state: FL

facility_name: Walton Academy for Growth and Change

summary: QI Residential - FY23-24 - 5 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Walton Academy for Growth and Change
Rite of Passage, Inc.
(Contract Provider)
286 Gene Hurley Road
Defuniak Springs, Florida 32433
Review Date(s): April 9-12, 2024
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:
Patrick McKinstry, Office of Accountability and Program Support, Lead Reviewer (Standard 4)
Cio’nna Allen, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Kristin Hansen, TrueCore Behavioral Solutions, Compliance Manager (Standard 2)
Ken Myers, Office of Education, Education Coordinator, Circuit 1 (Standard 2)
James Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Cedric Prince, Office of Accountability and Program Support, Regional Monitor (Interviews)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Walton Academy for Growth and Change MQI Program Code: 1443
Provider Name: Rite of Passage, Inc. Contract Number: 10358
Location: Walton County / Circuit 1 Number of Beds: 42
Review Date(s): April 9-12, 2024 Lead Reviewer Code: 144
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures),and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
2.10 Performance Plan Revisions 5.13 Tool Inventory and Management
3.12 Suicide Precaution Observation Logs *
5.08 Contraband Procedure
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 67 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Non-Applicable
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Non-Applicable
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)* Non-Applicable
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 67 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Limited
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 67 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Limited
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 67 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 67 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Limited
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 Failed
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 Limited
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 Non-Applicable
5.26 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 67 (Revised September 2022)
Program Overview
The Walton Academy for Growth and Change is a forty-two-bed program, for thirteen- to
eighteen-year-old males, located in DeFuniak Springs, Florida. The program is operated by Rite
of Passage, Inc., through a contract with the Department. The program provides services
including Substance Abuse Overlay Services (SAOS) and Mental Health Overlay Services
(MHOS), which include innovations in delinquency programming. In addition, the program
fosters each youth by providing Aggression Replacement Training (ART), Council for Boys and
Young Men, Impact of Crime, Seeking Safety, Thinking for Change (T4C), Trauma-Focused
Cognitive Behavioral Therapy (TF-CBT), and Skillstreaming the Adolescent. Additional
treatment services provided include family and individual therapy. Program administration is
comprised of a program director, director of group living, and director of youth services. Case
management services are provided by two transitional service coordinators and one part-time
transitional service coordinator. Mental health staff at the program include a clinical director who
is the designated mental health clinician authority (DMHCA), and two therapeutic managers.
Medical services are offered daily 7:00 a.m. to 5:00 p.m. by the health services administrator
(HSA) and one registered nurse (RN). The program did employ a licensed practical nurse (LPN)
for approximately four months. The program has a contract with a medical doctor, who serves
as the designated health authority (DHA). The DHA is on-site a minimum of two hours a week.
Educational services are provided by Walton County School Board. The layout of the program
includes three building structures, one building housing most of the program operations, one
building housing the Home Builders Institute (HBI) program, and the third building is for the
Project Anchor program. The program had eighty-two out of eighty-four operating security
cameras providing coverage. The two remaining cameras have a work order to be fixed. At the
time of the annual compliance review, the program had two vacant positions including one shift
supervisor and one recreation therapist.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 67 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program reported having no volunteers, interns, or mentors who required initial background
screening during the annual compliance review period. The program submitted its Annual
Affidavit of Compliance with Level 2 Screening Standards to the Background Screening Unit
(BSU) on December 14, 2023. Background screening for teachers is done through the Rader
Group, which is contracted to provide educational services at the program. Documentation also
was provided indicating the lead teacher at the program submitted their Affidavit of Compliance
with Level 2 Screening Standards for School Board Personnel on January 3, 2024. Based on
the current staffing roster provided, the program had thirty staff who required initial background
screening during the annual compliance review period. All thirty records were reviewed, and
each was screened and found eligible prior to their initial date of hire. Criminal history report
information was reviewed and included for all thirty records reviewed. All but one staff had
evidence of inclusion in the Clearinghouse employee roster; however, was added by the human
resources staff during the annual compliance review. All thirty staff records reviewed also
included evidence each completed Ergometrics as their pre-employment assessment tool. Each
staff had a passing score, which was reflected and included in all the reviewed records.
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 had no applicable staff to review for five-year rescreening requirements during the
annual compliance review period. The program has a policy and procedures which notes
background rescreening/resubmission shall be conducted for all program staff, contracted
providers, volunteers, mentors, and interns with access to youth and confidential youth records.
Staff and volunteers are rescreened every five years from the initial date of employment.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 67 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
Observations found evidence of postings in various program areas for emergency numbers to
the Department’s Central Communications Center (CCC) and Florida Abuse Hotline. The
program has a policy and procedures regarding abuse reporting, which indicates all staff,
volunteers, interns, or contracted staff shall immediately report any allegations or suspicion of
an incident of abuse or harassment which has occurred in the program to the Florida Abuse
Hotline or the CCC, for youth eighteen years of age or older. If a youth refuses to place an
abuse call, staff must place the call if the staff has reasonable suspicion abuse has occurred.
Staff shall notify the program director and on duty supervisor as soon as the call has been
placed, as well as provide the reason for the call. An internal incident report shall be completed
and forwarded to the respective supervisor once the call has been made. Based on a review of
CCC reports received for the annual compliance review period, the program had a total of seven
incidents related to physical, psychological, or emotional abuse. Three incidents were
documented with substantiated findings. A total of six incidents were reviewed, which indicated
the Florida Abuse Hotline or CCC had been notified. None of the reviewed incidents included
evidence there were any potential human trafficking victims, child sexual exploitation, or labor
trafficking. Seven reviewed staff personnel records included evidence each staff signed for
receipt of the program’s code of conduct. The program director provided documentation
indicating the Trauma Responsive and Caring Environment (TRACE) self-assessment was
completed on July 11, 2023. The program director was interviewed and outlined/summarized
the program’s staff code of conduct. The program director reported the program incorporates
trauma responsive practices through their Champions Team, completing TRACE self-
assessments, staff training on trauma, and providing a voice to youth through student
government, Town Hall meetings, One on One Requests, and the grievance process. The
program director further explained the program’s incident reporting process by stating the
program director or designee is notified as soon as possible of an incident and an internal
incident report is completed. If reportable, the CCC and Florida Abuse Hotline are called.
Incidents are discussed daily in management meetings and daily shift briefings. Five interviewed
staff all were able to summarize the abuse reporting process. None of the five staff reported
ever hearing another staff refuse a youth’s right to report abuse allegations. Four of five
reported never observing a co-worker using profanity when speaking with a youth. One reported
they had heard a co-worker use profanity speaking with a youth; however, the incident was
more regarding a situation and not directed at the youth. All five interviewed staff reported
familiarity with the Florida Abuse Hotline number. Five interviewed youth all reported feeling
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Office of Accountability and Program Support Page 11 of 67 (Revised September 2022)
safe in the program. None of the youth reported ever having been stopped from reporting abuse
while in the program. All five youth reported they knew the Florida Abuse Hotline number. All
five youth reported staff were respectful when speaking with them. Four of five reported they
have not heard staff use curse words when speaking with them or other youth. One reported
they have heard this; however, the youth reported the incident was not worth remembering.
None of the five interviewed youth reported having ever exchanged emails, social media, or
telephone numbers with staff at the program.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
A total of five incidents were reviewed, and they contained evidence of program management
taking immediate action and applying applicable corrective actions for incidents related to
allegations of abuse or neglect. The program director was interviewed and stated allegations of
abuse are addressed through mandated reporting and an internal investigation, and necessary
corrective action is determined by the findings.
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.
Since the last annual compliance review, up to March 29, 2024, the program had a total of fifty-
eight incidents reported to the Department’s Central Communications Center (CCC). Since
March 29, 2024, the Department has experienced technical issues with the Department’s
Juvenile Justice Information System (JJIS) which has restricted access to JJIS and reviewing
alert information as well as CCC daily report information. There were no additional internal
incidents/grievances reviewed which should have been reported to the CCC based on
observations made. Seven CCCs were reviewed for incident reporting requirements, based on
the CCC information previously obtained. The review revealed all seven incidents were reported
within the two-hour time frame. All seven were also documented as required within the master
control logbook. The number of CCCs has increased since the last annual compliance review.
The program director reported they conduct monthly key performance indicators and statistical
reports to watch for trends relating to CCCs. In addition, the program director reported there has
been a higher level of accountability for staff since being hired for the position.
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Office of Accountability and Program Support Page 12 of 67 (Revised September 2022)
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program experienced an increase in Protective Action Response Right Interactions model
(PAR/RI) incidents since the last annual compliance review. The program’s PAR/RI rate during
the previous quarter was 2.78, which is above the statewide Residential PAR/RI rate of 1.76.
The program director was interviewed and stated they complete a monthly trend analysis on
each PAR/RI Summary Report to address patterns in relation to a PAR/RI involvement of youth
or staff. In addition, the program experienced a hold on youth admissions for a month due to an
evacuation, after which they experienced an influx of youth which created some behavior
problems. The program director reported administration is notified of any use of force incident
as soon as possible. Each incident is reviewed daily at management team meetings, along with
video and PAR/RI Reports. Corrective action and training are taken as needed. The program
had a total of thirty-nine PAR/RI incidents during the annual compliance review period. A
sample of five was reviewed which included documentation showing a statement completed by
each staff involved by the end of the staff’s workday. None of the reviewed incidents included
evidence of youth or staff injury, or usage of mechanical restraints. None included evidence of
allegations for abuse, requiring contact with the Florida Abuse Hotline. Each of the five reports
had documentation of a review by a supervisor and a PAR/RI-certified supervisory staff. Four of
five had documentation the report was reviewed by the administrator or designee within
seventy-two hours of the incident. The remaining one report had the administrator/designee
signature but did not include the date of the administrator review. PAR/RI Report documentation
is maintained in a centralized file within administration. Four of five interviewed staff confirmed
they had utilized PAR/RI in the program. Staff gave examples of the PAR/RI process by stating
they try to utilize verbal de-escalation techniques prior to using physical action. One confirmed
they had not used PAR/RI.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program utilizes the position of coach counselors as the primary direct care position. In
addition, shift supervisors and maintenance staff may also be utilized as direct care if not
working within their current job description. A sample of five pre-service training records was
reviewed for pre-service training requirements. Due to statewide technical issues affecting the
Department’s Juvenile Justice Information System (JJIS), the Department’s Learning
Management System (SkillPro) was unable to be viewed during this annual compliance review.
Verification of pre-service training was done through a review of each staff’s training records,
training calendar, and completed training list maintained by the program’s training coordinator.
Based on a review of provided documentation, all five staff records reflected each staff received
all essential skills training prior to youth contact, including training for Right Interactions, Suicide
Awareness and Prevention, Emergency Procedures, Facility Operating Procedures, Child
Abuse Reporting, Prison Rape Elimination Act (PREA), and first-aid/cardiopulmonary
resuscitation and automated external defibrillator trainings. Each staff was still within their initial
180 days of hire. Each of the five staff records also included evidence of additional required
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Office of Accountability and Program Support Page 13 of 67 (Revised September 2022)
trainings completed, as well as additional contractual trainings completed as required. All
instructors were qualified to deliver trainings as provided.
1.08 In-Service Training Non-Applicable
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.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
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. The program’s
grievance process includes an informal, formal, and appeal phase. In addition, youth may
complete one-to-one forms which give youth opportunities to request meetings with staff to
address issues which may arise. Observations made during the annual compliance review week
found evidence of grievance forms and one-to-one forms located in each of the living units. A
metal drop box with the blank forms was also located. The director of group living stated both
himself and the program director check the boxes daily for these completed forms. The program
maintains all one-to-one forms and grievance forms for the annual compliance review period in
binders. A sample of five grievance forms was reviewed and found each one was noted as
resolved, signed by the youth, and responded to by staff within the required time frame. The
program director was interviewed and stated the grievance process has three phases which
include the informal phase, where an attempt is made to process the incident with the staff, the
formal phase goes to the supervisory staff to review and determine resolution, and the appeal
phase is done if the youth did not agree with the resolution in the second phase, thus the
program director or designee would then review to provide a further determination. Five
interviewed youth were able to summarize the grievance process, and all five confirmed they
could ask for assistance when completing a grievance. Five interviewed staff were also able to
summarize the program’s grievance process.
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1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
Four staff records, including two therapists and two designated mental health clinician
authorities (DMHCAs), were reviewed for interventions and facilitator training requirements. All
four staff had the required education and work experience required to deliver delinquency
intervention services. Records indicated each staff received training in delivering groups they
have been facilitating. The program’s daily activity and group schedule reflected groups are
facilitated weekly as required. Cognitive Behavioral Therapy, Living in Balance, and
Skillstreaming the Adolescent groups are each facilitated three times weekly. All applicable
groups are being provided as outlined in the provider’s contractual agreement and contract
table. The activity schedule determined the program is providing structured, planned
programming, and activities at least sixty percent of the youth’s awake hours. The DMHCA was
interviewed and stated the program utilizes several evidence-based group curriculums to
include Seeking Safety, Aggression Replacement Training, Skillstreaming the Adolescent,
Cognitive Behavior Therapy, Living in Balance, and Impact of Crime. The program director was
interviewed and provided documentation of all staff who share responsibility for facilitating
groups at the program.
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 addressing life and social skills training
provided for youth. The policy indicates life and social skills address areas such as identification
and avoidance of high-risk situations, communication and relationships, non-violent conflict
resolution, critical thinking, and anger management. Life skills interventions provided are
evidence-based and include groups such as Living in Balance, Skillstreaming the Adolescent,
Seeking Safety, and Aggression Replacement Training (ART). The program’s life skills offered
address the needs of the program’s targeted gender group. Sign-in sheets were reviewed which
confirmed groups are being facilitated as required. In addition, medical records included
evidence of health education provided for youth by the program’s medical staff. The program’s
designated mental health clinician authority (DMHCA) was interviewed and confirmed groups
were being provided. The DMHCA stated youth complete role plays in groups and are provided
the opportunity to use the skills learned in daily interactions with others. Five interviewed youth
confirmed participation in groups and activities at the program. The program director interview
confirmed the program addresses the needs of a targeted gender group through needs
assessment and performance/treatment planning.
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1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s Impact of Crime (IOC) groups are considered primary services. In addition to
these restorative justice groups, youth are given opportunities to participate in community
service activities. Community service logs are maintained in the youth’s individual management
records. The designated mental health clinician authority (DMHCA) was interviewed and stated
the IOC curriculum is provided twice weekly. The program director was interviewed and
confirmed the program is providing the IOC curriculum restorative justice group. In the event a
youth has already taken IOC, the program director reported they will still retake the group. In
addition, youth are permitted to participate in activities such as community service hours, which
intentions are to restore victims and communities. Five interviewed youth confirmed they have
participated in the IOC curriculum. All five were able to give examples of things they have
learned while involved and participating in groups.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Non-Applicable
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
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 mental health, case management, and
medical. All youth records were labeled as confidential. All records were observed to be secured
in a locked file cabinet when not being used. The cabinet and staff office door outside the area
were labeled confidential. Youth individual management records are divided into sections which
include the youth’s legal information, demographics and chronological information,
correspondence, case management and treatment team activities, and miscellaneous
information. Each record contained the youth’s name, Department identification number, date of
birth, county of residence, and committing offense.
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1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program solicits involvement from all required representatives for participation in a quarterly
community advisory board meeting. Participants are emailed by the program, inviting them to
participate. Documentation of quarterly meetings was provided for the annual compliance
review period. Sign-in sheets and agendas were observed for meetings conducted on March 31,
2023, October 24, 2023, and February 8, 2024. The next scheduled meeting was documented
to be held on May 23, 2024. The program had no documentation of meetings conducted for the
quarter prior to the October 2023 meeting. There was evidence of a retraining conducted by the
provider’s corporate leadership for all program administration done September 21, 2023, which
served as corrective action intended to restart the community advisory board meetings as
required. Retraining included sign-in sheets for all program leadership and topics of discussion.
Since the retraining/corrective action occurred, the program has been conducting the quarterly
meetings as scheduled. Telephone contact was made with a member of the program’s
community advisory board. The individual confirmed they do participate in the meetings and
enjoy the process. They stated they are notified of meeting dates by emails sent by the
program. The program director was interviewed and confirmed the community advisory board
meetings are held quarterly. Participants include members from areas such as law enforcement,
community agency members, education, and faith-based representation. The program director
further stated they work on recruiting and improving the attendance of members. Any
recommendations provided in the meetings are documented in the minutes and utilized when
appropriate.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a written policy and procedures which indicate staff are to receive evaluations
on performance annually. Five different program job descriptions were reviewed and found
evidence each staff position had clearly identified performance standards. Five staff personnel
records were reviewed and each had a completed annual evaluation as required. Performance
standards for all five staff matched the job descriptions for each staff member reviewed. A
review of the provider’s contractual agreement was done in comparison with the program’s
current vacancy list and found the program had one key position vacant, which was of the
recreational therapist. Five interviewed staff confirmed they receive performance evaluations
annually, two stated the evaluations were done monthly. The program director was interviewed
and confirmed staff turnover and morale have been addressed in the hiring of a trainer
committed to improving pre-service training delivery, which results in a reduction of staff
turnover. An employee of the month is identified monthly and recognized by the team. Ongoing
trainings are also provided during all team meetings. The program director reported they are
currently overstaffed, so turnover does not impact service delivery. The program director stated
each staff is evaluated at ninety days, then one year from the date of hire. One on one quarterly
meetings are also completed by supervisors for staff to provide ongoing feedback.
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1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program director was interviewed and stated special contract specific services provided
include certifications for cardiopulmonary resuscitation (CPR) and first-aid, certified nursing
assistant (CNA), Occupational Safety and Health Administration (OSHA), and Florida Ready to
Work. Five youth interviews confirmed the youth participated in vocational opportunities at the
program. The program provided documentation of youth sign-in sheets and certifications
received for areas such as Project Anchor, Culinary Arts, Entrepreneurship Program, and
CPR/first-aid certification. Special contract conditions also include six family days each year.
The program’s third Saturday of each month will be considered Family Day for the program.
Visitation is from 11:00 a.m. until 3:00 p.m. The program provided the visitation binder which
included documentation showing Family Day was being conducted monthly.
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.
According to the provider’s contract, career and technical education services to be offered
include Occupational Safety and Health Administration (OSHA), certified nursing assistant
(CNA), ServSafe, Project Anchor, OSHA-10 certification, Florida Ready to Work, and
cardiopulmonary resuscitation (CPR)/first-aid certification. The program director reported they
had no youth at this time with expressed interest in the CNA program. According to the program
director, four youth have been identified to participate in the Florida Ready to Work program,
which is scheduled to begin April 15, 2024. Documentation included certifications, sign-in
sheets, and photos documenting youth participation in career and technical education services
offered. According to documentation received, a total of twenty-three youth received
certifications in ServSafe. Seven youth received certificates for Certified Breakfast Assistant,
two for Trip Advisor: Management for Front Line Staff, seven certifications were received for
Certified Guest Service Professional, and seven for Certified Kitchen Cook. Thirteen total youth
certifications were received for OSHA-10 and twenty-five youth for Project Anchor, with three
enrolled at the time of the annual compliance review. In addition, sixteen youth graduated from
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the Home Builders Institute (HBI) vocational program and earned certifications. HBI had ten
youth enrolled at the time of the annual compliance review. One youth received a certification
for the Entrepreneurship Program. Career and technical education services are provided by
qualified personnel based on a review of qualifications, education, and certifications. Five
interviewed youth confirmed their participation in vocational services provided at the program.
The program director was interviewed and stated contract specific pre-vocational and vocational
services were provided, including CPR/first-aid, CNA, OSHA, and Florida Ready to Work.
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 reviews and analyzes data in everyday decision-making practices. The program
creates charts for each data trend topic. Topics include areas such as numbers of restraints,
youth admissions/releases, physical altercations, and Protective Action Response Right
Interactions model (PAR/RI) use. A power-point is created and given to all staff and
administration monthly during staff meetings. Reviewed documentation supported the program’s
practice. The program director stated upon request from the Department, the provider would
share this information. Program administration also participates in monthly calls with the
Department’s Residential Operations staff to discuss significant or upcoming events, youth
admissions/releases, staff vacancies, PAR/RI incidents, pending work orders, outstanding
safety and security issues, and facility maintenance issues or concerns. Documentation of these
monthly calls was observed, confirming the program’s practice and participation. The program
director stated an internal system developed by the provider is used, as well as utilization of key
performance indicators and maintained Excel data to review for improvement of program
processes. Changes may then be made based on trends observed from the data collected.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a written policy and procedures in place to address initial contact with the
youth’s parent/guardian as well as the committing court. The program’s policy states within
twenty-four hours of the youth’s admission to the facility, case management staff shall contact
the youth’s parent/guardian by telephone to notify them of placement. Within forty-eight hours,
case management staff shall provide written notification of the youth’s placement to the
parent/guardian. Within five working days, case management staff notify the youth’s committing
court, assigned juvenile probation officer (JPO), and post-residential services case manager, as
applicable. Five youth case management records were reviewed, and the records contained
documentation the parent/guardian was contacted by telephone on the day of admission. All
records indicated the parents/guardians were mailed a parent/guardian admission letter on the
day of admission which spoke about length of stay, visitation, and the performance planning
process. Along with the admission letter, parents/guardians also received supplemental
information to include a parent/guardian intake survey and rules for visitation. All reviewed
records contained a copy of the judge notification of admission letter sent to the committing
court informing them of the youth’s placement which was mailed on the day of admission. The
documentation further indicated the youth’s assigned JPO was copied on the notification and, if
known at the time of admission, the youth’s post release counselor.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a written policy and procedures in place to address youth orientation. Five
youth case management records were reviewed, and all contained documentation showing the
youth participated in an orientation on the day of admission. The youth’s assigned case
manager completes the orientation checklist, which addresses the program’s rules,
expectations, goals, and services applicable to the youth. The orientation conducted with each
youth included all the required topics, which were discussed with the youth by the case
manager. Once all information is reviewed, forms are signed and dated by both the youth and
the case manager. All records contained a signed acknowledgement where each youth received
a copy of the program’s handbook. Additional information included a review of rewards and
consequences, Prison Rape Elimination Act (PREA) information, information on how to access
outside victim advocates for emotional support services related to sexual abuse, and items
deemed unauthorized when in possession of youth. Five youth were interviewed and stated
their orientation to the program began within twenty-four hours of admission and included a
review of program rules, procedures, and schedules. In addition, four out of five youth were able
to explain the orientation process. One youth indicated they do not remember for it was over a
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year ago. There were no admissions to the program during the annual compliance review week
while the team was on-site; therefore, a youth orientation could not be observed.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a written policy and procedures in place which require the 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 screening, assessment, or treatment. Five youth
case management records were reviewed to determine if the program obtained written consent
for providing youth information with the parent/guardian, Department of Children and Families,
or other applicable agencies. Only one reviewed record was applicable, as the remaining four
youth were under the age of eighteen. Two additional case management records for youth over
the age of eighteen were requested and reviewed. All three applicable records contained an
authorization to release information form signed by the youth on their eighteenth birthday or
upon admission to the program for those youth who were already eighteen years of age at the
time of placement, as well as signed by a witness.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a written policy and procedures in place which address a classification system
implemented in accordance with Florida Administrative Code and promotes safety and security
as well as the effective delivery of treatment services. On the day of admission, a classification
meeting is conducted to assign the youth to a living unit, sleeping room, and youth group or staff
advisor. During the classification meeting, a youth admission classification sheet is completed,
which addressed all required areas for classification. Completed classification sheets are signed
and dated by the treatment team members involved in the process. The youth’s
parents/guardians were also contacted to participate in the meeting, either in person or by
telephone. Five youth case management records were reviewed. Each record contained a
classification form completed on the day of the youth’s admission to the program which
addressed all requirements. In all instances, hard copies of the Vulnerability to Victimization and
Sexually Aggressive Behavior (VSAB) were completed by mental health staff on the day of the
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youth’s admission to the program and reviewed with the treatment team during the classification
process. During the annual compliance review week, the Department’s Juvenile Justice
Information System (JJIS) was down and unable to be accessed to verify if alerts and VSABs
were entered in a timely matter. An interview with the program director confirmed factors such
as, physical health status, level of aggression, age, and home county are all considered when
classifying youth and assigning them to a dormitory and sleeping room. The program has a
system in place for reassessing youth 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 off-campus
activities. At admission, an initial youth classification form is completed. As warranted,
reassessments are completed and filed in the youth’s case management record. All five
reviewed records contained evidence of an initial classification, and three out of five had
reclassification sheets which were signed and dated by members of the treatment team. Five
case management records were reviewed for risk assessments. All five youth in the sample size
had a risk assessment completed at admission to the program as well as monthly risk
reassessments/updates completed during their informal treatment team meeting.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a written policy and procedures in place which outline notification of law
enforcement regarding youth entering the program with suspected gang affiliation or
documented gang membership, as well as for youth who are observed engaging in gang
activities during their commitment to the program. Five youth case management records were
reviewed; however, only two youth were applicable for gang affiliation or membership. The
program was able to provide one additional youth record for review of gang identification and
notification. All three reviewed youth case management records contained a security threat
questionnaire which was completed at the time of admission to the program to gauge each
youth’s level of gang involvement, if any. Completed questionnaires were signed and dated by
both the youth and the youth’s assigned case manager. All documentation was maintained in
the youth’s individual record as well as in a gang binder. For all three reviewed youth records,
there was documentation showing notifications were made to all requisite jurisdictions. One of
the three reviewed records documented notification to local law enforcement prior to the annual
compliance review notification. Each youth had documentation of the youth’s gang status being
shared with on-site education staff and the youth’s juvenile probation officer (JPO). The
program’s process is to copy the educators and JPOs on the law enforcement notifications.
Information was unable to be verified against the Department’s Juvenile Justice Information
System (JJIS) alerts due to JJIS being inaccessible during the annual compliance review.
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2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a written policy and procedures in place which address the implementation of
gang prevention and intervention strategies. During the admission process, youth are screened
for gang involvement on the youth admission classification form as well as on a separate gang
questionnaire. Youth identified as having gang involvement have an alert entered into the
Department’s Juvenile Justice Information System (JJIS) as well as the program’s internal alert
board. Youth identified as being criminal street gang members, are affiliated with any criminal
street gang, or who are at a high risk of gang involvement are required to participate in gang
prevention and intervention activities. The program uses Gang Resistance and Drug Education
as its main gang curriculum. The program also uses Impact of Crime (IOC) as part of its gang
prevention and intervention strategies. Lastly, the program’s policy indicates a youth will be
provided the opportunity to dis-affiliate from their identified criminal street gang should they
choose to. Five youth case management records were reviewed; however, only two youth were
applicable for gang involvement. The program was able to provide one additional record to
review. All three reviewed youth had gang goals listed on their individualized performance plan,
though one was entered at the youth’s first formal treatment team after it was determined to be
initially omitted from the initial performance plan. A review of the program’s gang binder found
all three youth were participating in monthly gang intervention groups as evidenced by observed
sign-in sheets. The program director interview identified practices for if a youth has a gang alert,
the youth is placed in a monthly gang intervention group.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a written policy and procedures to ensure a Residential Assessment for Youth
(RAY) is completed within thirty days of the youth’s admission to the program, and the RAY
Reassessments are completed every ninety days after the completion of the initial RAY. Five
youth case management records were reviewed, and four out of five contained an initial RAY
completed within the required time frame. One youth’s RAY was ten days late. The
Department’s Juvenile Justice Information System was unable to be accessed during the annual
compliance review week to verify if the initial RAYs were maintained in JJIS. Each youth also
had a copy of their RAY overview report filed within their individual record. Five youth case
management records were reviewed to determine whether a RAY Reassessment was
completed within ninety days. Two records were applicable for RAY Reassessments. Both
records contained the required RAY Reassessment documentation completed every ninety
days, with one record having a total of four reassessments completed. The updated RAY
overview reports, along with the RAY comparative risk and protective reports, were maintained
in each youth case management record.
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2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
The program has a written policy and procedures in place to ensure the Youth Needs
Assessment Summary (YNAS) is conducted within thirty days of the youth’s admission to the
program. The youth’s assigned case manager is responsible for gathering information from all
members of the treatment team as well as collateral documents and incorporating this
information into the YNAS. Five youth case management records were reviewed, and four out of
five records contained a YNAS completed within the required time frame. One youth did not
have a YNAS contained in their record and was unable to be verified. The Department’s
Juvenile Justice Information System (JJIS) was down during the annual compliance review
week; therefore, none of the youth’s YNASs were able to be verified as documented in JJIS.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a written policy and procedures in place to ensure all members of the
treatment team, youth, juvenile probation officer (JPO), and parents/guardians are involved in
the development of the youth’s performance plan within thirty days of admission to the program.
The findings of the initial assessment completed on each youth, along with information/feedback
from the intervention and treatment team, are utilized by the assigned case manager to create
the youth’s performance plan. In addition, information provided by the youth’s parent/guardian
on the Parent Input form sent at admission is incorporated into the performance plan. Five youth
case management records were reviewed, and four out of five contained documentation of the
Individualized Performance Plan (IPP) being developed within the required time frame and
developed following the youth’s initial Youth Needs Assessment Summary (YNAS) and initial
Residential Assessment for Youth (RAY), as required. One youth did not have a completed IPP
within the record. Further, it was unable to be verified against the Department’s Juvenile Justice
Information System (JJIS) due to the system being down during the annual compliance review
week. Reviewed documentation in the four applicable records confirmed the youth’s intervention
and treatment team were present during the development of the IPP and included participation
and signatures from the treatment team leader (youth’s case manager), youth, program
administration, direct care/living unit representative, mental health treatment staff,
education/vocation staff, and medical staff. In the four case management records, a
documentation notification was sent to the youth’s parent/guardian from the assigned case
manager requesting they review and sign the signature sheet and return it in the self-addressed
stamped envelope provided by the program; however, none of the case management records
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contained an IPP signature sheet signed by the youth’s parent/guardian. All four performance
plans contained individualized goals based on the prioritized needs of the youth and the top
three criminogenic needs. Delinquency interventions, court-ordered sanctions, community
service hours, and transition activities were included in each performance plan. Each reviewed
IPP listed the responsibility of staff in completing the goal, the responsibility of youth in
completing the goal, start date, and projected completion/end date. Upon completion of the
performance plan, and after signatures by required parties, a transmittal letter and a copy of the
plan were mailed to the committing court, JPO, parent/guardian, and Department of Children
and Families (DCF) counselor, as applicable, within ten working days. Five interviewed youth
stated they received a copy of their IPP. In addition, all five youth stated they participated in the
development of their performance plan and two out of five were familiar with their current
performance plan goals. Three youth indicated they did not remember their goals.
2.10 Performance Plan Revisions Limited Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
The program has a written policy and procedures in place which address performance plan
revisions. After the creation of the Individualized Performance Plan (IPP), at thirty-day intervals,
the assigned treatment team meets to formally review the youth’s performance plan goals and
determine whether revisions are necessary. In addition, every ninety days after completion of
the initial Residential Assessment for Youth (RAY), case management staff complete a RAY
Reassessment and, should the results warrant, will revise the youth’s performance plan goals.
Five youth case management records were reviewed and two were applicable for IPP revisions.
An additional record was requested and provided. Each of the three reviewed records had at
least one RAY Reassessment completed; however, none of the findings were reflected on the
youth’s formal treatment team forms, with several forms indicating the youth didn’t even have a
reassessment during the annual compliance review period. Only one treatment team form
mentioned a RAY Reassessment was completed; however, did not go into details. In all three
reviewed records, there were clear indications the IPP interventions and goals should have
been reviewed for potential revision based on the RAY Reassessment findings. Two of the
youth also demonstrated regression in their goals without IPP revisions. Three closed records
contained documentation showing the youth’s IPP was updated to facilitate transition activities
during the last sixty days of the youth’s commitment.
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2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a written policy and procedures in place to ensure Performance Summaries
and transmittals are completed within the required time frames. At each ninety-day interval,
beginning ninety days from the signing of the youth’s Individualized Performance Plan (IPP), the
intervention and treatment team meet to create a Performance Summary. In addition, prior to
the youth’s release, discharge, or transfer from the program, the intervention and treatment
team will meet to create the Performance Summary. Five youth case management records were
reviewed for the completion of Performance Summaries. Only two records were applicable;
however, only one was able to be reviewed due to not being able to determine the original date
of one youth’s performance plan. Two additional records were requested and provided. A review
of the three applicable records validated each youth received a Performance Summary which
was completed at least every ninety days following the signing of their initial IPP. All
Performance Summaries included the youth’s status on each performance/treatment plan goal,
youth’s overall adjustment/progression in the residential commitment program, youth’s overall
progress during the rating period, educational and vocational progress including credits earned
and behavior in school, transition/discharge information, and youth comments. In addition, the
youth’s 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
were also addressed. Upon the youth’s assigned case manager completing the Performance
Summary, the document was signed and dated by the staff preparing the Performance
Summary, the treatment team leader, program director or designee, and the youth. There was
documentation in all applicable records showing the youth could read and add comments to
each Performance Summary prior to signing them. All case management records contained the
original Performance Summary. In all instances, within ten working days, a copy of the original
Performance Summary, along with a transmittal letter, were sent to the committing court,
juvenile probation officer (JPO), parent/guardian, and Department of Children and Families
(DCF) counselor, as applicable, except for one youth who was eighteen and did not provide
consent for the summary to be sent to parent/guardian. Supporting documentation was
maintained in the youth’s case management record. Three closed records were reviewed for
discharge and release summaries. All three records contained the original release summary
which included the justification for the youth’s release from the program. All records contained a
Pre-Release Notification (PRN), completed at least forty-five days prior to the youth’s release.
All summaries and PRNs were signed by the appropriate parties and maintained in the youth’s
closed case management record. All three records contained notification to the parent/guardian
confirming the youth’s release date once the program received the approved PRN from the
committing court. All three closed records contained documentation supporting the exit
Residential Assessment for Youth (RAY) was completed for each youth following approval of
their release. None of the reviewed youth were applicable for the Sexually Violent Predator
Program (SVPP) or for victim notifications.
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2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a written policy and procedures to encourage and facilitate the involvement of
the youth’s parent/guardian in the case management process. The program encourages
parent/guardian involvement in the assessment process, in the participation of the performance
plan, during progress reviews, during treatment team meetings, and during transition planning. If
the parent/guardian is unable to attend any of these meetings in person, they are given the
opportunity to participate by telephone and can provide verbal or written input as well. There
were no treatment team meetings scheduled to be observed during the annual compliance
review week. The program provides family visitation monthly, and the case managers and
therapists encourage parents/guardians to visit during treatment team meetings. The program
director was interviewed and advised parents/guardians are encouraged to attend and invited to
participate in all aspects of the youth’s treatment in the program. The program director stated
there are several ways, such as welcome letters, weekly calls, treatment teams, and monthly
family days, where family members are encouraged to participate in their youth’s treatment.
Five youth were interviewed, and all stated their parents/guardians are involved in their case
management.
2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
The program has a written policy and procedures in place to ensure the incorporation of other
plans into each youth’s Individualized Performance Plan (IPP). Five youth case management
records were reviewed. Four were applicable as one youth did not have an IPP filed in their
record. All four reviewed IPPs included a goal which addressed the youth’s compliance with
their academic, mental health treatment, and wellness/recreation plans. In addition, the program
advised none of the youth were served by the Department of Children and Families and/or the
Agency for Persons with Disabilities.
2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
The program has a written policy and procedures in place to ensure each youth and intervention
and treatment team meet on a bi-weekly basis (formally and informally) to review the youth’s
performance, Residential Assessment for Youth (RAY) Reassessment results, progress on
Individualized Performance Plan (IPP) goals, positive and negative behavior including behavior
resulting in physical interventions, and treatment plan progress. Five youth case management
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records were reviewed. Each record contained evidence of the youth’s parent/guardian, juvenile
probation officer (JPO), and other pertinent parties including the case manager, transition
specialist/transition services manager, medical/health services, education, administration,
mental health therapist, and youth counselor/living unit representative being invited and
encouraged through advanced notification. Each party was documented as actively participating
in treatment team progress review meetings. Formal reviews were conducted at least every
thirty days and were appropriately documented in the youth’s case management record. Each
formal review included a review of the performance plan progress report, status of performance
plan goals and objectives, contact with parents/guardians and JPO, changes in risk level,
current level, level status, performance plan goal focus for the month, and stage of change. In
addition, physical and medical progress reports, mental health/substance abuse progress
reports, youth and/or parent/guardian progress reports, and program behavior and performance
progress report were also reviewed. The one area not covered was performance plan revisions
based on results of the RAY Reassessment. In each of the five case management records
reviewed, there was documentation of bi-weekly informal treatment team meetings taking place,
with all required elements being addressed and all required parties attending or providing
written or verbal input. During the program’s annual compliance review, the annual compliance
review team was unable to observe treatment team meetings as no meetings were scheduled.
Five youth were interviewed and all youth confirmed their performance was reviewed with them
during treatment team meetings. In addition, all five interviewed youth stated they are given an
opportunity during treatment team meetings to demonstrate skills they have learned in the
program.
2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a written policy and procedures in place addressing the program’s transitional
planning process, to include participation of the program and the youth in the Community Re-
Entry Team (CRT) meeting. A review of three closed youth case management records found
documentation of the treatment team planning for the youth’s successful transition to the
community upon release from the program. Each record also contained evidence of a transition
conference and summary being completed at least sixty days prior to the youth’s targeted
release date. Documentation confirmed each transition plan was developed by the youth, case
manager (treatment team leader), administrative representative, clinical services representative,
education representative, medical representative, juvenile probation officer (JPO), and the
youth’s parent/guardian. Documentation in all three closed records verified all attendees signed
and dated the transition plan. During the transition conference, the treatment team members
reviewed transition activities listed on the youth’s Individualized Performance Plan, identified
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additional transition activities, identified target completion dates, and the person/persons
responsible for completion. Each of the three closed records showed evidence of the plan being
sent with a request for return with signature to the parent/guardian and JPO, with
documentation of both participating by telephone, although there was no evidence of the
parent/guardian returning the transition conference signature page. One of the youth’s plans
had a signed signature page from their JPO and one had been signed by their after-care
provider. Documentation in each case record noted the transition plan was transmitted
electronically to the JPO, though none of the emails had an acknowledgement receipt printed
and filed with the plan. All three closed youth records contained evidence of the youth and
assigned case manager participating in the CRT meeting held prior to the youth’s release. Email
invites were present in each closed record, with documentation of the CRT meeting recorded on
the case management chronological record, along with the date and the name of the staff
making the entry.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a written policy and procedures in place addressing the program’s exit
process, to include assembling an exit portfolio for each youth to assist them once they are
released back into their home community. A review of three closed youth case management
records found all records contained an exit portfolio. Each exit portfolio was discussed and
initiated for the youth at the transition conference, and then verified during the exit conference.
Each exit portfolio included a transition plan, a calendar containing the dates and times of
follow-up appointments for the youth to attend in their home community (documented on the A
Plan for Success form), sample employment applications, résumés, vocational certificates,
educational records, and school transcripts. Only one youth file contained a copy of their birth
certificate, and none contained state-issued identification and or Social Security cards; however,
each case file had noted various attempts to procure these items. For youth who were required
to complete community service hours, documentation of hours completed was included as part
of the exit portfolio. Upon release from the program, the completed exit portfolio was provided to
the youth and documented on the acceptance of custody form. In addition, case management
staff forwarded the exit portfolio information to the juvenile probation officer (JPO).
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a written policy and procedures in place which address participation of the
youth and treatment team in the exit conference. Three closed youth case management records
were reviewed for the completion of an exit conference. All three records contained
documentation of an exit conference being conducted after the juvenile probation officer (JPO)
was notified of each youth’s release. All the records reflected the exit conference was
conducted at least fourteen days prior to the youth’s release during which the status of goals
developed at the transition conference were reviewed and release plans were finalized. A
summary of the conference was found in all three records and included the date, signatures,
names of participants by phone, and a summary of pending transition goals. The individuals
who participated in the exit conferences for each youth included the case manager (treatment
team leader), education representative, mental health therapist, medical representative,
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program director/designee, and the youth. In all three records reviewed, the youth’s
parent/guardian participated by telephone, while the assigned JPO participated by telephone in
two of the three meetings. Exit conferences were held separately from the transition meeting
and Community Re-Entry Team (CRT) meeting. Each youth’s date of release was not able to be
verified within the Department’s Juvenile Justice Information system (JJIS) due to the system
being down during the annual compliance review week.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a formal process which promotes constructive input by youth as evidenced by
the policy. The program uses the one-on-one form, grievance forms and procedures, monthly
house meetings, and the student council meetings (youth advisory board) to solicit youth input.
Youth advisory board and town hall meeting agendas, minutes, and notes, as well as one on
one forms, performance plans input forms, and grievance logs, were reviewed during the annual
compliance review week. The youth advisory board meetings are held regularly at the program.
The program’s policy did not specify the required frequency of meetings; however, the program
documented minutes demonstrating they were held at least monthly and sometimes more
frequently. Five interviewed youth indicated there were different avenues, both formal and
informal, for them to provide input into programming, with most mentioning the town hall
meetings and one on one forms. The program director was interviewed and confirmed the
program has a number of ways for youth to provide input into programming.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program offers Type 3 educational programming and certifications to youth participating in
Home Builders Institute (HBI). The provided career education programming is appropriate for
the length of stay and custody characteristics of the youth in the program; therefore, the
program provides a Career and Professional Education (CAPE) credential, which is accessible
to all the youth, which leads to pre-apprentice certifications and industry certifications. The
career education programming includes communication, interpersonal, and decision-making
skills. The lead educator stated the school is offering career assessments and Florida Ready to
Work. The program director’s interview indicated the program offers five career and technical
programming services appropriate to the youth’s age, abilities, and goals, as well as the length
of stay and risk level. The program provides Occupational Safety and Health Administration
(OSHA), ServSafe, Entrepreneur and Small Business, and certified nursing assistant (CNA)
certifications.
Three closed youth case management records were reviewed, and each contained
documentation of a sample employment application and a résumé summarizing education
experience, and/or career training. All records contained a letter requesting required documents
to obtain the youth’s Florida identification. One of three closed records contained documentation
a Florida E-class permit was obtained. One of the three closed youth case management records
included documentation indicating the location and business hours of a local Career Source
Center. Two closed records were missing the documentation. Three closed youth case
management records had documentation the youth’s parent/guardian and juvenile probation
officer (JPO) were aware of the vocational plan and evidence the youth’s case manager and
parent/guardian were aware of the plan and post-discharge plans.
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2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program provided the program schedule, and the lead teacher provided the daily school
schedule and school year calendar. A review of the school schedule confirmed the youth at the
program participated in educational and career-related programs for 250 days of instruction,
distributed over twelve months, with a minimum of twenty-five hours of instruction weekly.
According to the education schedule, ten of the 250 days are utilized for teacher planning and/or
training. The youth receive credits for the educational and training experience at the program.
The activity schedule and logbook documented minimal interference of educational instruction.
Five days were chosen from the logbook for review. There were no issues noted, and a review
of the video confirmed the youth were arriving to school on time. The program’s logbook noted
rotation to and from school throughout the day. Five interviewed youth stated there was minimal
interference of education instruction. The lead teacher interview indicated the youth received
250 days of instruction with ten days of teacher planning or training and verified the schedule is
adhered to. There is a total of 310 classroom minutes each day.
2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
Three closed youth case management records were reviewed for documentation of an
Education Transition Plan which was developed at the beginning of admission. Each of the
three closed youth case management records had an individual Education Transition Plan
developed, which was based on the youths’ post release goals. All three closed youth case
management record’s participants included the youth, parent/guardian, instructional personnel,
Department personnel for youth in residential programs, personnel from the post-release school
district, certified school counselor, and registrar or designee of the program’s district who has
access to the district’s management information system. All three closed youth case
management records had documentation the Education Transition Plan was developed with the
youth and program, education, and aftercare staff with specific plans for continuation of
education and/or employment. An interview with the lead teacher indicated the Education
Transition Plan, which includes provisions for continuation of education and/or employment, is
reviewed at the initial treatment team and shall be included in the initial Performance Plan. The
three reviewed Education Transition Plans included services and interventions based on the
youth’s assessed educational needs and post-release education plans, recommended
educational placement for post-release based on individual needs and performance, and
specific monitoring responsibilities by individuals who are responsible for the reintegration and
coordination of the provision of support services. Five interviewed youth stated they were
involved in the development of your educational transition plan. Four interviewed youth stated
the program was preparing them very well for their high school equivalency diploma, high
school, vocational school, employment, and/or college, and one youth stated well.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The designated mental health clinician authority (DMHCA) is a licensed clinical social worker.
The DMHCA’s license was provided for review and is valid until March 31, 2025. The program
has had one other DMHCA during the annual compliance review period who is no longer
employed at the program. The license for the previous DMCHA expires on March 31, 2025. The
DMHCA is scheduled to be on-site Monday through Friday, which is enough time to ensure
appropriate coordination and implementation of mental health and substance abuse services
are taking place. The DMHCA’s position description was reviewed and there were no issues.
The program has a back-up DMHCA with a valid license, which expires on March 31, 2025.
The DMHCA reported they facilitate groups, conduct fidelity monitoring for groups, create the
group schedule, and ensure all youth who need specific services are enrolled or are on the
waiting list. The DMHCA also assigns youth to therapeutic managers and ensures all youth are
receiving individual, group, and family therapy. The DMHCA provides individual therapy two
times a month, family therapy one time a month, and group therapy four times a week. The
clinical staff receive group supervision weekly and daily communication verbally through email.
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 does not have additional licensed mental health and substance abuse clinical staff
outside of the designated mental health clinician authority. The program has licensed mental
health and substance abuse clinical staffing in accordance with the current contract and Florida
Administrative Code. All copies of licenses were available for review.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMCHA) assures the non-licensed staff
working under their supervision are performing services they are qualified to provide based
upon their education, training, and experience. Each non-licensed mental health clinical staff
working under the direct supervision of a licensed mental health professional received a
minimum of one hour a week on-site, face-to-face direct supervision by the DMHCA as
evidenced by a review of weekly supervision documentation. The direct supervisions were
recorded on a form which included all required elements of the Department’s Licensed Mental
Health Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision
Log form. The program has a Chapter 397 license located in the front lobby. The Chapter 397
license expires on March 22, 2025. The program’s contract does require a recreational
therapist; however, the position was not occupied at the time of the annual compliance review.
The program did have a recreational therapist employed for one day, from February 29, 2024, to
March 1, 2024. There has not been a recreational therapist hired since March, though the
program is actively promoting. The position was vacant for four months prior to the previous
hire, which was a two month process due to verification of credentials. The program has non-
licensed mental health and substance abuse clinical staffing in accordance with the contract,
which includes the number of hours. The program has two non-licensed mental health clinical
staff. Both staff hold a master’s-level degree from an accredited university or college in the field
of counseling, social work, psychology, or related human services field. The two non-licensed
substance abuse clinical staff provided substance abuse services in a Department program only
as a staff of a service provider which holds a Chapter 397 license. The two non-licensed mental
health clinical staff who conducted Assessments of Suicide Risk (ASRs), completed twenty
hours of training and supervised experience in assessing suicide risk, mental health crisis
intervention, and emergency mental health services.
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.
Five youth mental health records were reviewed for mental health and substance abuse
admission screenings. All five youth records included documentation of the Massachusetts
Youth Assessment Screening Instrument, Second Version (MAYSI-2). All youth records
included documentation the screeners reviewed available information to include the
commitment packet, reports, and records for existing documentation of mental health or
substance abuse problems. All MAYSI-2s were completed timely in the Department’s Juvenile
Justice Information System (JJIS). The staff training could not be reviewed due to the
Department’s Learning Management System (SkillPro) being inaccessible during the annual
compliance review week. All MAYSI-2s were completed on the day of admission for the youth,
and completed in full. Three of the five MAYSI-2s indicated further assessment was required. All
youth receive a mental health and substance abuse assessment referral upon intake to the
program regardless of MAYSI-2 results. Information regarding staff entering information into
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JJIS could not be confirmed or reviewed due to the system being down during the annual
compliance review week. All five youth received referrals for a comprehensive evaluation and
the reason for the referrals was documented.
The program maintains a written policy and procedures for the implementation of a standardized
admission/intake mental health and substance abuse screening process. The policy was
reviewed and included a standardized screening process which includes a review of
commitment packet information, reports, and records; administration of the MAYSI-2 in JJIS or
clinical mental health screening by a qualified professional, and referral of juvenile offenders
identified as in need of further evaluation or immediate attention. The policy also included 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 or Baker Act or Marchman Act receiving facility. The policy also
included staff training in mental health and substance abuse issues and administration of the
MAYSI-2.
The program director reported the youth receive the comprehensive evaluation, How I Think
Questionnaire, Adolescent Substance Abuse Subtle Screening Inventory (SASSI-A3),
Massachusetts Youth Screening Instrument-2 (MAYSI-2), Assessment of Suicide Risk (ASR),
Beck's Depression Inventory, and Adverse Childhood Experiences (ACE) upon intake.
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.
Five youth mental health records were reviewed and all included documentation the program
completed a combined mental health and substance abuse evaluation for the youth. All
evaluations were new and not updated. All five evaluations were completed within thirty
calendar days of admission. Two of the five evaluations were completed by non-licensed mental
health clinical staff, and both were reviewed and signed by a licensed mental health
professional within ten calendar days of the evaluation being completed. All five evaluations
included identifying information, reason for evaluation, relevant background information
including home environment and family functioning, history of physical abuse, sexual abuse,
neglect, witnessing violence and other forms of trauma, behavioral functioning, physical health,
mental health, substance abuse history, education functioning, behavioral observations, Mental
Status Examination, interview procedures administered, discussion of findings, diagnostic
impressions, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)
diagnosis, and recommendations.
All five youth mental health records included documentation the youth provided consent for
substance abuse services. All five youth received a new substance abuse evaluation upon
admission to the program. All five substance abuse evaluations included the reason for
assessment, relevant background information, behavioral observations, methods of
assessment, patterns of alcohol and other drug abuse, impact of alcohol and other drug abuse
on major life areas, risk factors of continued alcohol and other drug abuse, clinical impressions
including DSM-V diagnoses, and recommendations.
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3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
Five youth mental health records were reviewed for mental health and substance abuse
treatment. All five youth records included documentation their initial treatment plans were
developed within seven days of initiation of treatment. All five initial mental health treatment
plans included the required elements. All five initial mental health and substance abuse
treatment plans were developed within seven days of the onset of treatment. All five initial plans
were signed by the clinical staff completing the initial treatment plans. Two of the five initial
treatment plans were completed by non-licensed mental health clinical staff. Both plans were
signed by the licensed clinical supervisor within ten days of completion. All treatment team
members signed the initial treatment plan for all five youth. One of the five initial treatment plans
did not include a parent/guardian signature; however, there was documentation the plan was
sent to the parent/guardian requesting signatures. All five initial treatment plans included
information for a referral to the psychiatrist.
Five youth mental health records included documentation of the individualized treatment plan.
All five individualized treatment plans were developed for the youth within thirty days of their
admission. All individualized treatment plans were developed on a form which contained all
required elements. All five individualized treatment plans were signed by the clinical staff
completing the plan. Three of the five individualized treatment plans were completed by non-
licensed staff. All three included documentation the plans were reviewed and signed by the
licensed supervisor within ten days of completion. All five individualized treatment plans were
signed by all treatment team members. One of the five did not have a parent/guardian
signature; however, the youth record contained evidence the plan was mailed to the
parents/guardians requesting signatures. All five individualized treatment plans included
documentation of psychiatric services.
Five youth mental health records included documentation the individualized treatment plan
reviews were completed on a form which included all required elements. Twenty-four of the
twenty-five individualized treatment plans reviews were completed every thirty days. One plan
review was twenty-seven days late. All five individualized treatment plans included individual
therapy, group therapy, and family therapy. Two of the five individualized treatment plans
included applicable prescribed services for psychiatric care. The other three youth did not have
medications prescribed. All reviewed goals and objectives were individualized for each youth.
Two mental health groups, Aggression Replacement Training and Seeking Safety, were
observed on April 9, 2024. All groups were conducted for the required length of time and had
the appropriate number of youth in each group. All groups were held as required in accordance
with the contract.
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3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
Five youth mental health records were reviewed for treatment and discharge planning. All five
youth records included documentation the youth were assigned a treatment team upon arrival to
the program as evidenced by a signature page in the youth records for treatment team
assignments. All five records included documentation the treatment teams were comprised of
the youth, program administration, residential living unit staff, education staff, medical staff,
mental health staff, and the parents/guardians. All five youth records included documentation
the youth received individual, group, and/or family counseling for substance abuse treatment by
a licensed or non-licensed substance abuse clinical staff in accordance with the youth’s initial or
individualized treatment plan. All five youth records included documentation of a properly
executed Authority for Evaluation and Treatment (AET) form. All five youth records included
documentation the youth provided consent through a signed Youth Consent for Substance
Abuse Treatment form. All clinical treatment notes reviewed were documented on the
counseling progress notes form which contained all required information. The program’s mental
health and substance abuse group therapy included individual psychotherapy or counseling and
psychosocial skills training. All reviewed progress notes included documentation the youth
received services as stipulated in their treatment plans.
Three closed youth mental health records were reviewed for treatment and discharge planning
documentation. All three closed records included documentation the discharge plans were
documented on the Department’s Mental Health/Substance Abuse Treatment Discharge
Summary form. None of the youth reviewed were released while on suicide alert/precautions. All
three discharge summaries documented services needed for daily maintenance of the positive
improvement in behavioral, emotional, and social skills made by the youth during treatment. All
three closed youth records included documentation of the discharge plan, which was discussed
with the youth, parent/guardian, and juvenile probation officer (JPO) during the exit conference
and copies were provided to the same parties.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program provides Substance Abuse Overlay Services (SAOS). The program is required to
facilitate Aggression Replacement Training (ART), Seeking Safety, Skillstreaming the
Adolescent, Living in Balance, and Trauma Focused Cognitive Behavioral Therapy as
supplemental clinical services. Four out of five interviewed youth reported they are participating
in both family and individual counseling. One youth reported not participating in either type of
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counseling. The designated mental health clinician authority (DMHCA) reported the program
provides ART three times a week for ten weeks, Seeking Safety two times a week, Living in
Balance two times a week, and Skillstreaming the adolescent three times a week. The program
director reported the program provides substance abuse treatment.
As part of the SAOS program, the program provides urinalysis drug testing, with positive results
followed by appropriate clinical intervention and sanctions. The program provides individual,
group, and family therapy, at least five days a week and as part of each youth’s treatment plan.
Group therapy is limited to no more than fifteen participants as evidenced by a review of group
sign-in sheets. All youth receive daily therapeutic activities and mental health treatment. The
program has a Chapter 397 license and has a qualified professional on-site, at least five days a
week. A licensed psychiatrist provides psychiatric evaluations, medication management, and
participates in treatment planning. Clinical staff are scheduled to be on-site seven days a week.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
The psychiatrist reported conducting psychiatric initial assessments and follow-ups, which
typically involve medication management for psychotropic medications. The psychiatrist
reported being on-site two times a month. The psychiatrist meets with the designated mental
health clinician authority (DMHCA) and program director to discuss youth receiving psychiatric
services on an as needed basis. The psychiatrist also reported the therapist or nursing staff will
provide critical feedback regarding any medical issues pertaining to the youth at the program
receiving psychiatric services. The psychiatrist conducts face to face or telephonic
communication with representatives from the treatment team as needed. The psychiatrist
reported not having any issues or concerns with the program.
The DMHCA reported meeting with the psychiatrist two times a month.
Five youth mental health records were reviewed for psychiatric services. All five youth were
referred for a psychiatric interview. None of the youth entered the program on psychotropic
medications. All five youth records included documentation the initial psychiatric interview
included the youth’s history, which included medical, mental health, and substance abuse
history, Mental Status Examination, Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-V) diagnosis, and treatment recommendations. All five youth records included
documentation the diagnoses were consistent with each treatment plan.
Two of the five youth were prescribed medications. Both records included documentation of an
explanation of the need for psychotropic medications related to the youth’s diagnosis, target
symptoms, initial treatment goals, potential side effects, risks, benefits of taking the medication,
and frequency of medication monitoring and management. All five initial diagnostic psychiatric
interviews were documented on the Department’s Clinical Psychotropic Progress Note (CPPN).
All five CPPNs were clearly identified as an “Initial Diagnostic Psychiatric Interview.” Two youth
were prescribed psychotropic medications and page three of the CPPN was completed for both
youth. Each youth received medication reviews once a month by the psychiatrist. All medication
reviews were documented on the CPPN form. Both youth mental health records included
documentation of identifying data, diagnosis, target symptoms of each medication, evaluation
and description of effect of prescribed medication on target symptoms, the medication name,
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dosage, quantity, normal dosage range, ordered dosage, frequency and route of administration,
side effects, youth adherence to the medication regime, height, weight, blood pressure,
parent/guardian contact to discuss medications, and the signature and date of signature of the
psychiatrist. All medication reviews included documentation the psychiatrist and nursing staff
monitored for Tardive Dyskinesia monthly on the CPPN. The program does not utilize tele-
psychiatry.
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 and procedures. The plan was reviewed and
included the identification and assessment of youth at risk of suicide, staff training, suicide
precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, and the review process for suicide attempts and mortality reviews.
The review process for suicide attempts and mortality reviews included the circumstances
surrounding the event, facility procedures relevant to the incident, all relevant training received
by involved staff, pertinent medical and mental health services involving the victim, possible
precipitating factors, and recommendations for changes in policy, physical plant, medical or
mental health services, and/or operational procedures. The Suicide Prevention Plan was
reviewed annually, with the most recent date of review being August 25, 2023, by the program
director.
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.
Five youth mental health records were reviewed for suicide prevention services. None of the
reviewed records were applicable. Three additional records were reviewed. Two of the three
youth reviewed were placed on precautionary observation (PO) by program staff, and one was
placed on PO upon admission to the program.
All three youth records included documentation of the completed Assessment of Suicide Risk
(ASR) form, which included PO placement start dates, referral dates, and level of supervision.
All ASRs were completed on the Department’s ASR form. All three youth records included
documentation on the ASRs the youth’s parents/guardians and juvenile probation officers
(JPOs) were notified of the youth’s potential suicide risk. All three records included
documentation the mental health staff provided supportive services. Two of the three youth
records had documentation a Follow-Up ASR was completed prior to the removal of the youth
from PO. The Follow-Up ASRs were completed on the Department’s Follow-Up ASR form. One
of the youth was Baker Acted prior to a Follow-Up ASR being completed. This youth did not
return to the program once released from the Baker Act facility. The other two youth were
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maintained on suicide precautions with constant supervision until the Follow-Up ASR indicated
suicide precautions could be discontinued. Both youth were stepped down to close supervision
prior to transition to normal routine and standard supervision. Both youth were maintained on
close supervision until it was no longer determined necessary by the designated mental health
clinician authority (DMHCA) or licensed mental health professional. Both youth records included
documentation the discontinuation of close supervision was completed by mental health clinical
staff. In both records there was documentation of a conference being held by the program
director and licensed mental health professional to reduce the level of supervision. The
discontinuation of close supervision was documented for both youth in accordance with the
program’s suicide prevention plan. Both assessments were completed by a licensed mental
health professional or by clinical staff under the supervision of a licensed mental health
professional. Alerts in the Department’s Juvenile Justice Information System (JJIS) could not be
reviewed due to the system being down during the annual compliance review week. A review of
the program logbook revealed administration or supervisory staff provided instructions related to
the suicide risk assessment findings and suicide precaution decision for two of the three youth.
One PO reviewed was not documented in the program logbook. An informal interview was held
with the administration staff. It was reported the administration staff and the staff in master
control were made aware of the youth being placed on PO, but it was not documented in the
logbook.
Two of the three youth records included documentation an ASR was completed within twenty-
four hours of concern. One youth did not have an initial ASR completed until their return from a
Baker Act facility. The youth was placed on PO by staff due to staff observations of the youth’s
behavior. The youth was transported to the Baker Act facility approximately twenty minutes
later. The incident took place while clinical staff were not on-site due to it being after hours. All
three ASRs were completed by licensed staff or by an appropriately trained non-licensed staff.
Two of the three ASRs were completed by non-licensed staff. Both ASRs were reviewed by a
licensed staff within twenty-four hours. The two discontinuations were documented by a non-
licensed staff, which were reviewed and signed by a licensed staff. The program director also
signed the documentation of close supervision in the facility logbook for all three youth. The two
youth were not transitioned to a lower level of supervision until the non-licensed mental health
clinical staff conferred with both a licensed mental health professional and the program director.
The date and time the clinician conferred with the program director was documented on the
ASRs. Two of the three youth were in crisis. One of the two ASRs were conducted immediately
for the youth in crisis. One youth did not have an ASR completed until they returned to the
program from the Baker Act facility. The program does not utilize secure observation.
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3.12 Suicide Precaution Observation Logs (Critical) Limited 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.
Five youth mental health records were reviewed for Suicide Precaution Observation Logs. None
of the five youth selected were applicable. Three additional youth mental health records were
provided for review. Two of the three youth records included documentation the Suicide
Precaution Observation Logs were maintained for the duration the youth was on suicide
precaution. Two of the three youth records included documentation the appropriate level of
supervision and observations of the youth’s behavior were documented in real time, every thirty-
minutes. One youth did not have Suicide Precaution Observation Logs completed for five hours
and thirty-seven minutes out of the twenty-six hours the youth was on precautionary
observation. The logs for this youth were completed incorrectly for seven of those hours. These
observations were documented at one-hour intervals instead of the required thirty-minute
intervals. Two of the three youth did have warning signs observed and notification to the
program director and mental health clinical staff were documented on the logs. All three youth
records included documentation the logs were reviewed and signed by each shift supervisor
and by the mental health clinical staff. Two of the three youth records included documentation
the 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.
Five staff records were reviewed for pre-service training and all five staff records included
documentation of receiving the required training prior to youth contact. Due to the Department’s
Juvenile Justice Information System (JJIS) being down at the time of the annual compliance
review, in-service training could not be reviewed. The program has two suicide response kits
located in master control. The suicide response kits are co-located with first-aid kits. The
program provided suicide training and drills for review. The mock suicide drills were held, no
less than quarterly on each shift for all staff who encounter youth, including kitchen and
maintenance staff. All mock mental health drills were in response to a suicide attempt and/or
incident of serious self-injury and no program youth were used in the drill simulations. The
program provided semi-annual training on emergency response procedures, which included
“mock” training in emergency response to a suicide attempt or incident of serious self-injury.
Any staff who were not present during a quarterly drill had the opportunity to review each drill
scenario and procedures during staff meetings.
The program director reported trainings are held monthly. All five interviewed staff reported they
notify mental health, put the youth on constant sight and sound, and document supervision
when a youth expresses suicidal thoughts. Additionally, three staff reported they search the
youth and room for any sharp objects and one staff reported they report the information to their
supervisor. All five staff reported the suicide response kits are in master control. One staff
reported there was a suicide kit in medical. Two staff reported suicide and emergency drills are
conducted once a month. One staff reported they are conducted either once a week or once a
month.
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3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a combined crisis intervention plan and emergency mental health and
substance abuse services plan. The combined plans included a notification and alert system,
means of referral, immediate staff response, notifications, communication, supervision,
authorization to transport for emergency mental health or substance abuse services, transport
for emergency evaluation and treatment under Chapter 394, Baker Acts, transport for
emergency substance abuse assessment and treatment under Chapter 397, documentation,
training, and review.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
Five youth mental health records were reviewed for Crisis Assessments. None of the youth
selected were applicable. Youth records were requested for review; however, there were no
youth applicable for a Crisis Assessment during the annual compliance review period.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a combined crisis intervention plan, emergency mental health, and substance
abuse services plan. The combined plans included the notification and alert system, means of
referral, immediate staff response, notifications, communication, supervision, authorization to
transport for emergency mental health or substance abuse services, transport for emergency
evaluation and treatment under Chapter 394, Baker Acts, transport for emergency substance
abuse assessment and treatment under Chapter 397, documentation, training, and review.
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3.17 Baker and Marchman Acts (Critical) 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.
Five youth mental health records were reviewed for Baker and Marchman Acts. None of the five
youth were applicable. Two additional youth mental health records were provided for review. No
other youth were applicable for Baker and Marchman Acts during the annual compliance review
period. One youth was determined to need emergency care by staff and one by the assigned
therapist. The staff completed an Assessment for Suicide Risk (ASR). Both youth were placed
on supervision at the time of discovery. Mental health staff was involved for both youth and they
were placed on precautionary observation (PO). One youth was transported to the Baker Act
facility by emergency medical services. The second youth was transported by program staff and
the program director. One youth returned to the program after being released from the Baker
Act facility. The other youth was transported to a different program. The youth who returned to
the program had a mental health referral completed and a Mental Status Examination was
conducted. The one applicable youth had an ASR completed by a licensed clinical staff. The
youth was maintained on constant supervision until properly transitioned to a lower level of
supervision. The youth’s supervision was not lowered until an appropriate assessment was
conducted by the licensed mental health professional.
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.
Five youth mental health records were provided for review of safety planning processes for
youth. All five youth records included documentation of safety plans. Twenty-three safety plans
for the five youth were reviewed. All the safety plans included warning signs, youth’s baseline
behaviors, crisis recognition, jointly developed coping strategies, intervention strategies
preferred by the youth, and the debriefing procedure. All initial safety plans were completed
within fourteen days of the youth’s admission. The plans were jointly prepared by the youth,
parents/guardians, and the program’s clinical staff. Two of the five safety plans did not include
parent/guardian input. One parent/guardian did not participate, and the other youth was
eighteen and did not have parent/guardian participation. All safety plans included the
incorporation of recommendations from previous or current clinical assessments, screening
instruments, and trauma responsive practices. All safety plans were reviewed and updated as
necessary, to include following any significant behavioral or mental health event identified by the
youth’s intervention and treatment team, at least every thirty days. All safety plans were
reviewed by staff who have contact with the youth. All youth safety plans were maintained in the
youth mental health records and in master control. All five interviewed youth reported they
contributed to their safety plans. All five interviewed staff reported safety plans are in the master
control room. Two staff reported they are updated on youth safety plans during daily briefings at
the beginning of their shifts, and two staff reported they can get the book from master control
and review them. One staff reported there is no formal process, whenever they have free time
they review the safety plans and learn about the youth. All five staff reported they reviewed the
safety plans on the day of their interview. The program director reported the safety plans are
updated monthly and as needed.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The designated health authority (DHA) is a licensed medical doctor. The DHA holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
the State of Florida. The DHA’s license is set to expire on January 21, 2026. The DHA has
specialty training in family practice. There was no indication the DHA had any disciplinary
complaints on record. The program does not have a physician assistant or advanced practice
registered nurse. A review of sign-in/out logs was conducted and confirmed the DHA was on-
site at least once a week. The program’s contract requires the DHA to be on-site two hours a
week. There were no indications of any absences during the annual compliance review period.
The program has a back-up DHA who holds an unrestricted license to practice in the State of
Florida. The license for the back-up DHA is set to expire on March 31, 2026. There was no
indication the program uses tele-medicine services. An interview with the DHA was conducted.
The DHA confirmed performance duties as completing Comprehensive Physical Assessments
(CPAs), periodic evaluations for chronic conditions, sick call, and policy development. The DHA
is on-site once a week. The DHA communicates with program staff by text, phone calls, and
during on-site visits. The DHA communicates with staff by text and telephone calls when not on-
site. The DHA performs on-site clinical services. The DHA reviews information once a week and
documentation is kept by nurses on-site. The DHA meets weekly to discuss all concerns.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has two licensed nurses to include on site-nursing coverage provided by
registered nurses (RNs). The program employed a licensed practical nurse (LPN) during the
annual compliance review period; however, the LPN is no longer employed at the program.
When the LPN was utilized, the RN provided supervision and direction in reviewing all medical
cases daily when necessary. A review of nursing licensure credentials on the Florida
Department of Health (DOH) medical quality assurance website confirmed all the nursing
licenses were clear and active. All nursing staff have current cardiopulmonary resuscitation
(CPR) certifications. The contract indicates on-site nursing will be covered by two RN’s, one of
whom should be a health service administrator. Total hours should be forty hours a week for
each RN. The program follows the contracted requirements for nursing coverage.
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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.
An annual review of all respective treatment facility operating procedures (FOPs) was
conducted by the designated health authority (DHA). The DHA signed the FOPs on January 7,
2024. An annual review and signing of treatment FOPs were also initiated by the program
director on January 7, 2024. An annual review and signing of treatment FOPs were initiated by
the program’s psychiatrist on January 9, 2024. A review of documentation confirmed nursing
staff reviewed, signed, and dated the cover page where medical FOPs, treatment protocols, and
other procedures are listed. All newly employed healthcare personnel received a
comprehensive clinical orientation to the Department’s healthcare policies and procedures
conducted by a registered nurse. Treatment protocols or standing procedures were authorized
by the 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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of the Authority
for Evaluation and Treatment (AET) form. Four of five youth had a completed AET filed in their
IHCR. One of the five youth was eighteen years of age and the IHCR contained a documented
release of information. Each applicable youth’s AET had a parent/guardian signature provided.
There was no indication on any AET of refusal of parent/guardian signature. Applicable AETs
were signed by a Department representative. All AETs were observed to be valid. There were
no cases of youth in the care of the Department of Children and Families. During an interview
with nursing staff, it was stated current AETs are found in the youth's electronic commitment
packet or in their medical packet upon arrival. If not valid, the youth's juvenile probation officer
(JPO) is notified prior to the youth coming to the program and the JPO obtains a valid AET.
Youth eighteen years of age or older sign for their own medical consents. They fill out an
eighteen-year-old authorization to evaluate and treat. The youth select who, if any, they would
like the program to notify and what information they would like the program to give out.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for parental/guardian
notification/consent. Five youth were applicable for parental/guardian notification for over-the-
counter (OTC) medications beyond those covered by the Authority for Evaluation and Treatment
(AET). All youth records contained documentation of parental/guardian consent. All records
indicated through documentation an attempt was made to contact the parent/guardian when
medication was ordered. The written notification was sent utilizing the Department form. Two of
the five youth were applicable for being prescribed psychotropic medications after admission to
the program. Each youth prescribed psychotropic medications had documentation of staff
witnessing telephone call attempts. For each youth on psychotropic medications whether new,
discontinued, or significant dosage change, a parent/guardian consent was found documented
on page three of the Clinical Psychotropic Progress Note (CPPN). No youth were under the
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care of the Department of Children and Families. Five youth had documentation to indicate
vaccinations were verified within thirty days of admission. No youth were applicable for a
religious exemption or parental/guardian non-consent for vaccinations.
During an interview, nursing staff reported parental/guardian notification is obtained when OTC
medications not covered by the AET form are prescribed, vaccinations/Immunizations not
consented for on the AET form, significant changes are made to existing medication, and
discontinuation of medication prescribed prior to youth entering custody of the Department. For
off-site emergency care, hospitalizations, surgeries/invasive procedures, and non-routine dental
procedures notifications are made by telephone and, subsequently, in writing. Nursing staff
reported parental/guardian notification is made within twenty-four hours by mail. Telephone
notifications are made with three attempts at different times to get consent verbally. Nursing
staff also confirmed the designated health authority (DHA) is notified, orders are received, and
the parent/guardian is notified when the youth’s illness or injury requires emergency medical
services or is life threatening. When obtaining consent for new psychotropic medications,
discontinuances, or psychotropic medication adjustments, nursing staff reiterated the
parent/guardian is contacted for consent. The CPPN page three is mailed to parent/guardian
within twenty-four hours. If the youth is eighteen, the youth signs the CPPN for consent. Nursing
staff confirmed vaccinations are not provided on-site. Nursing staff stated immunization records
are obtained through youth's electronic commitment packet, medical cart, Florida Shots, or
through school records and further stated this is obtained prior to intake and on day of intake. In
the event a parent/guardian does not consent to a vaccination, they would need to complete a
Religious Exemption from Immunization form. Copies of the exemption shall be filed in the
youth’s IHCR. If a parent/guardian does not consent to a vaccination for medical reasons, a
signed letter shall be provided to the program by the youth’s physician or the Department of
Health exemption form indicating the reason for the exemption shall be provided. Copies shall
be filed in the youth’s IHCR.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of healthcare
admission screening and rescreening forms. Each IHCR contained a Facility Entry Physical
Health Screening (FEPHS) form completed on the date of admission. Four of five FEPHS forms
were completed by a registered nurse (RN). The remaining FEPHS form was completed by a
licensed practical nurse (LPN). No FEHPS forms were completed by direct care staff. No youth
was applicable for a change in physical custody greater than twenty-four hours. An interview
with the program’s nursing staff indicated all youth are seen upon admission in less than an
hour. On arrival, master control is notified the youth has entered the building. Nursing staff
further confirmed admission screenings are completed by the licensed nursing staff. If a change
in physical custody takes place the nurse, director of group living, or supervisor, if after hours,
will complete a FEPHS with the youth. If not completed by a nurse, the nurse will review it with
the youth within twenty-four hours.
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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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of youth
orientation to healthcare services/health education. All reviewed youth IHCRs contained
documentation indicating each youth received a general healthcare admission orientation which
included all topics of the orientation process and was signed by the youth.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of notification
to the designated health authority (DHA) or designee. Four of five youth were applicable for
known or suspected chronic conditions. Each applicable youth IHCR contained documentation
indicating a referral to the physician was initiated. No youth was applicable for being identified
as in need of emergency care upon admission. All IHCRs provided documentation indicating
notification was made to the DHA within twelve hours of youth admission. No youth were
identified as taking psychotropic medications upon admission. The program has a process
wherein the psychiatrist is notified of all newly admitted youth. An interview with nursing staff
indicated the program’s practice for youth admitted with a serious or chronic condition is to
notify the DHA on intake or within four hours, and the notification is filed in the progress notes
section of the IHCR.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of a Health-
Related History (HRH) form. All youth IHCRs contained documentation indicating the HRH was
completed within seven calendar days of admission. All reviewed HRHs indicated completion
prior to the Comprehensive Physical Assessment (CPA) and contained signature and date of
completion. All reviewed youth IHCRs indicated the designated health authority (DHA) reviewed
the HRH form which was accomplished through a check box on the CPA. An interview with
nursing staff confirmed the registered nurse is responsible for completion of the HRH upon
intake.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of a
Comprehensive Physical Assessment (CPA) form. All CPAs were completed within seven
calendar days of admission and were completed by the designated health authority (DHA).
Each of the CPAs reviewed had the correct Medical Grade documented. Each CPA was marked
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with an “X” or “O” accordingly. All five reviewed IHCRs indicated each youth refused a portion of
the examination. Each youth signed a refusal form completed on the date of the examination.
Five of five youth were applicable for updating the Department’s Problem List. All five youth had
at least one verified tuberculosis skin test (TST) documented in the IHCR. The TSTs were found
documented on the CPA and Infectious and Communicable Diseases form. An interview with
the nursing staff confirmed the DHA completes a CPA at every intake. Additionally, nursing staff
reported TSTs are conducted during intake. If there is a need for a TST, the DHA is notified of
the need for an order.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for sexually transmitted
infection (STI) screening and human immunodeficiency virus (HIV) screening requirements.
Three of the five youth were applicable for screening, and their records included evidence each
was screened and evaluated for STIs. All three were referred to the designated health authority
(DHA) for further screening, but each of the three refused screening. There was evidence in all
five IHCRs indicating each youth was offered counseling, testing, and treatment, if indicated, for
HIV. All but one youth refused the HIV testing. Documented consent for this youth was
provided, along with evidence the youth was tested for HIV as requested. Results of HIV testing
were filed confidentially in a sealed envelope marked ‘Confidential’, and consistent with Florida
Administrative Code. There was also evidence on the sealed envelope indicating the DHA
reviewed the results. Documentation of pre and post-test counseling was observed in the
youth’s IHCR as required. The youth’s confidentiality was protected as the youth’s HIV status
was not listed on the program’s internal alert system.
Five of the interviewed youth confirmed they can ask for an HIV test if they choose. The
registered nurse was interviewed and stated youth are screened for STIs on intake using the
Department form. In the event screening indicates a need for further evaluation, the nurse
stated they will test the youth and the DHA will review the form and then indicate whether the
youth needs further testing within seven days of the intake. Rescreening is conducted if the
sexually active youth has been out of the Department’s physical custody and/or if symptoms are
present. The nurse stated HIV test results are filed in a confidential manner consistent with
Florida Statute. Documentation of pre and post-test counseling is maintained in the Health
Education Record. Youth have the right to request or decline HIV testing. A local testing center
provides all testing services for HIV. Testing is done for youth with or without risk factors
identified. Referrals for testing are documented on the Department form and on the
practitioner’s order. Results are captured on the Infectious and Communicable Disease form in
the youth IHCR.
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4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of the sick call
process. Two of five IHCRs were applicable. A request for an additional IHCR was initiated and
provided to meet minimal sample requirements. None of the applicable reviewed youth
presented with similar sick call complaints three or more times within a two-week period. All
applicable reviewed IHCRs indicated youth completed a sick call request form. All applicable
IHCRs indicated nursing completed the sick call form and none of the sick calls were completed
by a licensed practical nurse. All applicable sick call request forms were filed in the IHCRs in
reverse chronological order. None of the youth had been in restricted housing of any kind. The
sick call forms were documented in accordance with Florida Administrative Code. All sick calls
were documented on the sick call index. All sick calls were documented on the sick call referral
log. All dates listed on sick call corresponded to the completed sick request form located in the
IHCR. A review of the daily schedule, posted schedule, and nursing interview confirmed sick call
was conducted daily or as pursuant to contract requirements. Sick call is provided from 12:00
p.m. to 2:00 p.m. daily. Sick call hours are posted on the medical area door. Documentation
supports sick call is only conducted by a licensed nurse. The program has a procedure in place
which allows shift supervisors to review all sick call requests when there is no licensed nurse on
site. The sick call is reviewed as soon as possible and within four hours after the request is
submitted. Sick call request forms are available to youth and are located on dormitories. An
exam table and medical equipment used to perform sick call is in the medical clinic.
An observation of a sick call request was completed during the annual compliance review week.
The youth was escorted to sick call by direct care staff. The medical provider identified
themselves and stated why youth was at sick call. The youth was seen in a private area and
was examined by a licensed staff. The nursing staff was able to maintain privacy as the direct
care staff present during the exam was in the hallway. An interview with nursing staff was
conducted to verify the process for youth requesting to be seen by a nurse or physician for
health complaints and the nurse verified the program’s policy. The nurse confirmed the
registered nurse routinely conducts sick call. The designated health authority (DHA) does
conduct sick call when on-site. Sick call is conducted from 12:00 p.m. to 2:00 p.m. daily. Nursing
further confirmed youth presenting with repeated similar complaints as youth presenting with
similar sick call complaints three or more times within a two-week period require a referral to the
DHA. Youth complaints of severe pain with which staff are unfamiliar shall be treated as
emergencies and an immediate referral made to the licensed healthcare professional. Nursing
confirmed protocols are in place which have been approved by the DHA. The nursing interview
reiterated the process for access to youth in restricted housing or confinement as youth in
restricted housing of any kind are questioned daily for sick call/health complaints, and
information is documented in the IHCR. An interview was conducted with five youth and each of
the five youth reported they are seen within one day of requesting a sick call. An interview was
conducted with five staff and each staff reported the nurse reviews and conducts sick call.
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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.
Five youth Individual Healthcare Records were reviewed for episodic, first-aid, or emergency
care. Three of five youth IHCRs were applicable. All applicable IHCRs indicated youth required
on-site first aid or episodic care. On-site care was documented in the subjective, objective,
assessment, and plan (SOAP) narrative. No episodic or first-aid care was provided by non-
healthcare staff. A review of the program’s episodic and emergency care procedures was
conducted and confirmed all required elements were included. The program has a total of eight
first-aid kits. There are four kits located in master control, of which two are designated for
transportation vehicles, one in dietary, one in the Home Builders Institute (HBI) workshops, one
in maintenance, and one in education. An observation of checklists revealed first-aid kits are
checked monthly by medical staff. As items expire, they are changed out. All applicable items
with expiration dates were in compliance. Each first-aid kit has designated health authority
(DHA) approved contents listed on the front of the kit. The DHA has designated the nursing staff
to inspect the contents of the first-aid kits and emergency equipment monthly. A review of three
first aid kits was conducted. Observations concluded each kit was fully stocked with approved
items. Documentation with date of inspection and nursing initials confirmed monthly inspections
were completed as scheduled. The program has a functioning automated external defibrillator
(AED) located in master control. AED procedures are located along with the AED in master
control. On-site medical staff have been identified as the responsible party to ensure AED
batteries and pads are operable. Nursing staff conducted a self-test of the AED in front of
annual compliance review team members. No issues were discovered during the self-test.
Documentation confirmed the expiration date of the AED batteries as February 2029. The AED
batteries were last changed in July 2023. Documentation confirmed the expiration date of AED
pads as August 2024. The AED pads were last changed in August 2024 and October 2025,
respectively. A review of training records indicated direct care staff participated in at least one
annual drill which included the use of cardiopulmonary resuscitation (CPR). Documentation also
supported the drill simulated episodic care which called for immediate first-aid or administration
of CPR techniques and the initiation of the emergency procedures to follow when a life-
threatening emergency occurs. A review of the program’s mock emergency medical drills
reflected a drill was conducted on each shift monthly. Emergency medical drills included the
demonstration of CPR and the AED at a minimum of annually. The emergency medical drills
consisted of both announced and unannounced. Emergency numbers were observed in medical
and master control. The emergency numbers are accessible to staff and not accessible to
youth. Staff authorized to administer the epinephrine auto-injector were designated in writing. A
total of five staff training records were reviewed. Only pre-service training was observed. The
remainder of the training records were unable to be reviewed as the Department’s Learning
Management System (SkillPro) was inaccessible. An episodic care event was observed during
the annual compliance review week. Nursing staff were able to maintain privacy as the escorting
staff was in the hallway.
An interview with the nursing staff was conducted. Nursing staff confirmed the program has a
total of eight first-aid kits. Four kits are located in master control, of which two are for transport,
one in education, one in HBI, one in the kitchen, and one in maintenance. Nursing further
confirmed the process for documenting episodic care as episodic care provided by licensed staff
requires documentation in the youth’s chronological progress notes in either SOAP elements, or
standard narrative charting which includes all SOAP elements. There shall be an on-site
tracking log for episodic care. Nursing reported tracking for off-site emergency care is
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maintained on the on-site tracking log and chronic roster. Nursing staff confirmed the program
does have an AED located in master control and procedures are located with the AED. The
registered nurse ensures batteries and pads are operable. The nursing interview further
confirmed emergency drills are conducted on each shift every month and emergency numbers
are posted in medical and master control. Emergency numbers are inaccessible to youth.
Emergency medical drills are conducted once a month on every shift. Five staff were
interviewed. Four staff indicated they were allowed to call 9-1-1 for the purpose of youth
emergencies. One staff stated they are not allowed to have phones. Master control usually calls
while staff are attending to youth. Five youth were interviewed. Three youth indicated they are
allowed to see a dentist if necessary. Two youth indicated they are not allowed to see the
dentist. Five of five reported they are allowed to see a doctor if needed.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
Five youth Individual Healthcare Records (IHCRs) were reviewed for off-site care referrals.
Three of five were applicable and required off site-care. In each off-site care case, the Summary
of Off-Site Care Consultation Report form was utilized and filed in the IHCR. Each IHCR had
documented parental/guardian notification efforts. All cases were applicable for discharge
documents. In all cases, the designated health authority (DHA) reviewed and signed the off-site
care findings. One youth was applicable for follow-up appointments. The one youth received the
appropriate follow-up care.
An interview with the nursing staff was conducted. The nursing interview confirmed the internal
chronic roster is utilized to track youth who are sent off-site for first-aid or emergency care
needs. Nursing reported the process to ensure orders are followed, including reviewing the
orders, calling the DHA, and the DHA reviews and signs orders while on-site. Nursing further
reported they ensure the DHA reviews and initiates care findings, instructions, and information
by ensuring youth are seen by the DHA within seven days and all documentation is flagged in
the IHCR for review and signature. Nursing confirmed tracking for follow-up testing referrals and
appointments are tracked on the chronic roster.
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.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of chronic
condition periodic evaluations. Four of five youth were applicable for having a chronic condition.
Each of the four applicable youth were identified on the Facility Entry Physical Health Screening
(FEPHS) form upon admission as having a chronic condition. None of the youth were identified
as having any communicable diseases. Two of the four youth were identified as taking
prescribed medications on an ongoing basis. Three of the four youth were identified as having a
chronic condition. The remaining youth was not classified as having a chronic condition
according to a review of the IHCR; testing was conducted by the designated health authority
(DHA) and later determined the youth did not have a chronic condition. None of the youth were
undergoing treatment for a physical health condition. Three of four youth were classified with a
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Medical Grade between two and four. The remaining youth’s Medical Grade was reclassified
from a one to a five according to documentation on the Comprehensive Physical Assessment
(CPA). This youth is not identified as having a chronic condition; however, is in receipt of
psychotropic medications. The three youth identified as having a chronic condition were placed
on a chronic illness list. The one applicable youth did receive periodic evaluations at least every
ninety days. The two remaining youth were not eligible for evaluations as they had not yet been
in the program long enough. There was no indication any of the youth were administered anti-
tuberculosis medications. None of the youth required an off-site evaluation to be conducted. The
Department’s Problem List was updated as required for all applicable youth.
An interview with the program director (PD) was conducted. The PD confirmed the program
conducts daily morning meetings and meets during treatment team meetings. An interview with
the DHA was conducted. The DHA confirmed chronic conditions are monitored and evaluated
every ninety days or less. An interview with nursing staff was conducted. Nursing staff
confirmed chronic conditions are monitored and evaluated every ninety days. Additionally,
psychiatric evaluations should be conducted prior to the change of psychotropic medications,
and no less than every thirty days when psychotropic medications are prescribed.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for medication management
requirements. All five youth records indicated none of the youth were admitted to the program
on medications. Medications were prescribed for all five youth subsequent to their admission. A
review of each record found all medications received by youth had a current, valid order, and
were administered pursuant to a current prescription. Evidence was found in each record
indicating the designated health authority (DHA) placed the order on the practitioner order form.
Over-the-counter (OTC) medications not listed on the Authority for Evaluation and Treatment
(AET) form were administered for each applicable record according to the Practitioner Order
form as required. None of the five had evidence of being in restricted housing during the annual
compliance review period. The program utilizes the Department’s Medication Administration
Record (MAR), as well as the pharmaceutical MAR for each of the five youth records reviewed.
Each youth MAR contained all required elements. There was evidence in four of five records
indicating trained non-healthcare staff assisted in the delivery of medications at periods where
the licensed medical staff was not on-site. One of five records was not applicable, as no
evidence was discovered of medication administration by a non-licensed medical staff. There
was evidence in the four applicable records showing the non-licensed staff initialed each
medication entry. No lapses or errors were discovered for the records reviewed. There was
evidence in each of the five healthcare records of weekly side-effect monitoring by the nursing
staff as indicated on each MAR. Refusals of medications were noted as required for all MARs
reviewed. None of the five reviewed IHCRs indicated the youth required parenteral medications.
Four of five applicable youth records contained documentation each youth received an initial
diagnostic psychiatric interview within fourteen days of their admission to the program. Two of
these four youth were referred for the initial diagnostic psychiatric interview; however, no
medications were required. For the remaining two applicable youth, there was evidence both
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received medication monitoring reviews every thirty days as required. The program had no
standing orders, pro re nata (PRN) orders, or emergency treatment orders for psychotropic
medications.
A medication administration was observed during the annual compliance review week. The
youth was observed being escorted to the medication area by direct care staff. The licensed
nurse was observed identifying themselves and verifying the youth, as well as the youth’s alert
status and allergies. The licensed nurse was observed preparing the medications as required
and initialing on the youth’s MAR. Staff were observed monitoring the youth to ensure the
medication was swallowed. OTC medications were administered and documented as required.
The Six Rights of Medication Delivery/Administration were verified during observations made.
An interview with five youth was conducted. Four of five youth reported the nurse gives
medications. One of five reported he does not take medications. An interview with five staff was
conducted. Five staff stated the nurse dispenses medication. One of five staff additionally stated
certified supervisors can dispense medications. An interview with nursing staff was conducted.
Only medications from a licensed pharmacy with a current, patient specific label intact on the
original medication container may be accepted into the program. All medications shall have a
current, valid order and are given pursuant to a current prescription or practitioner order.
Documentation of prescription verification shall occur in the chronological progress notes in the
IHCR or by utilizing the prescription medication verification checklist. The DHA and when
applicable the psychiatrist shall be contacted to obtain an order to resume the specified
medications a youth is prescribed prior to admission. There shall be no standing orders for
psychotropic medications. There shall be no emergency treatment orders for psychotropic
medication. There shall be no PRN orders for psychotropic medications. The program utilizes
the Department and pharmacy MAR. Non-healthcare staff may provide medications and are
trained by a registered nurse (RN). Medication pass times are 7:00 a.m., 1:00 p.m., and 5:00
p.m.
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 medical equipment classified as sharps were secured and inventoried utilizing a routine
perpetual inventory. Three sharps were observed and counted. The final count listed on the
inventory matched the actual count observed. All medications were identified and secured in the
locked area designated for storage of medications. The medication cart was clean, organized,
and stocked with medication separate from youth specific medications. Three over-the-counter
(OTC) medications were observed and counted. The final count listed on the inventory matched
the actual count observed. All controlled substances had a perpetual inventory and were stored
separately from other medications. All medications were stored separately and secured in a
locked area which is not accessible to youth. Narcotics and other controlled medications were
stored behind two locks. The program only had two controlled substances to observe at the time
of the annual compliance review. The final count listed on the inventory matched the actual
count observed. Medications requiring refrigeration were stored in a secured refrigerator used
for medications only. An informal interview with nursing staff was conducted to verify the
program’s process for the destruction and disposal or return of medications. Medications are
destroyed by the pharmacist and two nurses utilizing the pill buster. Expired medications are
returned to the pharmacy for credit. Perpetual and weekly inventories of sharps and stock OTC
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medications were completed as required. There was a shift-to-shift inventory count of all
controlled substances documented on the youth’s individualized controlled medication record
pursuant to board of pharmacy regulations. A list of trained program staff who can administer
youth medications is located on the wall in the medical clinic. The training was administered by
a registered nurse. The program has policy and procedures in place addressing inventory
discrepancies. By policy, if the count is incorrect, it shall be reconciled before the off-going shift
is released from duty. If the count cannot be reconciled, the RN shall be notified. An incident
report shall be completed and submitted to the program director before the off going shift is
released from duty. The Department’s Central Communications Center (CCC) must be notified if
the count cannot be reconciled. An interview with the nursing staff was conducted. The nursing
staff stated medications are sent back to the pharmacy for credit. Controlled medication is
destroyed by pharmacists and RNs using a drug buster. Medications are locked behind two
locks and a locked door. A count is conducted by shift with sign-offs. The program has a
contract with a pharmacy consultant who is on-site once a month. The program maintains a
copy of the pharmacy consultant license.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program’s infection control procedures include prevention, containment, treatment, and
reporting requirements related to infectious diseases, according to federal regulations and the
Centers for Disease Control and Prevention (CDC) guidelines. The infection control procedures
were reviewed last by the designated health authority (DHA) on January 7, 2024, by the
program director (PD) on January 7, 2024, and by the health services administrator (HSA) on
January 7, 2024. The infection control procedures included all required elements. There were
no instances in which the local county health department, CDC, and or the Department’s
Central Communications Center (CCC) had to be notified of any infectious diseases. The PD
has established a separate file of documents for youth and staff who have experienced a
facility/occupational exposure. The program has an exposure control plan which is available to
staff and is written in accordance with Occupational Safety and Health Administration (OSHA)
standards. Documentation supporting the plan was reviewed annually and signed by the PD.
The plan was last signed on January 7, 2024. The program has a policy and procedures in
place for needle stick post-exposure evaluations. The plan identifies the responsibility of the
HSA whenever a youth or staff has been exposed to a high-risk situation. There were no cases
of any reportable infectious diseases or any instances of quarantining or hospitalization. An
interview with the PD was conducted. The Exposure Control and Infection Control Plans are in
the medical department and reviews are conducted yearly. An interview with the nursing staff
was conducted. A copy of the Exposure Control Plan is available for access and is in medical
and master control. Infection control training for staff is conducted by the registered nurse (RN).
Infection control training for youth is conducted at intake by the RN. The RN is responsible for
providing staff with the exposure control plan.
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4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator in rated non-applicable.
Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a written policy and procedures for youth supervision, movement, and
checks. The policy states program staff shall maintain active supervision of youth, including
interacting positively with youth, engaging in a full schedule of constructive activities, closely
observing the behavior of youth and changes in behavior, and consistently applying the
behavior management system. The program’s staff to youth ratio is one to eight youth during the
daytime hours and one to twelve youth during the nighttime hours. The supervision of youth was
observed each day during the annual compliance review week. There were no discrepancies in
youth and staff ratios and positive interactions were observed between youth and staff. The
youth were observed to be engaged in a full schedule of activities each day during the annual
compliance review week. Three staff were informally interviewed, and each was able to provide
an accurate count of youth they were supervising without having to physically count them. Five
staff were interviewed. All five staff were able to summarize the program’s process and
procedures in the event a youth count is not 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 for comprehensive and consistent
implementation of the behavior management system (BMS) and staff training. The BMS was
reviewed within the provider’s contractual agreement and revealed all appropriate parties were
involved in the development, implementation, and on-going maintenance of the BMS, including
the education department. The program’s policies include a protocol where staff are provided
feedback regarding the implementation of the BMS. The program has a trainer who trains all
staff and education staff on the program’s BMS. Five youth case management records were
reviewed and revealed youth orientation included BMS. Three staff positions were reviewed,
which included the coach counselor, senior coach counselor, and shift supervisor. Each of these
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position descriptions detailed job functions which included implementation of the program’s
BMS. Five staff records were reviewed, and each staff completed training in the program’s BMS
as required. The program’s BMS was observed to be documented within the program’s policy
and procedures, youth handbook, and seen posted on walls in all living areas. The program’s
BMS has not changed from the previous year. The program’s written BMS policy includes
promoting safety, respect and fairness, promoting and protecting youth rights, positive and
negative consequences, constructive disciplinary actions/non-punitive, opportunities for positive
reinforcement, recognition of accomplishments and positive behaviors at a four to one ratio,
promoting socially acceptable means for youth to meet their needs, process for explaining to
youth the reasons for any sanctions imposed, youth having the opportunity to explain his/her
behavior, opportunities for staff and youth to discuss the impact of behavior on others,
reasonable reparations for harm caused to others, discussions of alternate behaviors, promoting
positive dialogue and peaceful conflict resolution, and separation of youth from population is
minimized. Additionally, the BMS policy states the length of stay is not increased solely as a
form of discipline for a violation of program rules. Modifications to the youth’s performance plan
shall be made by the therapeutic manager if the youth’s length of stay is increased because of
performance plan revisions or the addition of performance plan goals. The BMS policy opposes
denial of youth’s basic rights, promotion of group discipline, punishment of youth by other youth,
and disciplinary confinement. Staff and youth interactions were observed to be in adherence to
the BMS. Negative consequences are in direct relation to the severity or seriousness of
inappropriate behavior exhibited as required. A review of the BMS process revealed staff explain
to the youth the reason for any sanction imposed prior to the end of the staff’s workday, the
youth is given an opportunity to explain his or her behavior, and staff and the youth discuss the
behavior’s impact on others, reasonable reparations for harm caused to others, and alternative
acceptable behavior. Five staff were interviewed. All staff stated they received training in the
BMS. All five staff were able to summarize the BMS process. All five staff gave examples of
rewards the program provides such as snacks, canteen every Friday, five extra minute phone
calls, movie night, and game night. Three of five staff stated points, television privileges, and
other extra rewards received can be taken away as a consequence. The remaining two staff
stated nothing can be taken away as a consequence. All five staff stated special treatment team
is how youth are informed of consequences and are given an opportunity to explain behaviors.
Four staff stated they receive feedback on the implementation of BMS through morning
meetings or shift briefings. The remaining staff stated meetings with staff happen on an as
needed basis. Five youth were interviewed. All five youth were able to summarize the
consequences and process used for when receiving consequences. Four of five youth were
able to summarize the rewards received from the program. The remaining youth stated no. All
five youth were able to summarize the difference between each level of the BMS and how to
move from level to level. Each youth stated they are not allowed to punish other youth. All five
youth stated staff use rewards the same. One youth stated the BMS is very poor, one youth
stated it was poor, two youth stated it was fair, and the remaining youth stated it was good. An
interview with the program director revealed Rite of Passage’s (ROP) BMS is integrated with its
treatment services to provide trauma-informed, highly individualized responses based on the
risks, needs and acuity of each youth. It also aligns with their mission, values, and belief their
programs must assist youth in succeeding well after they transition to their home communities.
ROP uses daily progress notes as a calibrated daily measurement of a youth’s behavior as it
relates to how they are fulfilling individual case plan objectives and demonstrating safe
behaviors, coping, and pro-social skills. Direct care staff provide immediate feedback on
behavior and response to interventions and share the information with the youth on a daily and
weekly basis.
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5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program does not utilize room restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program maintains a written policy and procedures to conduct and document ten-minute
checks during sleep hours or at other times. The program has a total of eighty-four cameras,
and two of them were non-operational during the annual compliance review week. An informal
interview with master control revealed a work order was placed the week prior. Video recordings
are stored for up to thirty days. Video observations of nine forty-minute period increments were
conducted during the annual compliance week and revealed ten-minute checks were conducted
in the required frequency, in real time, and the checks were met with fidelity. A review of thirty-
six ten-minute check logs during the annual compliance review week revealed checks were
initialed and conducted as required. Five staff were interviewed. All staff stated room checks are
conducted in ten-minute intervals when youth are placed in their room for sleeping.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program has a written policy and procedures outlining the requirements for youth census,
counts, and tracking of youth. The policy states staff shall conduct, and document counts
minimally at the beginning of each shift, after each outdoor activity, and during emergency
situations such as escapes or riots. Observations of formal headcounts were made during the
annual compliance review week. A logbook review was conducted for one day each month of
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the annual compliance review period and found no discrepancies or exceptions. Documentation
included any applicable admissions, releases, youth movement, emergency situations, and
formal headcounts. Five staff were interviewed. Each staff knew the youth census, youth counts
are conducted every thirty minutes and every movement, and when emergency courts are
conducted.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a written policy and procedures for logbook entries and shift reports. A
review of three full days from each month during the annual compliance review period revealed
master control logbooks were bound with numbered pages. All entries were made in ink with no
erasure or white-out areas. There was no indication of logbook entries being destroyed or
removed. All errors were struck through with one line and initialed by the staff correcting the
error. All master logbooks included dates, times, events, names of staff and youth, if applicable,
brief description of events, and names and signatures of staff making entries. According to the
director of group living, the program does not maintain living unit logbooks. A review of shift
reports maintained during the annual compliance review period indicated incidents, events, and
activities were documented, and oncoming staff initialed shift reports. A copy of the shift report
was maintained in living units at least for forty-eight hours. A review of master logbook indicated
they documented emergency situations, incidents, special instructions, drills, population counts,
perimeter and security checks, transports, and admissions and releases as required. The
logbook was reviewed for incidents reported to the Department’s Central Communications
Center, and all were found to be documented in the master control logbook.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program maintains a written policy and procedures which address key control. A review of
the program’s policy includes 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, reporting, and replacement of damaged keys. On-site observations of the
distribution and collection of keys indicated personal keys are turned in before entering the
program. Master control handles inventory, issuance, and return of keys from shift to shift. A
review of the key inventory revealed the inventory and actual keys matched. The keys were
secured in a key storage box behind a combination lock when not in use. Staff who are issued
permanent key assignments sign a permanent key assignment acknowledgement form.
Restricted keys were observed to be locked and secured or assigned to a staff member. In case
of damaged keys, a damaged keys and tools form is filled out by the staff member and a work
order is placed. The key box was observed to be inaccessible when locked. A review of the key
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logbook indicated on March 3, 2024, a staff member dropped a key down a drain in the laundry
room. Staff were not able to recover key and did not call the Department’s Central
Communications Center (CCC) as required. Staff called the CCC during the annual compliance
review week to report incident. All restricted keys are kept in administration in a closed
combination box and staff members are given restricted keys when they start their shift,
according to director of group living. The program’s method for daily tracking and reconciliation
of keys is to keep daily sign-in and out logs. A sampling of five key rings was observed and
compared with the inventory and key log, which confirmed all keys were in their required
location and matched the key number and total number of keys listed. Three random staff were
questioned regarding their work issued keys. Each staff had the correct keys as noted on their
signed key log and were able to articulate the function of each key. Five staff were interviewed.
All staff were able to summarize the program’s key control process.
5.08 Contraband Procedures Limited Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a written policy and procedures for contraband procedures. The
contraband policy defines items/materials considered contraband and exemptions. Youth are
given a handbook during orientation with a list of contraband and consequences if contraband is
found. The policy outlines searches of the physical plant, facility grounds, youth, incoming mail
in the presence of youth, and outgoing mail. A review of the visitor logs revealed the program
does not contain a contraband attestation statement on the visitor log nor are contraband
attestation forms completed by visitors. A review of five staff records revealed two of five did not
contain the contraband attestation form and five newly hired staff did not have the contraband
attestation form. The program’s policy addresses any staff who is found in possession of
contraband in the program will be subject to disciplinary action up to and including dismissal.
Law enforcement is contacted in the event any item found would be considered illegal as
defined in Florida Statutes. The program clearly delineates those items considered contraband.
Facility searches, incident reports, and search reports were reviewed to determine the
frequency and quality of searches with no issues. Five staff were interviewed. Each staff was
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able to articulate the program's process for youth room searches. An interview with the program
director confirmed contraband procedures adhere to the program's contraband policy.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a written policy and procedures outlining searches of the youth, staff,
and facility grounds for contraband items. Youth searches were observed during the annual
compliance review week when youth were seen moving from one location to another. Youth
were treated with dignity and respect to minimize the youth’s stress and embarrassment.
Searches were conducted by same gender staff. Observations revealed searches were
thoroughly completed, staff gave clear instructions, and were conducted in accordance with the
Protective Action Response Right Interactions model training manual as required. Searches
before or after transport, admission, visitation, or off-campus activities were unable to be
observed for none were scheduled during the annual compliance review week. Five youth were
interviewed. Each youth stated they are searched whenever they move locations. Five staff
were interviewed. All staff were able to articulate when and how youth searches are conducted.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a written policy and procedures regarding the transportation of youth
and the maintenance of vehicles used in these transports. The program has two vans used for
transport. A review of inspections for each van documented deficiencies, which were corrected
as required. A review of documentation revealed both vans had annual safety inspections
documented, maintenance records documented, fire extinguishers, appropriate number of
seatbelts, the door could not be opened from the inside, and a safety screen was installed. A
first-aid kit with a seatbelt cutter and window punch are in master control for each van to utilize
during transports. During a walkthrough of the parking lot, both vans and ten additional vehicles
were secured as required. Five youth were interviewed. Three youth stated during transport
they are secured in the vehicle with shackles, one youth stated with seatbelts, and the
remaining youth had never been transported. Five staff were interviewed. All staff were able to
summarize how youth are secured during transports.
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5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a written policy and procedures regarding the transportation of youth
and vehicle maintenance requirements. The program’s policy ensures compliance with all
requirements outlined by the Department relating to transportation of youth and driver eligibility.
The supervisor cellular telephone is issued by the program to the transporter according to the
program director and policy. The one to five staff ratio is used during all transports as required.
A transport did not occur during the annual compliance review week; therefore, one could not be
observed. A review of five staff records confirmed staff have a current and valid driver’s license.
Youth are not permitted to drive program vehicles. Five youth were interviewed. All five youth
stated they have never seen anyone place contraband in the vehicle. All five youth stated they
felt safe being transported in a vehicle by staff. Five staff were interviewed. Four of five staff
reported having a radio or program issued cellular telephone during transport. The remaining
staff stated their personal phone is used. All staff stated first-aid kits were placed in transport
vehicles as safety equipment. In addition, two staff members stated a fire extinguisher. All staff
stated youth are not allowed to be transported in personal vehicles. All staff stated transport
vehicles are searched for contraband prior to and after each use. All staff were able to
summarize the emergency response process during vehicle transport. All staff stated the staff to
youth ratios were two staff and one youth. Four staff stated the vehicles have a safety screen in
the back. The remaining staff stated they had not been in a vehicle for five months and was
unsure. An interview with the program director revealed there are two Department vans with a
cage. Staff are in the back of the van during transport.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a written policy and procedures outlining the weekly safety and security
audit inspection process. The director of group living is responsible for conducting the weekly
security audits and safety inspections. The documentation is captured using the Department’s
Facility Security Audit and Safety Inspection form. The development and implementation of any
corrective actions warranted for areas of concern were observed to be documented on the
corresponding forms. A review of this documentation was done for the annual compliance
review period which confirmed the program’s practice. The period between December 6, 2023,
and January 17, 2024, indicated no weekly safety inspections were completed due to the
program being evacuated for a gas leak. The safety and security specialist confirmed the
program provides all required documentation weekly and responds to any actions needed. The
program also had no outstanding deficiencies at the time of the annual compliance review week.
An interview with the program director revealed the process of identifying and tracking safety
and security deficiencies involves weekly safety and security audits, daily perimeter checks, and
findings documented.
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5.13 Tool Inventory and Management Failed Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a written policy and procedures for tool inventory and management. The
program’s policy addresses issuance, inventory, control of equipment and tools, in addition to
prohibited items such as machete, bowie knives, and long blade knives. A review of issuance
and return of tool logs maintained during the annual compliance review period revealed no
issues. An informal interview with maintenance revealed procedures for missing tools is to
conduct an investigation and search, notify the program director (PD), complete the missing
tools form, and complete the Department’s Central Communications Center (CCC) report. Tools
which need to be replaced require staff to gain approval from the PD, complete the replacement
tool form, and update the inventory sheet. Daily inventories of Class A tools and monthly
inventories of Class B tools were not completed during the annual compliance review period.
Through observations and informal interviews with maintenance, not all tools were on the Class
A master list and Class B master list. Maintenance is aware of the issue and is in the process of
organizing the shed and inventorying all tools. A sample of seven Class A tools revealed five
were not on the Class A master list; however, each tool was secured. The Class B master list
was handwritten, and according to policy should be typed and readily available for inspection.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. A review of the program’s policy and procedures
includes supervision requirements when youth use tools, issuing tools to youth and staff,
including an assessment to determine a youth’s risk to self and others, established ratios, tool
distribution and collection, and search criteria during work projects. There were no work projects
where youth utilized tools during the annual compliance review week; therefore, observations
could not be made. A review of five youth records confirmed each contained documentation
indicating youth were trained in tool usage. Youth who have been given permission to utilize
tools have an approved risk assessment completed by the treatment team. Five youth were
interviewed. All five youth stated they can use mops, brooms, saws, and hammers. Four youth
stated they could use a screwdriver and scrub brush. Five staff were interviewed. All five staff
stated youth could use mops and brooms, three staff stated youth could use screwdrivers,
hammers, saws, and scrub brushes, and one staff stated youth could use kitchen knives. Youth
are only allowed to use saws, hammers, and screwdrivers during Home Builders Institute/work
activities and are only allowed to use kitchen knives when assisting in the kitchen during or after
obtaining the ServSafe certification, while being supervised, only after they have achieved a
certain level, and obtained permission from the treatment team.
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5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a written policy and procedures which address outside contractor’s
tools. A review of the program’s policy and procedures confirmed they include private
contractors shall receive written instruction detailing responsibilities regarding tool management
and contraband and shall confine their work to the authorized area using safety and security
precautions. A review of sign-in sheets for the annual compliance review period revealed each
contractor signs a contractor agreement form which includes tools being checked upon arrival
and departure, tool restrictions while in the facility, youth being restricted from the work area,
missing tool follow-up, and a list of prohibited items. A review of three invoices for completed
projects confirmed they matched dates for outside contract sign-in forms. The program staff
check contractor tools upon arrival and exit from the program. The tools are also inventoried on
the contractor agreement form, signed by the contractor upon arrival. If the contractor's use of
personal cellular telephones or electronic devices capable of taking pictures is required on-site,
the program director/designee is responsible for providing approval/permission in accordance
with the program's policy and procedures.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program maintains a written policy and procedures which address fire, safety, and
evacuation drills. The program practices emergency drills, such as fire drills and Continuity of
Operations Plan (COOP) drills once monthly on each shift. Reviewed drill documentation
included all requirements such as type of drill, date, time, a list of participants, brief scenario,
and recommendations or corrective actions needed. Fire evacuation and egress routes were
clearly posted within all program areas of the facility. The program has a total of sixteen fire
extinguishers. A sampling of eight extinguishers found each was inspected monthly by the
program’s maintenance staff. Five youth were interviewed. Four youth stated they have been
instructed on what to do in case of fire. The remaining youth stated no instruction was received.
Two youth stated drills are conducted once a month. One youth stated they have not
participated in a fire drill. The remaining two did not respond. Five staff were interviewed. All five
staff reported participating in a fire drill monthly. Four staff reported participating in a weather,
major disturbance, and escape drill. Three staff reported participating in a chemical spill drill.
Two staff reported participating in a bomb threat. One staff reported participating in a flooding
drill. One staff reported recently returning to the program. An interview with the program director
revealed medical, fire, COOP, and mental health drills are conducted monthly.
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5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program maintains a written policy and procedures for disasters and the Continuity of
Operations Plan (COOP). The COOP is located in master control and program director’s (PD’s)
office and is readily accessible to staff members. The COOP was last approved by the
Department’s Office of Residential Services in March 2023. The Department provided an email
notification to the program on March 25, 2024, advising the program to postpone submitting a
new COOP at this time due to some changes being made with the template, with an estimated
time of completion by April 15, 2024. The program’s COOP addresses alternative relocation
sites approved by the Department. The COOP included all the required elements. The program
administration reported they have utilized COOP procedures during the annual compliance
review period, as they underwent an evacuation earlier in the year due to a gas leak in the
program. There were no issues reported for the evacuation process. Emergency supplies and
equipment are stored in a pantry located in the kitchen with an inventory sheet. The program
maintains a hard-copy binder which includes all required demographic, legal, and medical
information for each youth. A sample of five youth from the COOP binder revealed all
information was documented as required. An interview with the PD revealed the COOP is
readily available to staff and is located in master control and the PD’s office.
5.18 Storage and Inventory of Flammable, Poisonous, and
Limited Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program maintains a written policy and procedures for the storage, inventory, and disposal
of flammable, poisonous, and toxic items and materials. All flammable, poisonous, and toxic
chemicals are maintained in secure locations which are inaccessible to youth. Areas used to
store these items include the front bathroom, kitchen, master control, and maintenance shed.
An inventory of five items in the front bathroom revealed nine bottles of cleaner in the closet, but
the inventory documented eight. In addition, two of the cleaners were documented on the
inventory sheet but were not located in the front bathroom closet. Maintenance stated the
chemicals were in the maintenance shed. There were no Safety Data Sheets (SDSs) for any
chemicals in the front bathroom closet. An inventory of five chemical items in the kitchen
revealed all items were accounted for as required; however, two were missing SDSs. The
kitchen staff stated chemicals were new and they were in the process of obtaining the SDS for
both chemicals. Kitchen staff added SDSs to the chemicals during the annual compliance
review week. An inventory of four chemical items in master control revealed all items were
accounted for and each had the appropriate SDS as required. An attempt to inventory items in
the maintenance shed revealed there was no inventory of chemicals or SDSs. Observations
revealed chemicals were located all over the shed and not in one area. Maintenance staff are in
the process of cleaning and organizing the shed. Maintenance and trained floor staff are
authorized to handle chemicals.
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5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a written policy and procedures for the storage, inventory, and disposal
of flammable, poisonous, and toxic items and materials. According to the program’s policy,
youth shall not be permitted to use, handle, or clean with dangerous or hazardous chemicals,
respond to chemical spills, or clean, handle, or dispose of any person’s biohazardous material,
bodily fluids, or human waste. The program maintains strict control of all hazardous chemicals.
All areas observed to store these items were secured and inaccessible to youth. No youth were
observed using any cleaning agents during the annual compliance review week. Five youth
were interviewed. Three youth reported using paint and window or toilet cleaner. Two youth
reported using rubbing alcohol and laundry soap. One youth reported using bug spray and paint
stripper. The program does provide a Home Builders Institute (HBI) vocational program;
therefore, youth would utilize certain chemicals for vocational training once approved by the
treatment team.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program maintains a written policy and procedures for the storage, inventory, and disposal
of flammable, poisonous, and toxic items and materials. According to the program’s policy,
disposal of hazardous chemicals is accomplished within parameters of state, local, and federal
laws. The maintenance staff is responsible for the safe and lawful disposal of these items. The
list of individuals authorized to dispose of items includes maintenance staff and trained floor
staff. All disposal procedures are in accordance with Occupational Safety and Health
Administration (OSHA) standards. The medical staff maintain a contract with a local disposal
company, which comes monthly to the program to collect all bio-hazardous waste. An informal
interview with maintenance revealed cooking oil is placed in a separate bin outside and
disposed of by an outside contractor, who maintenance contacts when it’s time for disposal.
Liquid waste from work details is disposed of in sinks located in the mop storage and kitchen
liquid is disposed of in kitchen sinks as required. An interview with the maintenance staff
confirmed no chemical spills during the annual compliance review period, but the program
would utilize the policy if necessary. An interview with the program director confirmed all
disposals adhere to the program's disposal policy.
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5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a written policy and procedures for visitation and communication. The
program has a visitation schedule posted in youth handbooks and in the lobby area of the
program. According to the program’s policy, youth will be provided at a minimum, at least one
telephone call each week by the program. Youth with hearing or speech disabilities and youth
who wish to communicate with parties who have such disabilities shall be afforded access to
necessary equipment to promote effective communication. Outgoing calls may include calls to
parents/guardians, family members, and others identified on the youth’s approved
correspondence list. Outgoing calls are also permitted to the youth’s attorney of record, juvenile
probation officer (JPO), and, if applicable, dependency case manager. Outgoing calls to officials
are not limited. Each youth shall be provided with writing materials, designated times to draft
correspondence, as well as envelopes and postage as needed for mailing. Youth may
correspond with individuals specified on an approved correspondence list. Visitation is
scheduled for the third Saturday of every month and reservation is required. The telephone
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schedule was provided but when compared to youth telephone logs the telephone schedule did
not match. The mail schedule was not provided and an informal interview with program staff
could not articulate when youth can write letter. No information was provided if youth had written
a letter during the annual compliance review period. A log of only January through March 2024
was provided for mail. The three month log revealed two youth received mail and one was not
accepted due to inappropriate content. An informal interview with the program director (PD),
during admission classification meetings confirmed it is determined if a youth with a history of
human trafficking has family members who have a human trafficking related charge. An informal
interview with the director of group living confirmed outgoing mail is searched. If a youth or
family has a language barrier and a bilingual staff is unavailable, a language translation service
is used. Five youth were interviewed. All five youth stated they can call or send a letter to their
parent/guardian. Each youth stated they don't know what the program has in place for youth
who do not speak English as their primary language. Five staff were interviewed. Three staff
stated they have bilingual staff for youth who do not speak English as their primary language.
The remaining two staff stated they were not sure. According to the PD, the program utilizes
Language Line Solutions as a translation service for youth.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a written policy and procedures for recreation and leisure activities. The
program has an activity schedule posted and visible in all program areas. The program provides
outdoor and indoor activities for youth, which was confirmed in a review of the daily activity
schedule and logbook documentation. Activities provided and observed promote social and
cognitive skill development, creativity, teamwork, healthy competition, mental stimulation, and
physical fitness. The program takes precautionary measures to prevent overexertion, heat,
stress, dehydration, and frostbite. The provider’s contractual agreement requires the
employment of a recreational therapist; however, the position recently became vacant. Five
youth were interviewed. All five youth stated the program allows the opportunity for recreation
time and reported recreation time is at least one hour. Five staff were interviewed. All staff
stated youth receive at least an hour of recreation time. Examples given were basketball,
football, board games, card games, PlayStation, movie nights, kickball, double dutch, and
exercise equipment.
5.24 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program maintains a written policy and procedures for controlled observation. The
controlled observation rooms meet the requirements including a minimum of thirty-five
unencumbered square feet, hardwood or metal doors with shatter-resistant windows, vents not
easily accessible and covered with small mesh or a metal plate, fire retardant plastic mattress
suitable for use on the floor or a suicide-resistant bed, recessed light fixtures covered with
shatter-resistant material, shatter resistant windows or glass windows covered with security
rated screens, no electrical outlets, and electrical switches were covered or secured. The
program did not utilize controlled observations during the annual compliance review period.
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5.25 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program did not have controlled observations during the annual compliance review period;
therefore, this indicator is rated non-applicable.
5.26 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program did not have controlled observations during the annual compliance review period;
therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 67 (Revised September 2022)

source: DJJ

report_type: QI Residential

program_name_raw: Walton Academy for Growth and Change

rule: Indicator 2.10

excerpt: Performance Plan Revisions

rating: Limited Compliance

rule: Indicator 3.12

rule: Indicator 5.08

excerpt: Contraband Procedures

rule: Indicator 5.13

excerpt: Tool Inventory and Management

rating: Failed Compliance

rule: Indicator 5.18