment team meeting.
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.
SECURE
The program has a written policy and procedures to provide for educational access for the
youth. Educational services are provided by the Rader Group which is contracted by the
Okaloosa County School District who approves the 250-day school calendar. A review of the
daily education schedule indicated youth are provided with a minimum of twenty-five hours of
instruction each week, incorporating six, fifty-minute class periods, as indicated on the daily
school schedule provided by the lead educator. The youth are receiving 240-days of instruction,
the calendar allows for the teachers to utilize ten days for training and teacher planning
throughout the school year. Three days were reviewed in the logbooks and on video, and each
showed no issues pertaining to the daily school schedule. The reviewed logbooks showed on
the three days the youth arrived and left during the expected times. Video footage confirmed the
youth began and ended classes according to the schedule.
NONSECURE
The program has a written policy and procedures to provide for educational access for the
youth. Educational services are provided by the Rader Group which is contracted by the
Okaloosa County School District who approves the 250-day school calendar. A review of the
daily education schedule revealed youth are provided with a minimum of twenty-five hours of
instruction each week, incorporating six, fifty-minute class periods, as indicated on the daily
school schedule provided by the lead educator. The youth are receiving 240-days of instruction,
the calendar allows for the teachers to utilize ten days for training and teacher planning
throughout the school year. Three days were reviewed in the logbooks and on video, and each
showed no issues pertaining to the daily school schedule. The reviewed logbooks showed on
the three days the youth arrived and left during the expected times. Reviewed video showed the
youth began class and ended as expected.
According to the lead educator, the daily schedule is consistently followed without significant
interruptions, and school is never cancelled. The facility administrator and the youth interviews
indicated there are minimal interruptions during the school day. All six of the interviewed youth
confirmed adherence to the daily schedule and attendance at school each day. The youth
expressed confidence in their preparation for obtaining a high school equivalency diploma
(GED), returning to their home school, or pursuing a vocational or secondary education. In the
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interview, the lead educator confirmed the youth consistently arrived at and departed from
school punctually.
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.
SECURE
The program maintains a written policy and procedures requiring an educational transition plan
to be developed upon each youth’s admission. The review of five closed case management
records confirmed the education transition plans were established for the youth upon entry.
These plans outlined the youth’s post-release educational goals. Additionally, all closed case
management records contained an exit plan, indicating the case manager, parent/guardian, and
youth were all aware of the plan.
NONSECURE
The program maintains a written policy and procedures requiring mandating the development of
an educational transition plan for each youth upon admission. Three closed youth case
management records were reviewed. The youth records included an individual education
transition plan developed upon entry which included the youth’s post-release goals. Three
closed case management records contained an exit plan indicating the case manager,
parent/guardian, and youth were all aware of the plan.
Six youth were interviewed. The youth reported they were involved in the development of their
transition plan. All youth also reported they felt the program was preparing them very well or
well when it came to preparing them for the high school equivalency diploma (GED), high
school, vocational school, employment, and/or college.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program maintains a written policy and procedures ensuring the employment of a State of
Florida licensed clinician to serve as the clinical director and the designated mental health
clinician authority (DMHCA). The program has a licensed mental health counselor (LMHC), who
serves as the DMHCA. The DMHCA has a clear and active license under Chapter 491, Florida
Statutes, which expires on March 31, 2025. The DMHCA is a full-time position and is on-site
forty hours weekly to ensure coordination and implementation of mental health and substance
abuse treatment services. A copy of the DMHCA’s licensure and the position description were
reviewed. The program provides substance abuse services for the secure youth and
developmental disability (DD) and borderline developmental disability (BDD) services for the
non-secure youth, whereas the DMHCA is responsible for the coordination and implementation
of the specialized services, along with mental health and substance abuse services.
Additionally, the program has a licensed clinical social worker (LCSW) designated as the
backup DMHCA, also holding an active license under Chapter 491, Florida Statutes, expiring
March 31, 2025. The DMHCA described their role in daily coordination and implementation of
mental health and substance abuse services. The DHMCA oversees the completion of the daily
group therapy sign-ins and individual therapy progress notes to ensure the youth are receiving
the services as outlined in their Individualized Treatment Plans. Schedules are created for the
mental health therapists regarding these services. The DMHCA provides individual and family
therapy services to youth identified to have acute needs and provides group therapy sessions
as needed, usually as a fill-in if another therapist is unavailable. Formal communication occurs
through weekly supervision meetings with all clinical staff. Informally, communication addresses
daily tasks, due dates, document review, and fidelity group monitoring.
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 one full-time licensed clinical staff other than the designated mental health
clinician authority (DMHCA), designated as a licensed clinical social worker (LCSW), who
serves as the back-up for the DMHCA. The LCSW has a clear and active license under Chapter
491, Florida Statutes, which expires on March 31, 2025. Additionally, another licensed mental
health counselor (LMHC) previously employed with the program returned part-time during the
annual compliance review period. The LMHC’s license is clear and active under Chapter 491,
Florida Statutes, and expires on March 31, 2025. The DMHCA ensures all licensed clinical staff
working under their supervision perform services they are qualified to provide based upon
education, training, and experience. The clinical staffing for licensed mental health and
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substance abuse professionals comply with the current contract and Florida Administrative
Code. Licensures of clinical staff, along with the program’s Chapter 397, Florida Statutes
licensure, were posted within public view. The program’s Chapter 397, Florida Statutes,
licensure is site-specific, expiring on April 1, 2024.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) ensures all non-licensed clinical staff
under their supervision perform services for which they are qualified, based on their education,
training, and experience. Documentation demonstrated the program had four non-licensed staff,
including one recreational therapist, at the time of the annual compliance review and two
previous non-licensed staff. The recreational therapist’s credentials were reviewed, and all
requirements were met. All non-licensed staff had a master’s-level degree which were provided
for review. Additionally, the program had two interns during the annual compliance review
period. One intern, who had a bachelor’s degree and was working on their master’s, transitioned
into the therapist position for less than two months. The other intern was at the program for
approximately a month, working on their bachelor’s degree and was referred to the program in a
partnership with the school. The program’s non-clinical staffing hours for mental health and
substance abuse services were in accordance with the program’s contract and the Florida
Administrative Code. A review of face-to-face direct supervision documentation during the
annual compliance review period revealed there were no supervision issues. The reviewed
therapists received a minimum of one hour a week of on-site face-to-face supervision by the
DMHCA. Documentation of the direct supervision was recorded on a form, which included all
information on the Department’s Licensed Mental Health Professionals and Licensed/Certified
Substance Abuse Professionals Direct Supervision Log. Each of the non-licensed substance
abuse clinical staff provided substance abuse services as part of the service provider’s staff,
licensed under Chapter 397, Florida Statutes. The program’s licensure expires on April 1, 2024.
All six reviewed non-licensed therapists completed the twenty hours of training and supervision
in assessing suicide risk, mental health crisis intervention, and emergency mental health
services. The intern who transitioned into a therapist did not work at the program long enough to
complete the twenty training hours and did not conduct any Assessments of Suicide Risk
(ASRs).
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.
SECURE
The program has a written policy and procedures which address the implementation of a
standardized admission and intake for the mental health and substance abuse screening
process. The written policy included a standardized screening process, staff training in mental
health and substance abuse issues, and a standardized process for referring youth identified as
in need of further mental health and/or substance abuse evaluation to an appropriate service
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provider or professional or, when immediate attention is needed, to a hospital, Baker Act or
Marchman Act receiving program. Five youth records were reviewed for mental health and
substance abuse treatment admission screenings. All five youth records included a
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) completed upon
admission to the program. The screener reviewed available information to include the
commitment packet, reports, and/or records for existing documentation of mental health or
substance abuse problems or history of human trafficking. The MAYSI-2 was completed for
each of the five youth by a trained staff. The screenings were administered on the day of
admission in the Department’s Juvenile Justice Information System (JJIS) in a confidential
manner. All five of the MAYSI-2s were completed in full. All five screenings indicated further
assessment was required, and a referral was made for further evaluation or immediate attention
for each youth. The admission process revealed all youth are referred for an Assessment of
Suicide Risk (ASR). When the MAYSI-2 or other admission information indicated the need for
an assessment, crisis intervention, or emergency services, the facility administrator (FA) or
designee was notified, and in all five reviewed records a referral was made to alert the
designated mental health clinician authority (DMHCA). The FA ensures an ASR was conducted
within twenty-four hours when the MAYSI-2 category “suicide ideation” indicated further
assessment was needed or other information obtained at intake suggested potential suicide
risk. All five records showed the youth were referred for an ASR, as part of the intake process,
and the referral documented the reason for the referral. The program is responsible for
developing a written policy and procedures for the implementation of a standardized
admission/intake mental health and substance abuse screening process. The program’s policy
outlines a standardized screening process which includes review of commitment packet
information, reports, and records, administration of the MAYSI-2 in JJIS or Clinical Mental
Health Screening by a licensed mental health professional and Clinical Substance Abuse
Screening by a qualified professional, a referral of juvenile offenders identified by screenings as
in need of further evaluation or immediate attention, and staff training in mental health and
substance abuse issues and administration of the MAYSI-2. The policy also includes a
standardized process for referral of youth identified as in need of further mental health and/or
substance abuse evaluation to an appropriate service provider/professional or, when immediate
attention is needed, to a hospital, Baker Act, or Marchman Act receiving facility.
NONSECURE
The program has a written policy and procedures, which address the implementation of a
standardized admission and intake for the mental health and substance abuse screening
process. The written policy included a standardized screening process, staff training in mental
health and substance abuse issues, and a standardized process for referring youth identified as
in need of further mental health and/or substance abuse evaluation to an appropriate service
provider or professional or, when immediate attention is needed, to a hospital, Baker Act, or
Marchman Act receiving program. Five youth records were reviewed for mental health and
substance abuse admission screenings. Each youth record contained a completed
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2). The available
information reviewed for each youth upon entry to the program is the commitment packet which
includes reports, legal documentation, and previous assessments and services. The MAYSI-2
was administered on the youth’s date of admission in a confidential manner in all five reviewed
records. One record was dated the day before the youth admission in error and case notes
confirmed the MAYSI-2 was completed on the date of admission. Each of the reviewed
screenings were completed by a trained staff. The MAYSI-2 screenings were completed within
the Department’s Juvenile Justice Information System (JJIS). All five youth were referred for
further evaluation; though the MAYSI-2 did not indicate a referral was necessary in two of the
five records reviewed. An override was made after the initial MAYSI-2 was completed based on
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needed services indicated by collateral information. Staff entered the information, observations,
events, and/or concerns leading to the determination for further assessment in JJIS. All five
youth were applicable for completion of an Assessment of Suicide Risk (ASR) based upon the
program’s written policy and procedures. It is the policy of the program to administer mental
health and substance abuse screenings, including suicide risk screenings, upon a youth’s
admission to the program. None of the reviewed youth required emergency services. All five
reviewed youth records were applicable for a referral to complete a Comprehensive Mental
Health and Substance Abuse Assessment based on the program’s written policy and
procedures. The reason for referral was documented in each of the reviewed records. In an
interview with the designated mental health clinician authority (DMHCA), the process to ensure
services are provided for each youth was explained, each youth meets with medical and case
management upon intake. It is part of the normal process for youth to meet with a licensed
mental health counselor (LMHC) to complete intake assessments the same day of intake, prior
to youth’s classification meeting and going to the living unit.
An interview with the facility administrator (FA) confirmed the program’s policy regarding the
screening process to identify youth at risk for mental health and substance abuse problems and
suicide. The FA indicated all youth complete a MAYSI-2 questionnaire, an ASR, a depression
inventory, and receive an individualized assessment by a licensed therapist upon their
admission to the program.
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.
SECURE
The program has a written policy and procedures to provide an evaluation and assessment
process to determine the mental health and substance abuse treatment needs of the youth and
to guide the development of the youth’s Individualized Treatment Plan. Five secure youth
records were reviewed for mental health and substance abuse assessments/evaluations. The
program completed a new combined mental health and substance abuse evaluation within thirty
calendar days of admission for all five applicable youth. All five assessments were completed by
a licensed mental health professional. All five 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 of Mental Disorders, Fifth Edition (DSM-5) diagnosis, and recommendations. All five
evaluations also included the reason for evaluation. None of the five reviewed youth required an
updated evaluation.
NONSECURE
The program has a written policy and procedures to provide an evaluation and assessment
process to determine the mental health and substance abuse treatment needs of the youth and
to guide the development of the youth’s Individualized Treatment Plan. Five non-secure youth
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records were reviewed for mental health and substance abuse assessments and evaluations.
Each of the reviewed records were applicable for completion of a new Comprehensive Mental
Health Evaluation. The evaluations were completed within thirty calendar days of admission to
the program. Four of the evaluations were reviewed and signed by the licensed mental health
professional within ten calendar days after the evaluation was completed, one evaluation was
completed by the licensed mental health professional. Each of the five newly completed mental
health evaluations contained identifying information of the youth, reason for evaluation, relevant
background information, behavioral observations, Mental Status Examination, interview or
procedures administered, discussion of findings, diagnostic impression, and recommendations.
All five youth records were reviewed for completion of a new Comprehensive Substance Abuse
Evaluation, and all were completed within thirty calendar days of the youth’s admission to the
program. The substance abuse evaluation contained a reason for the assessment, relevant
background information, behavioral observation, methods of assessment, patterns of alcohol
and other drug abuse, impact of alcohol and other drug abuse, risk factors of continued alcohol
and other drug abuse, clinical impression, and recommendations. Each of the five reviewed
Comprehensive Mental Health Evaluation and/or Comprehensive Substance Abuse Evaluations
addressed the youth’s original referral reason.
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.
SECURE
Five secure youth records were reviewed for mental health and substance abuse treatment. All
five initial mental health treatment plans were developed within seven days of admission. All five
initial mental health treatment plans were completed on the required forms. The initial mental
health treatment plan or initial substance abuse treatment plan was developed within seven
days of the onset of treatment, or for youth prescribed psychotropic medication, within seven
days of the Initial Psychiatric Diagnostic Interview. The initial treatment plan was signed by the
mental health clinical staff or substance abuse clinical staff completing the form. All five initial
treatment plans were completed by a licensed mental health clinical staff. The plans were also
signed by all treatment team members who participated in the development of the plan and the
youth. Plans were mailed to the parents/guardians for signature and a request to return to the
program. Initial treatment plans included the youth’s psychiatric needs (when applicable),
including medication and frequency of monitoring by the psychiatrist. One of five reviewed youth
records had the wrong Department Identification number (DJJID) on the initial treatment plan.
Five secure youth records were reviewed for Individualized Treatment Plans. All five plans were
developed within thirty days of admission on the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan form. All five records showed the Individualized
Treatment Plan was signed by the mental health or substance abuse clinical staff completing
the plan. All five Individualized Treatment Plans were signed by all treatment team members
who participated in development of the plan, the youth, and parent/guardian (as allowed). Five
youth records were applicable for psychiatric services. Each of the five Individualized Treatment
Plans included psychiatric services, including psychotropic medication (when applicable), and
frequency of monitoring by the psychiatrist for all youth who received psychotropic medication.
All Individualized Treatment Plan reviews were completed on the Department’s Individualized
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Mental Health/Substance Abuse Treatment Plan Review form. Thirty-one treatment plan
reviews were reviewed for the five records. All reviews were completed at least once every thirty
days as required. Four of five youth plans included prescribed services which included
individual, group, and family therapy. Four of five plans included psychiatric service
requirements. Goals and objectives were individualized for each youth. Video observations were
conducted for three different groups. All the groups began and ended within the required time
frames. The appropriate number of youth were in each of the groups. A trained facilitator
facilitated all three of the groups. A comparison of video to the logbooks and sign-in sheets
verifying the facilitator of groups was conducted and found all groups were held for the required
group time/length.
NONSECURE
Five youth records were reviewed for mental health and substance abuse treatment. Each of
the reviewed records contained an initial treatment plan, which was developed on the date of
the youth’s admission to the program. Two of the five youth records included a revised initial
treatment plan due to the youth receiving psychotropic medications, which was completed
immediately after the youth were prescribed medications. The reviewed initial mental health and
substance abuse treatment plans were site-specific and included all the elements contained
within the Department’s Initial Mental Health/Substance Abuse Treatment Plan form. The
reviewed initial treatment plans and revised initial treatment plans were developed within seven
days of the onset of treatment. Each of the initial treatment plans were signed by the mental
health clinical staff or substance abuse clinical staff completing the form. Two of the five initial
treatment plans were completed by non-licensed clinical staff and all plans were reviewed and
signed by the designated mental health clinician authority (DMHCA) within ten days of
completion. Three plans were completed by a licensed staff. Each of the initial treatment plans
were signed by all treatment team members who participated in the development of the plan.
One of the five reviewed youth records was applicable for inclusion of psychiatric needs and
included the signature of the psychiatrist, medication, and frequency monitoring by the
psychiatrist. Five youth records were reviewed for an Individualized Treatment Plan. Each of the
Individualized Treatment Plans were developed within thirty days of the youth’s admission. The
Individualized Treatment Plans were developed on a site-specific form, which contained all the
elements of the Department’s Individualized Mental Health/Substance Abuse Treatment Plan
form. The individualized treatment plans were each signed by the mental health or substance
abuse clinical staff completing the plan. Four of the five Individualized Treatment Plans were
completed by a non-licensed clinical staff and signed by the DMHCA within ten days of
completion. One plan was completed by licensed staff. In addition, each of the Individualized
Treatment Plans were signed by all treatment team members who participated in the
development of the plan. Two of the five reviewed youth records were applicable for inclusion of
psychiatric needs and each of the two youth’s individualized treatment plans included
medication and frequency of monitoring by the psychiatrist. The Individualized Treatment Plan
reviews were completed and documented on a site-specific form which contained all the
elements in the Department’s Individualized Mental Health/Substance Abuse Treatment Plan
Review form. A total of forty-two Individualized Treatment Plan reviews were completed for the
five reviewed youth. Reviews were completed every thirty-days, as required, with no issues. The
youth’s Individualized Treatment Plans documented the prescribed services, such as individual
counseling three to four times a month, group counseling four to five times a week, and family
therapy once a month. Two youth were applicable for prescribed medications, and each youth’s
plan documented monthly psychiatric services. The review of the youth’s treatment plans
yielded the services prescribed were individualized for each youth. A sample of three groups
was reviewed by video to verify groups were conducted as prescribed. A review of video,
logbooks, and sign-in sheets demonstrated groups were being conducted as required.
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In an interview with the DMHCA, it was asked what the process is for reviewing and updating
plans. The DMHCA reported plans are reviewed with the treatment team as needed.
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.
SECURE
The program has a written policy and procedures for youth treatment and discharge planning.
Five secure youth records were reviewed for treatment and discharge planning. Each of the five
youth records showed each youth was assigned a treatment team upon arrival to the program.
A review of treatment team documentation showed the youth, facility administrator, residential
living unit representative, medical staff, mental health and substance abuse staff, and
parent/guardians were in attendance of treatment team reviews. Education and vocational staff
provided written input for the treatment team regarding the youth’s progress. Youth who
received mental health treatment had a properly executed Authority for Evaluation and
Treatment (AET) form. Youth receiving substance abuse treatment provided consent through a
signed Youth Consent for Substance Abuse Treatment form. All the youth signed a Youth
Consent for Release of Substance Abuse Treatment Records form. In all five youth records,
mental health treatment notes or substance abuse treatment notes were documented on a form
which contained all the required information. Mental health and substance abuse group therapy
included individual psychotherapy or one-to-one counseling between a youth with a diagnosed
mental health disorder and a mental health clinical staff in all five records reviewed. The mental
health and substance abuse groups included psychosocial skills training. All five reviewed youth
records included documentation of the youth attending psychosocial skills training groups. A
review of progress notes determined youth received services as stipulated on the treatment plan
in all five records reviewed. Three closed youth records were reviewed for discharge planning.
The three discharge plans were documented on the Department’s Mental Health/Substance
Abuse Treatment Discharge Plan form. No notification for suicide risk was necessary for the
three records reviewed. Each of the Mental Health and Substance Abuse Treatment Discharge
Summaries documented services needed for daily maintenance of positive improvement in
behavioral, emotional, and social skills made by youth during treatment. The discharge plans
reflected all were discussed with the youth, parent/guardian, and juvenile probation officer (JPO)
during the exit conference. A copy of the Mental Health and Substance Abuse Treatment
Discharge Summary form was provided to each youth, JPO, and parents/guardians.
NONSECURE
The program has a written policy and procedures for youth treatment and discharge planning.
Five youth records were reviewed for mental health and substance abuse treatment. Each of
the five youth were assigned to a treatment team upon arrival to the program. Each youth’s
individual planning process begins at the time of admission and is included within the initial
screening, assessment, and treatment plan development processes. Initial discharge planning
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and a tentative projected release date are established for each newly admitted youth. The
treatment team regularly reviews the youth’s Individualized Mental Health and Substance Abuse
Treatment Plan through monthly treatment plan review processes. Each reviewed youth record
contained treatment team documentation which reflected the composition of the treatment
teams, which included representatives from administration, education, vocational training,
medical staff, mental health staff, youth, and when possible, the youth’s parent/guardian. All five
youth records were applicable for substance abuse treatment services. Substance abuse
services consisted of individual, group, and family counseling, which was provided by non-
licensed substance abuse staff, who are employed by the program which is licensed under
Chapter 397, Florida Statutes. All five youth were in receipt of mental health treatment services,
and each had a properly executed Authority for Evaluation and Treatment (AET) on record.
Each of the five reviewed youth had a documented diagnosis from the comprehensive
evaluation. All five youth records had a documented substance abuse diagnosis which required
a Youth Consent for Substance Abuse Treatment form and a Youth Consent for Release of
Substance Abuse Treatment form. Mental health treatment and/or substance abuse treatment
notes were documented on the program’s form, which contained all the required information on
the Department’s Counseling/Therapy Progress Notes form. An informal interview with the
designated mental health clinician authority (DMHCA), review of group sign-in sheets, and video
review confirmed mental health treatment groups were limited to ten or fewer youth and
substance abuse treatment groups were limited to fifteen or fewer youth. Additionally, each of
the reviewed records contained documentation confirming the youth were involved in individual
psychotherapy or counseling. It had been noted within each youth’s treatment plan, youth were
engaged in psychosocial skills training designed to address specific skill deficits or maladaptive
behaviors, which promote skill development. In addition, treatment plans addressed frequency
of prescribed services for each youth to include individual, group, and family therapy sessions.
A review of progress notes identified those services as stipulated on the treatment plan were
delivered to each youth. Three of the five reviewed youth records included the youth’s discharge
summary. The three discharge summaries were documented on the Department’s Mental
Health/Substance Abuse Treatment Discharge Summary form. No notification for suicide risk
was necessary for all three records reviewed. Each of the mental health and substance abuse
treatment discharge summaries documented those services needed for daily maintenance of
positive improvement in behavioral, emotional, and social skills made by youth during treatment.
Two of the three discharge plans reflected all were discussed with the youth, parent/guardian,
and JPO during the exit conference. One youth had not reached the time frame in transition to
complete the exit conference. A copy of the Mental Health and Substance Abuse Treatment
Summary form was provided to each youth, JPO, and parents/guardians for the two records
completed at the exit conference.
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.”
SECURE
The program has a written policy and procedures for specialized treatment services provided at
the program. The program provides individualized, trauma-informed, developmentally
appropriate mental health, substance abuse, and developmental disability treatment services to
youth identified in need of such services. The program is contracted to provide specialized
treatment for thirty substance abuse treatment overlay services (SAOS) beds. The scope of
SAOS delivery is outlined within the contract between the provider and the Department. The
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program is licensed under Chapter 397 and has a qualified professional on-site at least five
days a week. Substance abuse clinical staff are on-site seven days a week. Counselor
caseloads for SAOS do not exceed sixteen youth. The program has a licensed psychiatrist who
provides psychiatric evaluations and medication management to youth in the program. All
treatment services are guided by an Individualized Treatment Plan which addresses the youth’s
needs in accordance with Florida Administrative Code. The program’s contract requires clinical
groups including Seven Challenges, Skillstreaming the Adolescent, Life Skills Training, and the
Teen Relationships workbook. Video and sign-in sheets verified all groups were conducted as
required. An interview with the designated mental health clinician authority (DMHCA) confirmed
treatment services included individual, group, and family therapy sessions for mental health
issues, as well as substance abuse issues as these apply to the youth. The program provides
mental health services through individual, group, or family therapy seven days a week to each
youth as part of the Individualized Treatment Plan. Mental health clinical staff provide daily
therapeutic activities, with co-occurring substance abuse services, if needed. The program
works with a contracted psychologist to provide services as needed. Therapist caseloads are
limited to ten or fewer youth, as required by contract. Therapy groups were limited to ten or
fewer youth in each treatment group.
NONSECURE
The program has a written policy and procedures for specialized treatment services provided at
the program. The program provides individualized, trauma-informed, developmentally
appropriate mental health, substance abuse, and developmental disability treatment services to
youth identified in need of such services. All treatment services are guided by an Individualized
Treatment Plan which addresses the youth’s needs in accordance with Florida Administrative
Code. The non-secure program’s required clinical groups are Trauma-Focused Cognitive
Behavioral Therapy (TF-CBT), Impact of Crime (IOC), and Skillstreaming the Adolescent. Video
and sign-in sheets verified all groups were conducted, as required. The program’s contract and
an interview with the designated mental health clinician authority (DMHCA) confirmed the non-
secure component provides borderline developmentally disabled and developmentally disabled
(BDD/DD) services to youth. The program provides mental health services through individual,
group, or family therapy seven days a week to each youth as part of the Individualized
Treatment Plan. Mental health clinical staff provide daily therapeutic activities, with co-occurring
substance abuse services, if needed. The program has a developmental specialist on-site once
a week as the contract requires. Therapist caseloads are limited to ten or fewer youth, as
required by contract. Therapy groups were limited to ten or fewer mental health treatment
groups. The program is licensed under Chapter 397 and has a qualified professional on-site at
least five days a week. The program has a licensed psychiatrist who provides psychiatric
evaluations and medication management to youth in the program. All program youth are pre-
screened and placed by the Department based upon identified treatment needs. Developmental
disability treatment services are provided for youth with an intelligence quotient (IQ) less than
seventy, whose level of impairment and related functional limitations impede their ability to
function in a general offender program. Treatment planning focuses on the provision of
developmental disability interventions, psychosocial treatment, and therapeutic activities as
appropriate to reduce or alleviate the youth’s symptoms of mental disorder and/or substance
abuse impairment. Those youth identified through assessment and/or evaluations deemed
diagnostically relevant with co-occurring disorders, are in receipt of mental health and
substance abuse services. The program has a licensed mental health counselor (LMHC), who
serves as the DMHCA and is on-site full-time weekly. The program has four therapists who are
on-site for coverage seven days a week. The therapist caseload is a ratio of one-to-ten. An
interview with the facility administrator confirmed youth identified with an IQ of seventy-nine and
under receive services for BDD/DD.
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Office of Accountability and Program Support Page 49 of 84 (Revised September 2022)
Six youth were interviewed, and all six youth stated they are participating in family and/or
individual counseling. Six interviewed staff stated direct care staff do not facilitate mental health
or substance abuse groups. Three interviewed staff indicated they sit in on group sessions with
the youth. The DHMCA and facility administrator were interviewed, and both confirmed the
program’s specialized services. Each youth was prescribed therapeutic activities. Youth with co-
occurring mental health disorders receive mental health treatment. They reported the program is
a secure facility and urinalysis drug testing is not necessary since the youth do not leave the
facility until released. Substance abuse groups offered do not exceed ten youth in each group.
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.***
SECURE
The program has a written policy and procedures for psychiatric services. Five secure youth
records were reviewed for psychiatric services. Two of the five youth were admitted to the
program while on psychotropic medications and underwent a psychiatric interview as part of the
intake process. All five youth received a psychiatric interview within fourteen days of admission,
as required, and one youth was prescribed medication after the interview. Each Initial
Diagnostic Psychiatric Interview included the youth’s medical, mental health and substance
abuse history, Mental Status Examination, a diagnosis based on the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5) consistent with the treatment plan, and
treatment recommendations. Four of the five youth Initial Diagnostic Psychiatric Interviews
addressed the prescribed medications, providing an explanation of the need for psychotropic
medications related to the youth’s diagnosis, target symptoms, initial treatment goals, potential
side effects, risks, health benefits, and frequency of medication monitoring/management. The
Initial Diagnostic Psychiatric Interview was documented on a form developed by the program
containing all the information from the Department’s Clinical Psychotropic Progress Note
(CPPN), clearly identified as the Initial Psychiatric Assessment in all five records. When the
psychiatric evaluation resulted in the prescription of psychotropic medication or changes to the
youth’s existing medication, page three of the CPPN was completed. When psychotropic
medications were prescribed by the psychiatrist, identifying data, diagnosis, target symptoms of
each medication, evaluation, and description of effect of prescribed medication on target
symptoms were documented in all five applicable records. Prescribed psychotropic medication
details, including the name, dosage, normal dosage range, ordered dosage, frequency, route of
administration, reasons for changes were documented in applicable records reviewed. Side
effects, medication adherence, height, weight, blood pressure, recent serum drug levels or
laboratory findings, appropriate telephone communication with the youth’s parent/guardian,
psychiatrist’s signature, date of signature and Tardive Dyskinesia monitoring were recorded in
all applicable youth records. Each of the three applicable youth received a monthly medication
monitoring with the psychiatrist.
NONSECURE
The program has a written policy and procedures for psychiatric services. Five non-secure
youth records were reviewed for psychiatric services. Two out of the five non-secure youth were
prescribed psychotropic medications, one youth entered the program on psychotropic
medications and one youth was placed on psychotropic medications during the initial psychiatric
interview. All five youth underwent an initial psychiatric evaluation within fourteen days of
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admission, as documented in their records. Both applicable records documented a referral was
made for a psychiatric interview and each youth received an Initial Diagnostic Psychiatric
Interview within fourteen days of admission. All five youth’s Initial Diagnostic Psychiatric
Interviews included history, Mental Status Examination, diagnosis, and treatment
recommendations. The Initial Diagnostic Psychiatric Interviews were documented on all three
pages of the Department’s Clinical Psychotropic Progress Note (CPPN) form for all five
applicable youth. Both youth prescribed psychotropic medications had detailed documentation
on page three of the CPPN, specifying the medication prescribed, target symptoms, treatment
goals, potential side effects, risks and benefits, and frequency of medication monitoring.
Psychiatric reviews for youth receiving psychotropic medications occurred at least every thirty
days, with documentation reviewed for telephone contacts with parents/guardians, psychiatrist’s
signature and dates, and nursing staff monitoring for Tardive Dyskinesia when applicable. None
of the youth had received a psychiatric evaluation within six months prior to admission.
Psychiatric services at the program are provided by a psychiatrist licensed under Chapter 459,
Florida Statutes. The psychiatrist has a clear and active license, which expires June 30, 2024.
The psychiatrist is available for emergency consultation twenty-four hours a day, seven days a
week. The psychiatrist briefs a representative of the treatment team on the psychiatric status of
each youth receiving psychiatric services, typically, face-to-face with the designated mental
health clinical authority (DMHCA) and treatment team. The psychiatrist’s evaluation and
recommendations for each youth are incorporated into the mental health staff’s evaluations and
the youth’s Individualized Mental Health and/or Substance Abuse Treatment Plan. The program
does not employ nor have a contract with a psychiatric advanced practice registered nurse
(APRN). A review of sign-in and sign-out logs revealed the psychiatrist has been on-site bi-
weekly for the past twelve months, as required by the service agreement. A copy of the
psychiatrist’s licensure was made available during the annual compliance review week. The
psychiatrist has ultimate responsibility for the prescription and monitoring of psychotropic
medications within the program. The psychiatrist actively participates in, manages, and
supervises psychotropic medication services within the program.
The DMHCA reported in an interview, staffing’s are held with the psychiatrist bi-weekly to
discuss youth on medications and any possible referrals or issues. An interview with the
psychiatrist revealed the therapists and treatment team have open communication to contact
the psychiatrist as needed, have a referral system in place for any youth exhibiting mood and/or
behavioral concerns which may warrant combined treatment, and conduct in-person treatment
teams. The only concern the psychiatrist noted was the historically short staffing on the therapy
side; however, the psychiatrist believes the current director is doing a good job addressing the
issue. The psychiatrist also reported evaluations are completed on every youth entering the
program and medication management is provided monthly to youth on psychotropic
medications. The psychiatrist confirmed being on-site every other week to provide psychiatric
services and psychotropic medication management. The psychiatrist meets with the DMHCA
while on-site.
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Office of Accountability and Program Support Page 51 of 84 (Revised September 2022)
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 written Suicide Prevention Plan detailing suicide prevention procedures in
accordance with Florida Administrative Code. The written plan included identification and
assessment of youth at-risk of suicide, staff training, which is six hours annually, to include drills,
suicide precautions, levels of supervision (one-to-one, constant, close, and standard
supervision), referrals, communication, notifications, documentation, immediate staff response,
and a review process. The written Suicide Prevention Plan was reviewed annually by the
designated mental health clinician authority (DMHCA), facility administrator (FA), and the
corporate clinical director on January 3, 2023. The FA has an established review process for
every suicide attempt or serious self-inflicted injury. The established review process includes
circumstances surrounding the event, facility procedures relevant to the incident, training
received by involved staff, pertinent medical and mental health services involving the victim,
possible precipitating factors, and recommendations, if any, for changes in policy.
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.
SECURE
The program has a written policy and procedures for suicide prevention services. Five secure
youth records were reviewed for suicide prevention services. Each of the reviewed youth were
screened during the admission process. An Assessment of Suicide Risk (ASR) was completed
during admission to the program. The ASRs were completed on the Department’s ASR form
within twenty-four hours of the youth’s admission. One of the five youth entered the facility on
precautionary observation. The youth was maintained on precautionary observation and
constant supervision until the Follow-Up ASR indicated suicide precautions could be
discontinued. When the youth’s Follow-Up ASR indicated suicide precautions could be
discontinued, the youth was stepped down to close supervision prior to transition to normal
routine and standard supervision. Close supervision was maintained until it was determined no
longer necessary by the designated mental health clinician authority (DMHCA) or licensed
mental health professional. Discontinuation of close supervision was documented in the youth’s
mental health/substance abuse record by a mental health clinical staff and there was
documentation of a conference held by the facility administrator and licensed mental health
professional to reduce level of supervision. An alert in the Department’s Juvenile Justice
Information System (JJIS) was ended following the recommendations of the ASR. The program
had an internal alert system where the suicide alerts were documented. There was
documentation on the suicide risk assessment indicating administration or supervisory staff
provided instructions related to the suicide risk assessment findings and suicide precaution
decisions. While on precautionary observation, the youth was allowed to participate in select
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activities with other youth in designated safe housing/observation areas of the facility. There
were no other youth in the program placed on precautionary observation during the annual
compliance review period.
NONSECURE
The program has a written policy and procedures for suicide prevention services. Five non-
secure youth records were reviewed for suicide prevention services. Each of the reviewed youth
were screened during the admission process. An Assessment of Suicide Risk (ASR) was
completed during admission to the program. The ASRs were completed on the Department’s
ASR form. All five youth were screened and subsequently placed on standard supervision
during admission. Three of the five youth came in on precautionary observation (PO). Each of
the reviewed ASRs were completed by a licensed mental health professional and were
completed on the Department’s ASR form within twenty-four hours of screening/concerns. None
of the reviewed youth required a Follow-Up ASR. Three youth on PO were stepped down to
standard supervision, a process which involved a conference with the licensed mental health
counselor (LMHC) and the facility administrator. All applicable alerts were entered and closed in
the Department’s Juvenile Justice Information System (JJIS) in a timely manner. None of the
five reviewed youth required a logbook entry of PO. While on PO, the three youth were allowed
to participate in select activities as deemed appropriate and the youth were not restricted to their
room.
Six staff stated they would notify mental health, place the youth on constant sight and sound,
and document supervision if a youth expressed suicidal thoughts. Five staff reported they would
search the youth’s room for sharp objects, and one staff stated they would await instruction from
their supervisor. Both program components utilize secure observation; however, the program
has not had any instances of youth requiring secure observation since the last annual
compliance review. The designated mental health clinician authority (DMHCA) was interviewed
and reported operations staff are notified of a youth’s suicide risk when arriving to the shift.
Mental health staff are alerted in person or by telephone. A mental health referral form is also
submitted. The DMHCA also stated in the interview, a conference with the facility administrator
is noted on the ASR and the outcome, when applicable, is entered into the logbook. Video
footage could not be observed for either program component as no youth had been placed on
PO in the last thirty days.
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.
SECURE
The program has a written policy and procedures for the use of Suicide Precaution Observation
Logs. Five secure youth records were reviewed for Suicide Precaution Observation Logs. One
of the five youth records reviewed was applicable for precautionary observation (PO) logs.
There were no other applicable youth to review for Suicide Precaution Observation Logs during
the annual compliance review period. The PO logs were maintained for the duration the youth
was on suicide precautions. In the PO logs available for review, the appropriate level of
supervision and observations of the youth’s behavior were documented in real time and did not
exceed thirty-minute intervals. Warning signs were noted in the reviewed logs. Notification of the
facility administrator or designee and mental health staff was documented on the reviewed PO
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logs . All the reviewed PO logs were signed by each shift supervisor, reviewed, and signed by
mental health staff, and documented the safe housing requirements.
NONSECURE
The program has a written policy and procedures for the use of Suicide Precaution Observation
Logs. Five non-secure youth records were reviewed for Suicide Precaution Observation Logs.
Three of the five youth records were applicable for Suicide Precaution Observation Logs. All
three applicable Suicide Precaution Observation Logs reviewed were documented on the
Department’s Suicide Precaution Observation Log form. The appropriate level of supervision
and observations of youth behaviors were documented in real time, at a minimum of thirty-
minute intervals. There were no noted warning signs in any of the logs reviewed. Each of the
logs were reviewed and signed by mental health clinical staff. Each of the completed 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.
Nine pre-service and nine in-service staff training records were reviewed for completion of six
hours of annual suicide prevention training and confirmed each staff completed the suicide
prevention training, as required. Training included suicide drills, which were held no less than
quarterly on each shift. The program has three shifts and each of the three shifts completed
suicide drills quarterly for the duration of the annual compliance review period. Forty staff
records were reviewed for participation in quarterly drills. Each of the forty reviewed staff
records showed emergency drills were completed, as required. The staff participated in at least
one drill which included the use of cardiopulmonary resuscitation (CPR) annually. Staff who are
not present during a quarterly suicide drill can review the drill scenario and procedures to
understand the process and receive necessary training. The program has two suicide response
kits which contain a knife-for-life, wire cutters, and needle nose pliers. The suicide kits are both
maintained within the program’s master control office. Six staff were interviewed, and each staff
reported they would notify mental health, have the youth remain in constant sight and sound,
and document the supervision. All six staff were able to identify the location of the program’s
suicide response kits. All six staff reported medical emergency and suicide drills are conducted
monthly. One staff reported drills are conducted every two weeks. The facility administrator was
interviewed and reported the program completes a mock suicide drill at least once a month. All
drills are reviewed in the monthly all-staff meeting.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written crisis intervention plan. The crisis intervention plan includes a
notification and alert system, a means of referral including youth self-referral, communication,
supervision, documentation, and review process.
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3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation conducted by a licensed mental health
professional (LMPH) or by a non-licensed mental health clinical staff working under LMPH
supervision. It evaluates youths demonstrating acute psychological distress (e.g., anxiety,
fear, panic, paranoia, agitation, impulsivity, rage) to determine the severity of their symptoms,
and level of risk level to themselves or others. When staff observations indicate extreme or
severe psychological distress in a youth who does not respond to ordinary interventions, the
program director or designee must be notified of the crisis and the need for a Crisis
Assessment. A Crisis Assessment should only be used when the youth’s crisis (psychological
distress) is not associated with suicide risk factors or behaviors. If the youth’s behavior or
statements suggest possible suicide risk, they must receive an Assessment of Suicide Risk
instead of a Crisis Assessment.
The program has a written crisis intervention plan which includes a process for implementing a
Crisis Assessment form. The form covers the reason for the assessment, Mental Status
Examination and interview, determination of danger to self and/or others, initial clinical
impressions, supervision, treatment, follow-up recommendations, and notification to the
parent/guardian of follow-up treatment. The annual compliance review period for both program
components revealed the program had no youth applicable for a Crisis Assessment.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
In the event of mental health or substance abuse emergencies, youth identified as an
imminent danger to themselves or others within the program require emergency care. This
care is provided in accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care
Plan.
The program has a written emergency mental health and substance abuse plan. This plan
includes 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 Baker Act, transport for emergency substance
abuse assessment and treatment under Marchman Act, documentation, training, and review
process.
3.17 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
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3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
SECURE
Five secure youth records were reviewed, and documentation showed all youth had a safety
plan. These plans included warning signs, the youth’s baseline behaviors, crisis recognition,
coping strategies, intervention strategies preferred by the youth, and a debriefing process. The
safety plan was completed within fourteen days of admission in all five records reviewed.
Additionally, all five records indicated the plan was jointly prepared with the youth,
parent/guardian, and clinical staff. All five safety plans incorporated recommendations from
previous or current clinical assessments or screening instruments and incorporated trauma
responsive practices. The plans were reviewed and updated as necessary following any
significant behavioral or mental health event identified by the youth’s intervention and treatment
team. A review of forty safety plans among the five youth records showed they were all updated
every thirty days. Furthermore, safety plans are reviewed by staff who have contact with the
youth. The plans are maintained in master control.
NONSECURE
Five non-secure youth records were reviewed for the safety planning process for youth. Each of
the reviewed safety plans contained warning signs necessary for identifying a youth escalating
in their behaviors. Additionally, each safety plan included the youth’s baseline behavior
gathered from collateral contacts, history, and evaluations. Furthermore, the plans included the
youth and staff perceptions of verbal and non-verbal stimuli which may have positive and
negative effects on the youth. Coping strategies, intervention strategies preferred and defined
by the youth, and a debriefing process were also included in each safety plan. All five safety
plans were completed within fourteen days of the youth’s admission to the program and
prepared jointly by the youth, parent/guardian, and program staff. Moreover, each plan
incorporated recommendations from previous or current clinical assessments or screening
instruments. Each of the five plans, for a total of forty-six reviews, were completed at a minimum
of every thirty days, as required. The safety plans are discussed during staff meetings and
treatment teams which are stored in master control for easy access and in the youth mental
health records.
All six interviewed youth indicated they contributed to their safety plan. Additionally, all six youth
were confirmed by staff to have safety plans in master control and in their records. Five of the
six staff reported the plans are reviewed if any changes are made. Four staff reported the plans
are reviewed at the intake of the youth, while one staff stated they are supposed to review the
safety plans every month. Two staff confirmed they last reviewed a youth’s safety plan last
week, two staff indicated a month ago, and two staff said within the last month. An interview with
the facility administrator confirmed youth update their safety plans every month during their
treatment team meetings.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 56 of 84 (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 has a licensed medical doctor serving as the designated health authority (DHA).
The DHA holds an unrestricted license and meets all requirements for independent and
unsupervised practice in Florida. The DHA’s license expires January 31, 2024 and their
specialty training is in family practice. Moreover, the DHA does not have any disciplinary cases
or public complaints on record and has not designated a physician’s assistant (PA) or advanced
practice registered nurse (APRN) for clinical duties. A review of sign-in and out logs noted the
DHA was on-site at least once a week for a minimum of two hours a week. Additionally, the
DHA was absent for two separate periods, one week each time. The program’s back-up
physician has an equal licensure, which expires March 31, 2024. Although the back-up
physician provided on-site services, the DHA performed all necessary administrative duties.
Furthermore, the contract for the program does not contain any information pertaining to
telemedicine or telehealth services.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) holds clinical responsibility for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) under the supervision of DHA, according to developed and authorized
protocols. This includes the intake evaluations, assessments, health education, medication
management, and other assigned duties as outlined by the Department’s Rule, as well as the
program’s facility operating procedures and nursing protocols approved by the DHA.
The program employs licensed nurses, including on-site nursing coverage provided by one
registered nurse (RN) and two licensed practical nurses (LPNs). The RN provides direction to
each of the LPNs, accomplishing this through the daily review of all medical cases and being
available for on-call consultation. This practice is supported by the review of youth medical
records and observation of sick call treatment forms. A review of nursing licenses found each
license was clear and active according to the Florida Department of Health Medical Quality
Assurance website, with the expiration dates of April 19, 2025, September 30, 2024, and
October 31, 2024. Additionally, each nurse holds a current certification in cardiopulmonary
resuscitation (CPR). In accordance with the contract and subsequent amendments, required on-
site hours for the nursing staff is eighty hours a week. The program’s contract allows for the
utilization of LPNs, and the nursing staff adhere to these contract requirements. The on-site RN
serves as the program’s health service administrator (HSA), available Monday through Friday,
from 7:00 a.m. to 3:30 p.m.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 84 (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 a written policy and procedures for all health-related protocols utilized at the
program. The designated health authority (DHA) revised and signed the program’s respective
treatment policy and procedures, on January 2, 2023, while the psychiatrist completed the same
on January 6, 2023. Additionally, the facility administrator revised and signed the program’s
respective treatment policy and procedures on January 2, 2023. Documentation confirmed the
on-site nursing staff reviewed, signed, and dated the cover page containing medical policies,
treatment protocols, and other procedures. When new policies or policy changes were
implemented during the year, nursing staff reviewed, signed, and dated a signature page listing
the specific policy and date of revision. The annual review of medical policies, procedures, and
protocols was conducted on January 2, 2023. Furthermore, a new licensed practical nurse
(LPN), received a comprehensive clinical orientation to the Department’s healthcare policies
and procedures, provided by the program’s registered nurse (RN). The approval of treatment
protocols and standing procedures were written and authorized solely by the program’s DHA.
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.
SECURE
The program has established policies and procedures to ensure the completion of the Authority
for Evaluation and Treatment (AET) for youth under its custody. All five reviewed youth
Individual Healthcare Records (IHCRs) contained legible copies of the AET form stamped with
the word “copy.” Furthermore, each AET was appropriately signed by both the youth’s
parent/guardian and a Department representative. The AET remains valid for the duration of the
youth’s stay in the program or until their eighteenth birthday. Among the reviewed records, three
youth had a documented release of information in their IHCR. Notably, one of these youth
reached eighteen years of age while in the program, while the remaining two youth were aged
eighteen upon admission. Importantly, there were no youth identified as being under the care of
the Department of Children and Families with terminated parental rights.
NONSECURE
During the annual compliance review, five youth Individual Healthcare Records (IHCRs) were
examined for the completion of the Authority for Evaluation and Treatment (AET). Each IHCR
included a clear copy of an AET; the word “copy” was stamped on each form. These AETs were
duly signed by both the youth’s parent/guardian and a department representative, indicating
their validity upon admission to the program. Notably, one of the five youth reached the age of
eighteen while in the program, leading to the documentation of a release of information within
the IHCR. Furthermore, none of the youth under review were under the care of the Department
of Children and Families.
In an interview with the nursing staff, it was revealed the AETs were obtained from the
Department and placed in the healthcare record with a copy stamp. Additionally, youth aged
eighteen or older are required to sign an “eighteen and up” AET and provide consent on-site.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 58 of 84 (Revised September 2022)
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
SECURE
The program maintains a written policy and procedures to ensure timely notification of the
parents/guardians regarding any changes in the youth’s condition, as well as documentation of
informed consent for youth healthcare. A review of five youth Individual Healthcare Records
(IHCRs) revealed three were applicable for parent/guardian notification concerning-over-the
counter (OTC) medications beyond those covered by the Authority for Evaluation and Treatment
(AET). In all three cases, consent was obtained, and documentation of attempted contact with
the parent/guardian was found within the progress notes. Notifications were sent using the
Department’s Parental Notification of Health-Related Care form, as required. Among the five
youth, three were taking prescribed psychotropic medications during the annual compliance
review period. Documentation showed staff witnessed telephone call attempts and
conversations for psychotropic medications in two of these cases. The remaining youth was
non-applicable due to being eighteen years of age. Additionally, two of the three applicable
IHCRs showed documentation of new psychotropic medication prescriptions, discontinuations,
or dosage changes, all of which were appropriately recorded on the Department’s Clinical
Psychotropic Progress Note (CPPN) form. Furthermore, there were no youth identified as being
in the care of the Department of Children and Families (DCF) with terminated parental rights.
Immunizations for all five youth were verified within thirty days of admission to the program.
Consent for vaccinations within this time frame was not required for any of the youth, as each
had up-to-date immunizations, and none were eligible for religious exemption.
NONSECURE
The program has a written policy and procedures to ensure prompt notification of the
parent/guardian regarding any changes in the youth’s condition and to document informed
consent for youth healthcare. The review confirmed a total of five youth Individual Healthcare
Records (IHCRs) were examined for compliance with parental notification and consent
protocols, particularly concerning new medications and treatments. Among the five IHCRs
reviewed, four were found to be applicable, with documented parental notification for over-the-
counter (OTC) medications prescribed beyond those covered by the Authority for Evaluation
and Treatment (AET). Each youth record also included documentation of consent provided by
the parent/guardian. In the case of these four youth, new medications were prescribed, and
records indicated attempts to contact the parent/guardian, with necessary written notifications
sent out accordingly. Furthermore, two of the five youth received psychotropic medication during
the annual compliance review period. The program’s nursing staff meticulously documented all
telephone call attempts and conversations regarding prescribed psychotropic medications.
Notifications to the parent/guardian were recorded on page three of the Department’s Clinical
Psychotropic Progress Note (CPPN) form whenever new psychotropic medications were
prescribed, discontinued, or when significant dosage changes occurred. Additionally, all five
reviewed youth IHCRs contained records of vaccinations, which were verified within thirty days
of the youth’s admission to the program. Notably, none of the youth were eligible for religious
exemption from immunization.
An interview with the nursing staff revealed parental notifications are made verbally or in writing
for any change in the youth's condition, particularly regarding medication orders,
discontinuations, or dose changes. If parents/guardians cannot be reached initially, a progress
note is made, and follow-up calls are made. In medical emergencies, parents/guardians are
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 84 (Revised September 2022)
updated upon the youth’s return to the facility. Written notifications, along with the CPPN, are
also sent for medication changes. The program utilizes immunization records from the Florida
Shots website, which are accessed prior to the youth’s arrival by on-site medical staff. Flu
vaccinations are available on-site, while other vaccines are administered at the health
department. The parent/guardian must complete a religious exemption form for immunizations,
which is submitted to the program.
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.
SECURE
The program maintains a written policy and procedures concerning youth healthcare admission
screening and rescreening each time there is a change in the physical custody of the youth. A
review of five youth Individual Healthcare Records (IHCRs) revealed each youth had a
completed Facility Entry Physical Health Screening (FEPHS) form on the date of admission.
These forms were completed by either a licensed practical nurse (LPN) or registered nurse
(RN); none were completed by a direct care staff. Furthermore, none of the reviewed youth
were out of the physical custody of the Department for more than twenty-four hours.
NONSECURE
The program has a written policy and procedures concerning youth healthcare admission
screening and re-screening each time there is a change in the physical custody of the youth.
Following the examination of five youth Individual Healthcare Records (IHCRs), it was
discovered each youth had a completed Facility Entry Health Screening (FEPHS) form on the
date of admission. These forms were completed by either a licensed practical nurse (LPN) or a
registered nurse (RN), with none being completed by direct care staff. Additionally, two of the
five youth were out of physical custody of the program for more than twenty-four hours. After
being readmitted, each of these youth had a new FEPHS form completed.
In an interview with the nursing staff, it was revealed the youth are attended to by medical staff
as soon as they enter the building. The nursing staff is notified of new intakes by email and
administrators. The admission screening process is solely conducted by health care staff. If
there is a change in physical custody since the youth's admission, the youth is assessed again,
and the assessment is documented on the Facility Entry Screening form.
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.
SECURE
The program has a written policy and procedures to ensure all youth admitted to the program
receive an orientation to healthcare services. Following the review of five youth Individual
Healthcare Records (IHCRs), it was documented the orientation was completed for each youth.
This orientation covered all required healthcare and health education services provided at the
program. Additionally, all five youth orientation sheets contained documentation of the youth’s
signature, indicating their acknowledgement of the orientation.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 84 (Revised September 2022)
NONSECURE
Five youth Individual Healthcare Records (IHCRs) were reviewed to assess the orientation
provided regarding healthcare services and health education. Each youth received a
comprehensive general care admission orientation, covering essential topics such as access to
medical care, sick call procedures, handling emergencies, medication process, refusal
protocols, sexual assault or attempted sexual assault response procedures, the non-disciplinary
role of healthcare providers, and standard universal precautions. Signatures confirming receipt
of the reviewed orientation topics were documented in each youth’s IHCR.
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.
SECURE
The program maintains a written policy and procedures to ensure prompt notification of the
designated health authority (DHA) or their delegate upon each youth’s arrival at the facility.
Additionally, immediate notification is provided if any youth admitted to the program requires
emergency medical care. After examining five youth Individual Healthcare Records (IHCRs), it
was observed one youth presented with a known or suspected chronic condition upon
admission. Two additional records were provided for review, totaling three youth with referrals to
the DHA and/or psychiatrist upon admission. None of the reviewed youth were identified as
requiring emergency medical care upon admission. The program notifies the DHA or designee
within twelve hours of admission for all youth, regardless of if the youth is presented with
chronic conditions. Furthermore, all three youth who were taking psychotropic medication upon
admission had the psychiatrist notified in accordance with program guidelines.
NONSECURE
A comprehensive review of five youth Individual Healthcare Records (IHCRs) confirmed the
program’s adherence to notification protocols for the designated health authority (DHA) or their
designee upon youth admission. Each IHCR contained documentation supporting the
notification process, regardless of youth’s condition upon admission. The program’s practice
dictates contacting the DHA for all youth admissions, which is annotated in progress notes by
medical staff. Notably, all notifications were made within the mandated time frame of twelve
hours following the youth’s admission to the program.
The interview with the nursing staff revealed the DHA is notified upon admission regarding
youth with serious or chronic conditions. The medical staff are responsible for this notification
and the notifications to the DHA are documented in the progress note.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
SECURE
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. A review of five youth Individual Healthcare Records (IHCRs)
indicated each had a completed and/or updated HRH form, within seven days of admission. The
reviewed IHCRs indicated the HRH form was completed prior to the CPA. The HRH was
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 84 (Revised September 2022)
reviewed by the designated health authority (DHA) which was documented by a checkbox on
the CPA.
NONSECURE
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. A total of five youth Individual Healthcare Records (IHCRs)
were reviewed to determine if the HRH form was completed for all youth admitted into the
physical custody of the program. The reviewed youth each had a completed and/or updated
HRH form within seven days of admission. None of the HRH forms were late. Each of the HRH
forms were completed prior to completion of the CPA. All the HRH forms were reviewed by the
designated health authority (DHA).
An interview with the nursing staff revealed within seven days of admission, the nursing staff
complete the HRH form and it is reviewed by the DHA.
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.
SECURE
The program has a written 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. A review of five Individual Healthcare Records (IHCRs)
demonstrated a Comprehensive Physical Assessment (CPA) was completed for each youth
upon admission. Each of the reviewed CPAs were documented on the Department’s CPA form.
A current CPA was on file for each youth at the time of admission to the program. The
designated health authority (DHA) completed a CPA within seven days of each youth’s
admission. Each of the reviewed CPAs documented the youth’s Medical Grade. There were no
missing or incomplete elements on any of the reviewed CPAs. All sections of the CPA were
completed using an “O” or “X” marking. The CPA was signed by each of the youth reviewed,
indicating refusal of the genital examination. Two of five youth were applicable for having the
Department’s Problem List updated. Each of the two youth had an updated Problem List within
their IHCRs. All of the youth had documentation of the most recent Tuberculosis Skin Test
(TST) administered within the last year, verified by the results on the CPA and the Department’s
Infectious and Communicable Disease (ICD) form.
NONSECURE
A total of five youth Individual Healthcare Records (IHCRs) were reviewed to determine if a
Comprehensive Physical Assessment (CPA) form was completed for all youth admitted into the
physical custody of the program. Each IHCR had a new CPA completed within seven days of
the youth’s admission and were annotated on the Department’s form. The CPAs were
completed by the designated health authority (DHA). Each of the youth’s Medical Grades were
documented on the CPA. All necessary sections of the CPA were marked with an “O” or an “X.”
Completed refusals were found for each of the youth reviewed, whereas part of the exam
conducted was refused by the youth. The youth’s problem list was updated when required.
Documentation was found in each IHCR for at least one verified Tuberculosis Skin Test (TST).
Subsequently, the TST correlated with entries made on the CPA and the Department’s
Infectious and Communicable Disease form.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 84 (Revised September 2022)
An interview with the nursing staff revealed a new CPA is completed within seven days of
admission. Additionally, tuberculosis (TB) screenings are done within seventy-two hours of
admission and yearly thereafter.
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.
SECURE
The program has a written policy and procedures to ensure all youth admitted to the program
undergo screening, evaluation, and treatment, if applicable, for sexually transmitted infections
(STIs) and human immunodeficiency virus (HIV). A review of five Individual Healthcare Records
(IHCRs) found all youth had undergone clinical screening and subsequent evaluation for STIs.
Screening, testing, and evaluation occurred upon admission to the program, and none of the
youth required further evaluation. Each youth had appropriate documentation filed within their
respective IHCR. None of the reviewed youth were ever out of the Department’s physical
custody. Furthermore, all five youth were offered counseling, testing, and a referral for treatment
for HIV, if necessary. They all received HIV testing, and documented consent was obtained from
each youth. Their HIV results were filed in their IHCR, maintained in a sealed envelope marked
“Confidential.” The five reviewed envelopes contained the designated health authority (DHA)
signature, attesting to a review of the sealed contents. Additionally, each youth had
documentation of pre-test and post-test counseling within their IHCR. There were no alerts
indicating HIV status within the program’s internal alert system. The program has a written
policy and procedures which reflect HIV test results are only disclosed to the youth and those
entities as outlined within Florida Statutes. The HIV pre-test and post-test counseling are
conducted monthly by a HIV counselor from an outside provider.
NONSECURE
A review of five youth Individual Healthcare Records (IHCRs) was conducted to ensure youth
were evaluated and treated, when necessary, for sexually transmitted infections (STIs). It was
found all youth underwent a clinical screening and evaluation for STIs. Each youth required
further evaluation and was subsequently referred to the designated health authority (DHA).
Each of the referrals were documented on the Department’s STI form. Testing was ordered,
performed, and results were documented on the Department’s Infectious and Communicable
Diseases (ICD) form. None of the youth were out of the Department’s physical custody and/or
presented with any symptoms. Each of the youth were offered counseling, testing, and if
indicated, treatment or referral for human immunodeficiency virus (HIV). All five youth
consented and received HIV testing. Consent forms were filed in the youth’s IHCR. The HIV
testing results were found filed in the IHCR and kept in a sealed envelope marked
“Confidential.” Each of the envelopes documented the practitioner signature. There was
documentation of each youth being provided pre/post-test counseling. No alerts were found
posting the HIV status of the youth on the programs internal alert system. The program has a
written policy and procedures, specifically for HIV test results, which are only disclosed to the
youth and entities described within Chapter 381, Florida Statute. An external agency provides
pre/post-test HIV counseling for youth.
Furthermore, six youth were interviewed, all of whom stated they can ask for a HIV test. An
interview with the nursing staff revealed STI screenings are conducted upon admission and
documented on the Department’s form. If the screening indicates further evaluation is
necessary, a notification to the DHA is done immediately. STI screenings, evaluations, referrals,
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 84 (Revised September 2022)
and testing are documented in progress notes and on the Department’s form located in the
youth's IHCR. If a youth has been out of the program's physical custody for more than thirty
days a facility entry form is done along with a new urine sample for STI and documented. All
HIV testing results are kept in a sealed envelope with the DHA’s signature after review. All HIV
counseling is offered upon admission. A HIV counselor is on-site monthly for pre and post-test
counseling. HIV testing is also available upon request.
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.
SECURE
The program has a written policy and procedures addressing the program’s sick call process. A
review of five Individual Healthcare Records (IHCRs) revealed five youth had completed a total
of ten sick call requests at the program. A Sick Call Request form was completed for each of the
ten sick calls reviewed. None of the youth presented with a similar sick call complaint three or
more times within a two-week period. Three of the ten Sick Call Request forms were completed
by a registered nurse (RN). The remaining seven sick calls were conducted by a licensed
practical nurse (LPN). Each of the seven sick calls completed by the LPN were reviewed daily
either telephonically or in person with a RN and documented on the sick call forms. Each of the
ten sick calls were filed within the youth’s IHCR in reverse chronological order. None of the
reviewed youth were in restricted housing. Each of the ten sick calls were documented in
progress notes in accordance with Florida Administrative Code. Each of the reviewed sick calls
were found to be recorded appropriately on the Sick Call Index. Each of the sick calls were
documented on the program’s Sick Call Referral Log. The dates listed on the Sick Call Index
corresponded to the completed Sick Call Request forms located in each of the youth’s IHCRs.
The program provides sick call daily, while nursing staff is on-site between 6:30 a.m. and 6:30
p.m., seven days a week. The sick call hours are posted on the medical office door, on each of
the youth housing modules, and are reviewed with each youth during orientation at admission. A
review of the daily schedule, along with the actual posted schedule, and nurse interview
confirmed sick call is conducted pursuant to contract requirements. Only licensed medical staff
conduct sick calls. The program has a written policy and procedures for all health-related
issues, which specifically addressed processes for the shift supervisor to review sick call
requests. Sick Call Request forms are available to youth located in each of the two youth
housing modules and in medical. The medial department has an exam table. The program did
not have any youth who requested a sick call during the annual compliance review week;
therefore, an observation of a sick call could not be conducted.
NONSECURE
A total of five youth Individual Healthcare Records (IHCRs) were reviewed for completion of sick
call practices. Four of the five youth were applicable for submission of a sick call complaint
during the annual compliance review period. There were twenty-four sick calls from the four
youth reviewed. There were no indications any of the youth presented with a similar sick call
compliant three or more times within a two-week period. Each of the complaints had a Sick Call
Request form completed by the youth. Sixteen of the twenty-four sick calls were conducted by a
licensed practical nurse (LPN). Subsequently, each was reviewed daily (documented on the sick
call form), either telephonically or in person with a registered nurse (RN). All sick calls were
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 84 (Revised September 2022)
found filed within the youth’s IHCR in reverse chronological order. There were no indications
from the sample of reviewed youth of them having been placed in restricted housing during the
annual compliance review period. Each of the reviewed sick calls were found documented on
the youth’s Sick Call Index. Each of the sick calls were found documented on the program’s
Sick Call Referral Log. The dates listed on the Sick Call Index corresponded to the completed
sick call forms located in the youth’s IHCR. A review of posted clinic hours along with the health
service administrator’s informal interview, supported sick call is conducted twice daily, seven
days a week, at a minimum. Sick call hours were observed to be posted outside the medical
office and in the youth dormitory areas. A review of sick call documentation revealed only
licensed medical staff conducted sick calls. The program has a written policy and procedures
whereby the shift supervisor reviews all sick call requests within four hours after the request is
submitted. Sick call forms were observed and available for youth in dormitory and medical. An
exam table was available for performance of medical duties; however, no sick call or episodic
event was able to be observed during the annual compliance review week.
Six youth were interviewed. Four youth stated they can see the nurse immediately once a sick
call request is made. The remaining two youth stated within one day. Six staff were interviewed.
All six staff stated the nurse reviews and conducts sick calls. An interview with the nursing staff
revealed sick call is completed at the scheduled times or within four hours of the sick call
complaint. Youth can see a nurse at any time for emergency complaints. Only nursing staff
conduct sick calls within the facility. If conducted by a LPN, the sick call is reviewed with the RN.
The DHA can be notified of a sick call as well. The DHA conducts sick call when scheduled on-
site. The sick call is conducted at medical. The nursing staff reported sick calls are conducted at
6:30 a.m. and 6:30 p.m. and if the youth have a same complaint three times within a two week
period, they are referred to an outside provider. Youth are assessed as soon as they are placed
in confinement and daily. Staff are to assess youth daily if nursing staff is not on-site.
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.
SECURE
The program has a written policy and procedures to ensure the youth have access to episodic
and first-aid care. A review of five youth Individual Healthcare Records (IHCRs) revealed four
youth required a total of six encounters for either on-site first-aid, episodic, or emergency care.
All provided care was conducted by a licensed healthcare staff while on-site. Each of the six
incidents were documented with problem-oriented elements, to include subjective, objective,
assessment, and plan (SOAP) formatting. None of the episodic or first-aid care was provided for
by non-healthcare staff.
NONSECURE
A total of five youth Individual Healthcare Records (IHCRs) were reviewed for completion of
episodic, first-aid, and/or emergency care. Four of the five youth had an indication of requiring
on-site first-aid or episodic care during the annual compliance review period. All the on-site care
provided was conducted by a licensed healthcare staff. Each of the encounters were
documented utilizing problem-oriented narratives documented within the youth’s IHCR. There
was no indication a non-healthcare staff provided any first-aid or episodic care.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 84 (Revised September 2022)
The program has a written policy and procedures which address episodic and emergency care
procedures. The program has a total of four first-aid kits. There are three first-aid kits located
within master control; one for master control and two for transportation purposes. The remaining
first-aid kit was in the program’s kitchen area. The program’s process for ensuring contents are
maintained and stored in accordance with guidelines to prevent expiration or deterioration and
are replenished as needed was reviewed. Each first-aid kit shall contain a list of the required
contents so staff can regularly determine whether the kit needs to be restocked. First-aid kits
shall be secured and clearly marked “First-Aid Kit.” In areas other than the living units, the first-
aid kits shall be secured in a specific location approved by the facility administrator. All staff
working in these areas shall be informed of the location of the first-aid kit for the area. Its
location shall be clearly designated on all egress plans throughout the facility. Living unit staff
and the shift supervisors shall regularly inventory the contents of the kits to determine whether
they need to be restocked. Additionally, the clinical manager shall ensure all kits are inventoried,
dated, and initialed at the time of inspection. Whenever a designated staff determines a first-aid
kit needs to be restocked, the staff shall bring the first-aid kit to the medical services manager or
designee, as soon as reasonably possible. The clinical manager or designee shall inventory the
first-aid kits at least monthly and will restock the kit, as appropriate. A review of a first-aid kit
revealed the kit was fully stocked with designated health authority (DHA) approved contents.
The program maintains an inventory log with expiration dates for each of the items in each first-
aid kit. Each of the first-aid kits are checked by medical staff on a monthly cycle. Observations
of monthly check logs revealed no issues with checks. The program has one automated
external defibrillator (AED), which is in master control. The AED procedures are located with the
AED and a copy is in the medical office. The AED batteries and pads are checked by nursing
staff monthly. The nursing staff conducted a self-test of the AED in the presence of an annual
compliance review team member during the annual compliance review week. There were no
noted issues observed during the AED testing. The batteries for the AED will expire December
2024. The batteries were last changed May 2022. The AED pads expire February 2024. The
pads were last changed January 2022. Emergency medical drills were reviewed for each of the
program’s three shifts. Each shift conducted emergency medical drills at a minimum of monthly;
with no exceptions noted. The reviewed emergency medical drills included the demonstration of
cardiopulmonary resuscitation (CPR) and AED at a minimum of annually. The drills consisted of
announced and unannounced type drills and were conducted at least quarterly on each shift.
The program has emergency telephone numbers for all staff within master control and medical.
The emergency contact numbers along with poison information control center number are in an
area which is not accessible to youth. Training for the epinephrine auto-injector is conducted for
all healthcare and direct care staff during orientation to the program and then yearly. Training for
the epinephrine auto-injector is conducted by the on-site registered nurse (RN). A review of nine
pre-service and nine in-service training records identified staff received training in episodic, first-
aid, and emergency care. No episodic care events occurred during the annual compliance
review week; therefore, an episodic care event could not be observed. The program has policy
on the use, access, and inventory of Narcan. A total of nine Narcan nasal sprays are maintained
in the medical office. Medical staff and trained non-medical staff have access to Narcan. Each
of the trained non-medical staff have received proper training on the use of Narcan. There was
a perpetual count of Narcan conducted on the weekly inventory.
Six youth were interviewed. All six youth stated they can see a dentist or doctor if needed.
Six staff were interviewed. Five of the six staff stated they are allowed to personally call 9-1-1 if
a youth has a medical emergency. The remaining staff stated they could not call personally but
would contact master control to call. All six staff were able to explain the process of calling 9-1-
1. An interview with the nursing staff revealed there are a total of four first-aid kits in the
program. Three are in master control and one is in dietary. Episodic care is documented on
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progress notes and placed on the Episodic Care Log. If staff provide first-aid/emergency care, it
is documented on the non-healthcare staff form. A transport log and summary of off-site forms
are used to track youth who are sent off-site for emergency care. The program has one AED
which is in master control and medical staff check the AED. Emergency drills are conducted on
each shift monthly. The CPR technique drills are conducted quarterly on each shift. The list of
emergency numbers is in master control are inaccessible to youth.
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.
SECURE
The program has a written policy and procedures to ensure for timely referrals and coordination
of medical services to an off-site healthcare provider. A review of five youth Individual
Healthcare Records (IHCRs) found three applicable for off-site care. In each of these cases, the
Department’s Summary of Off-Site Care Consultation Report form was completed and filed
appropriately in each youth’s IHCR. All off-site emergency care was documented on the
Episodic Care Log. A parental/guardian notification was found documented in two of the three
IHCRs. The one remaining youth was eighteen years old and did not require a
parental/guardian notification to be completed. Each of the three records had discharge
documents filed accordingly. There was documentation where the designated health authority
(DHA) reviewed and signed all off-site care findings, instructions, and information for each
youth. Each of the three youth required follow-up testing, referral, and/or an appointment. Each
of the youth had completed and/or were still receiving treatment, and appointments, as required.
NONSECURE
The program has a written policy and procedures to ensure for timely referrals and coordination
of medical services to an off-site healthcare provider. A total of five youth Individual Healthcare
Records (IHCRs) were reviewed for referrals and coordination of medical services to an off-site
healthcare provider. Three of the five youth were applicable for off-site care. There were six off-
site referrals made for the three reviewed youth. All off-site events were documented on the
Department’s Summary of Off-Site Care Consultation Report form and subsequently filed in the
youth’s IHCR. None of the reviewed events required off-site emergency care. Parental/guardian
notification efforts were found in each youth’s IHCR. Discharge documents were filed in each
youth’s IHCR. Additionally, the designated health authority (DHA) reviewed and signed off on all
findings, instructions, and or information pertinent to each youth. Two of the three youth
required follow-up appointments. Each of the youth had referrals made and subsequent
treatment was provided.
An interview with nursing staff revealed the transport log, Summary of Off-Site Care
Consultation Report forms, and progress notes are used to track youth who are sent off-site.
Hospital orders are followed by having orders reviewed by the healthcare staff upon the youth's
return and the DHA is contacted for review.
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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.
SECURE
The program has a written 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. A review five youth Individual Healthcare Records (IHCRs) was conducted, and one
was applicable for a chronic condition. Two additional IHCRs were provided for review. The
three reviewed youth were identified on the Department’s Facility Entry Physical Health
Screening (FEPHS) form with a chronic condition upon admission. None of the youth were
identified as having a communicable disease. Three youth were taking prescribed medication
on an on-going basis. One youth was undergoing treatment for a physical health condition.
Each of the youth identified with a chronic condition were classified with a Medical Grade two or
higher. Subsequently, each youth was placed on the program’s Chronic Illness List. Two of the
three reviewed youth were in receipt of periodic evaluations at least every ninety days. The
remaining youth was still within ninety days and had a future appointment scheduled within the
ninety-day range. An observation of each youth’s periodic evaluations revealed no issues. A
review of progress notes documented each youth’s periodic evaluation. None of the youth were
applicable for taking anti-tuberculosis medications. Each of the reviewed youth records had an
evaluation completed prior to a prescription renewal, change, or expiration. None of the
reviewed youth were applicable for an off-site evaluation. The Department’s Problem List was
updated in accordance with Florida Administrative Code for each of the reviewed youth.
NONSECURE
A total of five youth Individual Healthcare Records (IHCRs) were reviewed for chronic conditions
and periodic evaluations being conducted as needed. Only one youth from the original sample
was applicable for this indicator. Two additional IHCRs were requested to ensure a minimum
sample size of three youth were reviewed for this indicator. Each of the youth at admission were
identified with a chronic condition. The Department’s Facility Entry Physical Health Screening
form was completed for each youth. Youth were classified with a Medical Grade of either two,
three, or four. Subsequently, youth identified were placed on the chronic illness list. Each of the
youth received periodic evaluations at least every ninety-days, with no observed issues.
Progress notes reflected the youth’s periodic evaluations were conducted. There were no
occasions in lapse of care or missed periodic evaluations. The Department’s Problem List was
updated in accordance with Florida Administrative Code.
An interview with nursing staff revealed youth with chronic conditions are placed on the Medical
Alert Log with the next periodic evaluation date on the alert for tracking. An interview with the
designated health authority (DHA) revealed periodic evaluations for youth with chronic
conditions are completed at least every ninety days or sooner. The on-site nurses keep track of
youth with chronic conditions and follow up visits. An interview with the facility administrator
revealed the Medical Alert Log is updated weekly, or as needed and due to a new admission
and shared with staff, food services, supervisors, and the education department. Alert boards
are updated in conjunction with the log provided. Nursing staff routinely verify all alerts in the
alert systems are accurate and up-to-date.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
SECURE
The program has a written policy and procedures to ensure the accurate and safe
administration of youth medications. A review of five youth Individual Healthcare Records
(IHCRs) was conducted, and three youth were applicable for being admitted with medication.
The medications for all three youth were verified prior to the youth being admitted into the
program. Prescription medication verification was documented for each youth, included within
chronological progress notes and on the Department’s Prescription Medication Verification
Checklist form. For all three youth reviewed, the designated health authority (DHA) and, when
applicable, the psychiatrist were contacted to obtain an order to resume the specified
medication prescribed prior to admission. All medications had a current, valid order and were
administered pursuant to a current prescription. There was no indication any of the reviewed
youth were in restricted housing. Over-the counter (OTC) medications not listed on the
Department’s Authority for Evaluation and Treatment (AET) form were administered according
to approved protocols. The program utilizes the Department’s standard Medication
Administration Record (MAR) to document all medications. Each of the reviewed MARs met all
requirements outlined within Florida Administrative Code. Trained non-healthcare staff assisted
in the delivery of medications, only when licensed medical staff were not on-site, with no noted
issues. Staff initialed each administered medication entry as required. There were no
undocumented explanations for a lapse or errors in medication administration. The nursing staff
documented side-effect monitoring weekly, at a minimum, on each MAR. None of the youth
were applicable for refusing medication during the annual compliance review period. The MARs
contained all the required elements. None of the youth were applicable for parenteral type
medications. Three youth were applicable for receiving prescribed psychotropic medication
upon admission. The DHA and psychiatrist were notified upon youth’s admission. In all three
instances the psychiatrist conducted an Initial Diagnostic Psychiatrist Interview within fourteen
days of admission.
NONSECURE
A total of five youth Individual Healthcare Records (IHCRs) were reviewed for medication
management. Four of the five youth required or had some type of medication prescribed during
the annual compliance review period. Each of the youth had a standard Department Medication
Administration Record (MAR) used for all medications provided. One of the four youth was
taking medication upon admission. The remaining three were later prescribed over-the-counter
(OTC) medications not listed on the Authority for Evaluation and Treatment (AET) form, which
were administered according to approved protocols or practitioner’s order. In two of the four
reviewed youth records, there were indications a trained non-healthcare staff assisted in the
delivery of medications. There was no indication for any of the reviewed youth of any errors in
medication administration. Each reviewed MAR documented weekly side-effect monitoring by
nursing staff. One reviewed youth was applicable for completion of a refusal form. The youth
signed the Department’s Refusal of Treatment form indicating refusal, which was clearly
documented on the MAR. All the reviewed MARs contained all required elements as outlined
within Florida Administrative Code. None of the youth required parenteral medication. One
youth was on psychotropic medication at the time of admission and was prescribed different
medication after the initial psychiatric interview. In addition, one youth was later in receipt of an
initial psychiatric interview within fourteen days of referral and subsequently prescribed
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psychotropic medication. Each youth was in receipt of medication monitoring every thirty days
as required.
There was no indication of any standing orders for psychotropic medications. Additionally, there
were no emergency treatment protocols or pro re nata (PRN) orders for psychotropic
medications. One medication pass was observed during the annual compliance review week.
Youth were escorted by direct care staff to medication pass. One youth was called up at a time
to approach the medication cart and the registered nurse (RN) dispensed the medication. The
Six Rights of Medication Administration were followed during the medication pass process. Six
youth were interviewed. Four youth stated they receive medication from the nurse and were
able to explain the process. The remaining two youth stated they do not take medication. Six
staff were interviewed. All six stated the nurse or staff who are medically certified can dispense
medication to youth. An interview with the nursing staff revealed the medication regimen is
reviewed with the designated health authority (DHA) and psychiatrist after medications are
verified by the previous provider and pharmacy. The verification is documented on the
Medication Verification form and on the admission progress note. The standard Department
MAR is used. Medication pass is at 6:30 a.m. and 6:30 p.m. daily. All medications are procured
through a community vendor. The psychiatrist is on-site bi-weekly for four hours.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a written policy and procedures to ensure medical equipment classified as
sharps and medications are secured and inventoried utilizing a routine perpetual inventory. The
medical department equipment classified as sharps were observed and inventoried. Medical
sharps were observed to be secured and inventoried utilizing a routine perpetual inventory. In
addition, all medications were secured in locked areas designated for storage of medications.
The medication cart was observed to be clean and organized, with stock items separate from
youth specific medications. Controlled medications had a perpetual inventory, were stored
securely from other medications, and locked behind two locks. All medications were observed to
be stored in a separate, secure area, which was inaccessible to youth. Medications which
require refrigeration were stored in a refrigerator, which was observed to be locked. This
refrigerator was utilized for medication purposes only. The program’s process for destruction
and disposal or return of expired or discontinued medications is to have two medical staff place
medication in a solution which destroys the medication. A log of the destruction is maintained for
each instance of medication disposal. Perpetual and weekly inventories of sharps and stock
over-the-counter (OTC) medications were observed to be completed, as required, with no noted
issues. A shift-to-shift inventory count of all the program-controlled medications were
documented and maintained on the youth’s Individualized Controlled Medication Inventory
Record as required. A review of nine non-healthcare staff training records was conducted for
completion of delivery and oversight of medication administration. The training was conducted
by the on-site registered nurse (RN). Observations were made of the RN counting three
controlled medications, three OTC medications, and three sharps with no observed issues. The
program has a written policy and procedures which address practices for reporting any
inventory discrepancies. An interview with the nursing staff revealed medications are disposed
with two medical staff into a medication destroyer solution. Controlled medications are
destroyed with the pharmacy consultant. Narcotics and controlled substances are kept behind
two locks. The pharmacist consultant is on-site monthly. They inspect the medication area,
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controlled substances, Medication Administration Records, medication storage areas, fridge,
double locked cabinets for controlled substances, and labeling and expiration dates.
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 to 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.
A review of the program’s written infection control and exposure control plans was conducted.
The written plan included prevention, containment, treatment, and reporting requirements. The
plans are written in accordance with Occupational Safety and Health Administration (OSHA)
federal regulations and the Centers for Disease Control and Prevention (CDC) guidelines. The
designated health authority (DHA) reviewed the program plans on January 2, 2023. The facility
administrator reviewed the program plans on January 2, 2023. The psychiatrist reviewed the
program plans on January 6, 2023. A review of five youth Individual Healthcare Records
(IHCRs) documented youth are in receipt of standard universal precaution training during
orientation to the program. The program makes available Hepatitis B immunizations for all staff
if they choose to get them. Staff have access to protective equipment. There were no
documented instances in which the program had to notify the local county health department,
CDC, and/or the Department’s Central Communications Center (CCC) for any infectious
disease outbreaks. The facility administrator maintains a separate binder for any youth or staff
who may have experienced a facility or occupational exposure, which is maintained
confidentially for a ten-year period. The program has a written facility operating procedure which
addresses the process for needle stick post-exposure practices. There was no indication the
program has had any instances involving the quarantining or hospitalization of at least ten
percent of the total population since last annual compliance review.
An interview with the nursing staff revealed a copy of the exposure control plan is in medical
and master control. The infection control training for staff is conducted by healthcare staff.
Infection control training is provided upon hire and annually thereafter. Medications are stored
behind a locked cabinet or the locked medication cart. Controlled medications are behind two
locks. Medications are counted perpetually, and a weekly count is conducted. An interview with
the facility administrator revealed the exposure control plan is in nursing and master control and
is reviewed at least annually. Also, staff have access to review as needed.
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 always account for the whereabouts of
youth under their supervision.
The program maintains a written policy and procedures for youth supervision, movement, and
checks. The policy states active supervision of youth includes interacting positively with the
youth, engaging in a full schedule of constructive activities, closely observing behavior of youth
and changes in behavior, and consistently applying the behavior management system. The
supervision of youth was observed each day during the annual compliance review week. The
program’s staff to youth ratio is one staff to eight youth during the daytime hours and one staff to
twelve youth during the nighttime hours. The program’s safety and security specialists are
responsible for direct and active supervision of youth, described as sight and sound supervision
by the staff. The daily schedule is posted in the living area and contained a full schedule of
activities. Random observations of counts were made throughout the day. There were no
discrepancies in youth and staff ratios. Three informally interviewed staff were able to accurately
respond with the number of youth they were supervising at the time. Six staff were interviewed
and all six were able to summarize the proper procedures when a youth count cannot be
reconciled. Staff stated their responsibilities require active knowledge of the whereabouts of
each youth assigned to them as well as observing their behavior. When staff were asked what
to do if a formal head count could not be reconciled, they replied all movement is stopped, and
counts are reconducted until the correct number of youth is reconciled.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program maintains a written policy and procedures pertaining to the behavior management
system (BMS). The BMS is found in the staff and youth handbooks. The youth handbook
contains what are considered positive and negative consequences for behaviors. There have
been no changes in the BMS during the annual compliance review period. There was an
agreement between the program and the school related to the BMS. The facility administrator
(FA) trained the education staff in the jointly combined BMS plan, which included the use of
BMS during school. Five staff training records were reviewed and included documentation of
staff receiving training on the BMS. All six interviewed staff were able to summarize how
supervisors provided feedback regarding the implementation of the BMS. Ten youth case
management records were reviewed, five from the secured program and five from the non-
secured program. All ten records included documentation the youth received information on the
BMS during orientation to the program. The review presented observations of the BMS including
daily youth and staff interactions. All interactions were appropriate and within the guidelines of
the BMS.
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The FA was interviewed about the BMS. The FA accurately described the BMS system and how
a youth moves through the program. The FA reported rewards are monitored and provided
through the four-to-one ratio, meaning four positives to one negative. The treatment team
ensures positive reinforcers are applied through “gotchas,” earned points, awards, and nightly
incentives. The treatment team also monitors consequences in the program through the BMS.
The FA also reported the implementation of the BMS is discussed during all team monthly
meetings, shift supervisor meetings, and through performance evaluations. Six staff were
interviewed and confirmed rewards were given to youth for positive behavior which included
nightly incentives, “gotchas,” video games, and Big Friday where the youth can receive special
food. Youth who displayed negative behaviors have incentives taken away, such as television,
video games, and iPods. Six youth were interviewed, and all six interviewed youth could
articulate the BMS, how it works, and how to progress through the different levels. The youth
described losing points, not being able to attend outings, and privilege restrictions as the results
for negative behaviors. All six youth were able to adequately summarize rewards received in the
program and were able to provide examples. All six youth were able to describe the differences
between each level of the BMS and how one would move to each level. All six youth reported
they are not allowed to punish other youth. Five youth reported all staff use the rewards in the
same manner. One youth reported some staff have favorite youth and treat some of the youth
better than others. Five youth ranked the BMS system as good, and one youth ranked it as very
good.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program does not utilize room restrictions; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program maintains seventy-three cameras, and all were operational at the time of the
annual compliance review. Video recordings are stored for thirty days. Four samples of ten-
minute checks were reviewed by documentation and video. All checks were documented in real
time and the staff who completed the checks initialed or signed the check sheet. The staff were
observed conducting the ten-minute checks to fidelity. There were no issues with the review of
ten-minute checks. Six staff were interviewed regarding ten-minute checks. All six staff reported
youth are observed in their rooms while sleeping every eight minutes.
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Office of Accountability and Program Support Page 73 of 84 (Revised September 2022)
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are always accounted for through a system of physically counting
youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program maintains a written policy and procedures for youth census, counts, and tracking.
The program utilizes one logbook kept in master control. A review of the logbook was
conducted, and it was documented the counts are entered at the beginning of each shift, after
all activities and/or movements, and as required during emergency situations. It also was
determined the total daily census, head counts, youth movements, new admissions, releases,
transfers, and youth who are temporally away from the program were captured in the logbook.
Observations of random counts were conducted with no noted issues. Six staff were
interviewed, and all reported the appropriate times for when youth counts, and emergency
counts are conducted. All six staff reported the correct census the day of their interviews.
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.
Logbooks were reviewed for the annual compliance review period. All logbooks were bound with
numbered pages, there were no missing pages, and the books were not falling apart. Entries
were made in ink and there were no erasure marks or white-out areas found. When errors were
made, they were struck through with a single line and initialed by the staff correcting the error.
All entries contained the date and time, the name of the staff and youth involved, and a brief
description of the event, as well as the names of the staff making the entry. No logbooks are
kept in the living modules. The logbooks contained documentation of emergency situations,
incidents, special instructions for the supervision and monitoring of youth, population counts at
the beginning and end of each shift, and any other counts conducted. All daily activities, to
include educational instruction, were documented in the logbooks. Perimeter or other security
checks conducted, and transports with details are maintained in the logbook. Admissions,
releases, information relating to escapes or attempted escapes, and any incidents reported to
the Florida Abuse Hotline and/or the Department’s Central Communications Center were logged
in the master logbooks. A shift briefing was observed in master control and on each module. In
addition to the logbooks, shift reports are utilized for every shift. All pertinent information, such
as emergency situations, incidents, counts, and transports were documented.
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5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage.
• Inventory and tracking of keys.
• Secure storage of keys not in use.
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a written policy and procedures in place to govern the control and use of keys.
The policy includes a system of key assignment and usage, to include restricted keys. In
addition, the policy includes inventory and daily tracking of keys, secure storage of keys, and
the procedure to address lost and damaged keys. Personal keys are turned in upon arrival in
exchange for facility keys. Personal keys can only be attained by the return of the facility keys.
Staff assigned keys are inventoried by each shift to ensure accuracy. All keys were maintained
on rings and matched the key inventory form. Restricted keys consist of case managers,
dietary, and therapists. These keys are stored in a separate lock box in master control. Medical,
assistant facility administrators, unit managers, and clinical director keys are secured in a
restricted key lock box for authorized staff only. Unrestricted keys are stored in a lock box in
master control which consists of direct care staff, education, recreation yard, supervisors, and
personal keys. All keys are securely stored. Key and radio control logs are maintained daily on
key/radio log. Damaged keys are logged in the logbook and a tool and key issue form is
completed for maintenance to replace. There have been no lost or missing keys within the last
six months. The program has a process for reporting lost or missing keys within their key control
policy. Six staff were interviewed and accurately described the key control process. An informal
interview was conducted with three random staff. All three staff correctly identified the keys on
their assigned key rings and reported the function of each key. A sampling of six key rings were
observed and compared to the inventory and key log. There were no discrepancies.
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Office of Accountability and Program Support Page 75 of 84 (Revised September 2022)
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 written policy and procedures to address contraband being introduced into
the facility. The youth handbook outlines a list of items considered to be contraband. All youth
are given a copy of the handbook which contains a summary of what is considered contraband
and the consequences for being found with it. Anyone entering the facility is searched with an
electronic wand by a staff. The program has a developed system to implement the prevention of
contraband. The policy delineates what is considered contraband. It is the responsibility of every
staff to assist in the prevention of contraband. Staff should utilize trauma informed practices,
effective communication to alleviate stress, conduct random youth and room searches, and
contact law enforcement for illegal contraband. All staff and youth are given a list of all items
considered contraband. A review of items considered contraband determined all required items
are listed within the prohibited items. Consequences include the contraband being discarded,
returned to original owner, and mailed to youth’s home or stored and returned to youth upon
their release date. Illegal contraband is turned over to law enforcement. Staff are subject to
disciplinary action up to and including dismissal. An internal incident report and a report to the
Department’s Central Communications Center (CCC) are completed. The facility logbooks,
incident reports, and search reports were reviewed to determine the frequency and quality of
searches along with search results. There were no issues noted. There were no incidents of
contraband being found during the annual compliance review period. The facility administrator
reported if a youth, staff, or visitor has contraband, it is to be dealt with immediately. The
contraband is immediately confiscated and destroyed, disposed of, sent to the youth’s home, or
kept as evidence to submit to law enforcement.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 76 of 84 (Revised September 2022)
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
Youth were observed being frisk searched before and after groups and before and after
movement from one activity to another. There were no transports during the annual compliance
review week for observation. All other youth searches were conducted by the appropriate staff
and gender. Prior to conducting the search staff were observed explaining the purpose of the
search. The searches revealed the youth were treated with respect and dignity. Searches and
full body visual searches were based on the Protection Action Response Right Interactions
model (PAR/RI) training manual. Observations included appropriate searches completed upon
each movement of the youth from one area to another. This was observed each day of the
annual compliance review week. Six youth were interviewed and each reported searches are
conducted when returning from off-campus, after outdoor activities, when items are missing,
after visitation, after meals, and after work detail. Six staff were interviewed about searches and
all six reported searches are conducted at every movement.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has two vans on-site for the transportation of youth. A review of documentation
revealed both vehicles have had an annual inspection and required maintenance. There were
no transports scheduled for the week of the annual compliance review. Ten vehicle checks were
conducted during the annual compliance review week. All vehicles were found to be secured.
Vehicles contained fire extinguishers, a first-aid kit (available for transport), seatbelt cutter, and
window punches. Each vehicle contained the appropriate number of seatbelts and youth are not
attached to any part of the vehicle by any other means. Doors to the vans cannot be opened
from the inside. The van utilized for youth in the secure program included a safety screen. Six
staff were interviewed, and all were able to accurately explain how youth are securely
transported. Six youth were interviewed and able to describe how they are secured during
transports.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a written policy and procedures for transportation of youth. A transport cellular
telephone and/or radio is available to staff. One staff of the same gender as the youth is
maintained on all transports. The ratio of one staff to five youth was maintained during all
reviewed transport documentation. The program maintains two vehicles equipped properly for
all transports. A program vehicle sign-in and out log is maintained. A list of approved staff
eligible for transports was provided. All staff had a valid driver’s license and were able to
conduct transports. A youth transport was not able to be observed during the annual compliance
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 77 of 84 (Revised September 2022)
review week. The facility administrator reported the van for the secure youth has a safety screen
which separates the staff from the youth. The non-secure van does not have a safety screen.
Six staff were interviewed about youth transports. All six staff reported a supervisor telephone
and radio are utilized during youth transports. All six staff reported the safety equipment in the
transport vehicles include a first-aid kit, keys for handcuffs, fire extinguisher, seatbelt cutter,
window punch, and the steering wheel lock bar. All six staff reported the transport vehicles are
searched for any contraband before each use. All six staff also reported personal vehicles are
not allowed to be used for youth transports. Six youth were interviewed, and all reported they
have never seen anyone placed contraband in a transport vehicle. All the youth reported they
feel the staff are driving the transport vehicles safely.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a written policy and procedures which outline the weekly safety and security
audits. The facility administrator is responsible for conducting the weekly audits and the
implementation of corrective actions as deemed necessary by deficiencies found during any
internal and/or external review, audit, or inspection. Sample weekly safety and security audit
documents were reviewed and found to meet all requirements. The documentation revealed the
audits were conducted on a weekly basis. All areas of the program are reviewed during the
weekly audit and are emailed to the Department’s safety and security monitor. The program’s
Preventative Maintenance Checklist was reviewed for maintenance schedules and repairs being
completed as outlined in Florida Administrative Code. The facility administrator reported the
tracking of safety and security deficiencies is discussed during daily morning management
meetings along with any calls to the Department’s Central Communication Center (CCC) or
Florida Abuse Hotline. This information is also discussed during monthly all-team meetings with
the program staff. Youth are reminded of the procedures for calling the CCC or Florida Abuse
Hotline during weekly townhouse meetings along with postings of the numbers throughout the
facility.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a written policy and procedures which address the issuance, inventory,
and control of all tools. The policy outlines the process for missing and/or lost tools. There were
no reports of missing or lost tools during the annual compliance review period. All tools are
marked with an identifying number. The maintenance person conducts a daily inventory of all
tools with sharp edges and a monthly inventory of all other tools. The perpetual inventory
includes tools being signed in and out. Kitchen tools were also observed and are inventoried
daily. All staff were found to have completed training for the intended and safe use of tools. A
sample of tools in maintenance and the kitchen were reviewed and all tools were accounted for.
In an instance where a tool is found to be missing a contraband search is conducted and no
youth are allowed to leave the work area until the tool is located.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 78 of 84 (Revised September 2022)
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
to prevent injuries to themselves, other youth, and staff.
The program has a written policy and procedures in place for the issuance of tools to youth and
staff which includes an assessment to determine a youth’s risk to self and others. The program
only utilizes Class B tools for youth use which are mops and brooms. The program maintains
the following ratios during activities involving tools, one staff to five youth for activities involving
tools and one staff to three youth for disciplinary work projects. The vocational training ratio is
maintained at one staff to five youth. Five youth case management records were reviewed. All
five case management records included documentation of the youth being trained in the safe
use of Class B tools, as well as a risk assessment. Six interviewed staff reported youth are
allowed to use screwdrivers, scrub brushes, mops, and brooms. One staff reported the youth
are only able to use the tools when supervised. Two staff reported the youth can only use tools
with a completed risk assessment. Six interviewed youth reported they are allowed to use
screwdrivers, rakes, scrub brushes, mops, brooms, and rags or towels.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a written policy and procedures regarding outside contractors. The policy
provides contractors with a notice of tool/equipment instructions prior to any work occurring,
restricting use to only the tools deemed necessary. Contractor agreement forms were reviewed
and found all tools were checked upon arrival and again at departure. All required elements
were included on the contractor agreement forms. All youth are restricted from where the work
is being conducted during the process. Sign-in sheets were reviewed and found to be
completed correctly and signed by program staff. Only the program director can approve cellular
telephones or other devices.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a written policy and procedures to provide for the safety and security of both
staff and youth. All drills were provided for review. The documentation showed drills were
consistent with the Continuity of Operations Plan (COOP). All drills contained the type of drill,
date, time, participants, and a brief scenario, including findings and recommendations. Fire drills
were conducted monthly with no exceptions. Emergency drills were also conducted to include
disaster and bomb threat drills. Evacuation and egress routes were posted throughout the
facility, and all twenty-nine fire extinguishers were inspected annually. The facility administrator
reported fire drills and medical drills are conducted monthly. It was also reported suicide drills
and disaster drills are completed quarterly. Six staff were interviewed and reported they
participated in weather, major disturbance, bomb threat, hostage situation, chemical spills,
flooding, terrorism, escape, and fire drills. The staff also reported participating in suicide drills
and active shooter drills. Six interviewed youth reported they have been instructed on what do in
case of fire. Five of the youth reported drills are conducted once to twice a month. One youth
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 79 of 84 (Revised September 2022)
reported fire drills are conducted every few days. A review of drill documentation showed the
drills are conducted once a month.
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 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 has a written policy and procedures addressing the Continuity of Operations Plan
(COOP). The plan underwent review, approval, and was signed by the regional director on
February 23, 2023. Housed in master control, the plan is readily accessible to all staff within the
facility. Notably, the program’s disaster plan and the COOP are combined into one single
document, encompassing approved alternative housing plans as endorsed by the Department’s
regional director or designee. The COOP encompasses protocols for fire prevention,
evacuation, severe weather response, managing disturbances or riots, handling bomb threats,
hostage situations, chemical spills, flooding, terrorist threats or acts, delineates staff roles and
responsibilities, outlines necessary equipment and supplies, information about youth, alternative
housing arrangements, provisions for ensuring continuity of care and custody of the youth, as
well as provisions for public protection. Necessary equipment and supplies needed for
continuous operation and disaster response are stored in designated areas, including dry goods
and various canned foods. Records are packed, secured, and transported to the evacuation site
in emergency scenarios. Additionally, the program maintains comprehensive youth records for
emergency purposes. Five youth records were reviewed which included the youth’s full name,
the Department identification number, admission date, date of birth, gender, race,
parent/guardian contact information, who to notify in case of an emergency, the assigned
juvenile probation officer’s contact information, the committing judge, state attorney, public
defender, committing offense and judicial circuit, if the judge retains jurisdiction, victim
notification contact information, physical description of the youth, overall health status, personal
physician, and a photograph of the youth. The facility administrator reported the staff always
have access to the COOP in master control.
5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program has a written policy and procedures detailing a formal process for the storage and
inventory management of flammable, poisonous, and toxic materials. These substances are
securely stored in designated areas across the facility, including an outside storage shed,
outside closet, secured cabinets in the kitchen area, and a cabinet in master control. Flammable
materials like motor oil, gas, or pesticides are stored in the metal storage building outside, with
only maintenance staff and the facility administrator permitted to handle them. A sample
inventory of four chemicals was reviewed, confirming all items matched the inventories and
were accounted for on-site. All items on-site were accounted for on the observed inventories.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 80 of 84 (Revised September 2022)
Safety Data Sheets (SDS) were available for all reviewed materials. Access to the storage
areas is restricted to authorized staff only.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items, and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains strict control of flammable, poisonous, and toxic items, and materials,
with policy prohibiting youth access. These items are kept outside secure buildings, inaccessible
to youth. Observations affirmed this with no youth being seen handling chemicals. In interviews
with six youth, two reported using paint, while one mentioned using laundry soap. The youth
who used paint noted staff and maintenance supervision, adherence to safety protocols, and
staff assistance when more paint was required.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The maintenance staff oversees hazardous waste disposal, with kitchen grease managed
through an outside contractor stored outside the secure area. Liquid waste from the kitchen is
directed into drains. Corrosive and flammable items are properly disposed of in a hazardous
waste container, collected by the county for recycling and disposal. Procedures align with the
Occupational Safety and Health Administration (OSHA) guidelines for hazardous and toxic
substance disposal. The facility administrator confirmed compliance regarding disposal
regulations of flammables, toxic, caustic, and poisonous items. Additionally, kitchen grease
disposal occurs in the grease trap within the sally port, while all chemicals are safely disposed
of through drains located in the utility closet.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 81 of 84 (Revised September 2022)
5.21 Elements of the Water Safety Plan, Staff Training, and
Satisfactory Compliance
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 facility does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a written policy and procedures detailing visitation, correspondence, and
telephone use protocols. Visitation for non-secure youth occurs on Sundays from 1:00 p.m. to
4:00 p.m., with the schedule prominently displayed in the front lobby. Each youth receives a
youth handbook during orientation, outlining the visitation and communication process. Family
members must sign-in on a separate visitor roster. All reviewed documentation was complete,
and met requirements, with case management staff responsible for maintaining the youth’s
authorized telephone, mail, and visitation list. Youth with a history human trafficking have
clarification documentation from their juvenile probation officer (JPO). Youth are allowed to write
two letters a week and may earn additional correspondence and telephone privileges through
the behavior management system. Six youth were interviewed, four reported uncertainties about
available services for youth and their families who do not speak English as a primary language,
while one noted bilingual staff can assist, and two mentioned potential translators. Similarly, six
staff were interviewed, with two expressing uncertainty and four affirming translator availability.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 82 of 84 (Revised September 2022)
The facility administrator confirmed the use of interpreter services to aid non-English speaking
youth and families.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a written policy and procedures addressing activities tailored to the
developmental needs and levels of the youth in the program. Activity schedules were observed
to be posted in program areas, encompassing both leisure and recreational options. Activities
and games were observed during the annual compliance review week. Both indoor and outdoor
activities were observed to be provided for at least one hour daily. Logbooks documented
activities according to the schedule, with indoor games like four-square and dodgeball offered if
outdoor participation isn’t feasible. Additionally, the program hosts student council meetings
twice monthly, facilitated by the unit managers, with agendas and meetings records available for
review. According to the program’s contractual agreement, a recreational therapist is required,
whose credentials were reviewed and met all requirements. Staff confirmed various activities
provided for youth including cards, puzzles, checkers, dodgeball, basketball, video games,
football, and walking/running. Six youth interviews were conducted, and each youth affirmed
physical activities are provided for at least one hour daily. The youth gave examples of activities
including football, basketball, volleyball, use of outdoor exercise equipment, push-ups, sit-ups,
run, and elliptical.
5.24 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program has a written policy and procedures for the use of controlled observation. Fourteen
instances of youth placed in controlled observation were documented since the last annual
compliance review. Records for five youth placed in controlled observation were reviewed, all of
which met the search and inspection guidelines. The controlled observation room meets all the
required standards.
5.25 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program has a written policy and procedures concerning controlled observation, specifying
its use as an immediate short-term crisis management strategy when a youth displays
aggressive, violent, or potentially dangerous behavior, threatens physical safety of others, or
poses a risk to program security. Controlled observation is utilized as a non-physical
intervention. Five instances of controlled observation were reviewed, and each youth met the
criteria for placement on controlled observation, which was approved by the supervisor or
someone of higher authority. Visual checks were conducted every fifteen minutes and
documented for each of the five youth records reviewed. The medical department performed
Health Status Checklists on all youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 83 of 84 (Revised September 2022)
5.26 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program has a written policy and procedures in place regarding safety checks and release
procedures for youth on controlled observation. Five instances of controlled observations were
reviewed, and each youth met criteria for placement on controlled observation. The supervisor,
or someone of higher authority, approved each placement. Visual checks were conducted every
fifteen minutes and documented for each of the five reviewed instances. All five reviewed
releases were authorized by either the facility administrator (FA) or a supervisor. In all five
reviewed records, the FA or assistant facility administrator reviewed and approved all controlled
observation reports within fourteen days. Staff determine the need for an in-house alert after the
youth is released. The Controlled Observation Report, Health Status Checklist, and Controlled
Observation Safety Check forms were stored in both an administrative record and the youth’s
individual management record. Six youth were interviewed, and three youth reported they were
sent to their rooms when they were in trouble, while three others reported they were not. Two
youth reported being in their rooms for approximately twenty to thirty minutes. All three youth
reported the door was left open.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 84 of 84 (Revised September 2022)

report_type: QI Residential

program_name_raw: Crestview Youth Academy