summary: QI Residential - FY24-25

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Les Peters Academy
Truecore Behavioral Solutions, LLC.
(Contract Provider)
3920 W. Dr Martin Luther King Jr Blvd
Tampa, Florida 33614
Review Date(s): December 3-6, 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:
Tamara Mahl-Adkins, Office of Accountability and Program Support, Lead Reviewer (Standard
1)
Jeremy Curvan, Office of Accountability and Program Support, Regional Monitor (Interviews)
Cheryl Francis, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Amanda LoPresti, Probation Circuit 13, Juvenile Probation Officer Supervisor (Standard 2)
Amanda Nelson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Luis Rodriguez, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Jennifer Tummino, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Les Peters Academy MQI Program Code: 1282
Provider Name: Truecore Behavioral Solutions, LLC. Contract Number: 10778
Location: Hillsborough County / Circuit 13 Number of Beds: 24
Review Date(s): December 3-6, 2024 Lead Reviewer Code: 156
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, and (6)
Educational Services, which are included in the Residential Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 71 (Revised September 2022)
A ll in d ic a to rs h a v e b e e n ra te d
O v e
S a tis
ra ll R a tin
fa c to ry a n
g S
d n o
u m
c o
m a
rre c
ry
tiv e a c tio n is n e e d e d a t th is tim e .
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 71 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 71 (Revised September 2022)
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
2 .1 2
2 .1 3
2 .1 4
2 .1 5
2 .1 6
2 .1 7
2 .1 8
* T h e D e p a rtm e n
o p e ra te s b e lo w D
F a ilu re to d o s o w
In d ic a t o r R a t in g s
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n
Y o u th O rie n ta tio n
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y )
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S )
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls a n d T ra n s m itta l *
P e rfo rm a n c e P la n R e v is io n s
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s
In c o rp o ra tio n o f O th e r P la n s In to P e rfo rm a n c e P la n
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s )
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T )
E x it P o rtfo lio
E x it C o n fe re n c e
Y o u th In p u t
t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a
e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th
ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
tte n tio n if a p ro g ra m
e s e in d ic a to rs .
s id e n tia l, p ro b a tio n ).
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 71 (Revised September 2022)
3 .0 1
3 .0 2
3 .0 3
3 .0 4
3 .0 5
3 .0 6
3 .0 7
3 .0 8
3 .0 9
3 .1 0
3 .1 1
3 .1 2
3 .1 3
3 .1 4
3 .1 5
3 .1 6
3 .1 7
3 .1 8
3 .1 9
* T h e D e p a rtm e n
o p e ra te s b e lo w D
F a ilu re to d o s o w
In d ic a t o r R a t in g s
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity o r C lin ic a l C o o rd in a to r
L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff *
N o n -L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A d m is s io n S c re e n in g
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A s s e s s m e n t/E v a lu a tio n
M e n ta l H e a lth a n d S u b s ta n c e A b u s e T re a tm e n t*
T re a tm e n t a n d D is c h a rg e P la n n in g *
S p e c ia liz e d T re a tm e n t S e rv ic e s *
P s y c h ia tric S e rv ic e s *
S u ic id e P re v e n tio n P la n *
S u ic id e P re v e n tio n S e rv ic e s *
S e c u re O b s e rv a tio n *
S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
S u ic id e P re v e n tio n T ra in in g *
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s *
C ris is A s s e s s m e n ts *
E m e rg e n c y M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e rv ic e s *
B a k e r a n d M a rc h m a n A c ts *
S a fe ty P la n n in g P ro c e s s fo r Y o u th
t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a
e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th
ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
tte n tio n if a p ro g ra m
e s e in d ic a to rs .
s id e n tia l, p ro b a tio n ).
Standard 4: Health Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 71 (Revised September 2022)
4 .0 1
4 .0 2
4 .0 3
4 .0 4
4 .0 5
4 .0 6
4 .0 7
4 .0 8
4 .0 9
4 .1 0
4 .1 1
4 .1 2
4 .1 3
4 .1 4
4 .1 5
4 .1 6
4 .1 7
4 .1 8
4 .1 9
* T h e D e p a rtm e n
o p e ra te s b e lo w D
F a ilu re to d o s o w
In d ic a t o r R a t in g s
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e *
L ic e n s e d M e d ic a l S ta ff*
F a c ility O p e ra tin g P ro c e d u re s
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t
P a re n ta l N o tific a tio n /C o n s e n t
H e a lth c a re A d m is s io n & R e s c re e n in g F o rm
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e A d m is s io n N o tific a tio n
H e a lth -R e la te d H is to ry
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g
S e x u a lly T ra n s m itte d In fe c tio n & H IV S c re e n in g
S ic k C a ll P ro c e s s
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re
O ff-S ite C a re /R e fe rra ls
C h ro n ic Illn e s s /P e rio d ic E v a lu a tio n s
M e d ic a tio n M a n a g e m e n t
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s
In fe c tio n C o n tro l/E x p o s u re C o n tro l
P re n a ta l C a re /E d u c a tio n
t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a
e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th
ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
tte n tio n if a p ro g ra m
e s e in d ic a to rs .
s id e n tia l, p ro b a tio n ).
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 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 71 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 71 (Revised September 2022)
6 .0 1
6 .0 2
6 .0 3
6 .0 4
6 .0 5
6 .0 6
6 .0 7
6 .0 8
* T h e D e p a rtm e n
o p e ra te s b e lo w D
F a ilu re to d o s o w
In d ic a t o r R a t in g s
S ta n d a r d 6 - E d u c a tio n a l S e r v ic e s
C o n tra c t S p e c ific C T E S e rv ic e s (R e s id e n tia l C o n tra c t)
E d u c a tio n a l A c c e s s (R e s id e n tia l C o n tra c t) *
E d u c a tio n a l A c c e s s (E d u c a tio n C o n tra c t) *
C a re e r E d u c a tio n (E d u c a tio n C o n tra c t)
E d u c a tio n T ra n s itio n P la n (E d u c a tio n C o n tra c t)
Q u a lifie d In tru c tio n a l P e rs o n n e l (E d u c a tio n C o n tra c t)
F lo rid a Y o u th C o lle g e (E d u c a tio n C o n tra c t)
F lo rid a Y o u th C o lle g e (P o s t-S e c o n d a ry C o n tra c t)
t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a
e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th
ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
N o n -A p p lic a b le
N o n -A p p lic a b le
N o n -A p p lic a b le
N o n -A p p lic a b le
N o n -A p p lic a b le
tte n tio n if a p ro g ra m
e s e in d ic a to rs .
s id e n tia l, p ro b a tio n ).
Program Overview
The Les Peters Academy is a twenty-four bed program, for fourteen to eighteen year old
females, located in Tampa, Florida. The program is operated by Truecore Behavioral Solutions,
LLC., through a contract with the Department. The program provides the following services:
intensive mental health. In addition, the program fosters each youth by providing Moral
Reconation Therapy, Dialectical Behavior Therapy, and Impact Of Crime. Additional treatment
services provided includes family/individual therapy, Seeking Safety, Resilience Builder
Program for children and adolescents, recreational therapy, board certified behavioral analyst
services, and registered behavioral technician therapy. Program administration is comprised of
one facility administrator, one assistant facility administrator, and one administrative assistant.
Case management services are provided by one director of case management, one transitional
service manager, and two case managers. Mental health staff at the program includes one
director of clinical services, one licensed therapist, two unlicensed therapists, and one
recreational therapist. Medical services are offered from 7:00 a.m. to 7:00 p.m. every day of the
week and are provided by one health services administrator, one registered nurse, and one
licensed practical nurse. Educational services are provided by the Florida Scholars Academy.
The layout of the program includes one main building which houses the dormitory, the day area,
the kitchen, administration/case management/clinical offices, the clinic, and a patio. The
program also has two education portables, and maintenance sheds. The program has forty-
seven security cameras providing coverage two were not operational during the annual
compliance review (ACR) week and had a work order. At the time of the annual compliance
review, the program had six vacant positions including one shift supervisor, three youth care
worker (YCW) I, one YCW II, and one registered behavior technician.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 71 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures to address background screening, which is
completed on all staff, volunteers, mentors, and interns regardless the amount of time spent
with youth at the program. The program completed and sent an Annual Affidavit of Compliance
with Level 2 Screening Standards to the Department’s Background Screening Unit (BSU) on
December 11, 2023, prior to the January 31 deadline. They also send an annual screening for
the teachers who are paid by the local school board on December 11, 2023. The program had
twenty-six new staff, as well as twenty-four new volunteers since the last annual compliance
review. All fifty staff/volunteers had a background screening completed prior to contact with
youth and confidential youth records, including a criminal history report review with none
requiring an exemption. Four of the twenty-six staff had a break in the Staff Verification System
and received a new background screening. Fifteen of the twenty-six staff were direct-care
applicants and had a pre-employment assessment tool administered prior to hire with a passing
score being documented in each applicant’s record. The program added all staff to their
Clearinghouse employee roster, with the exception of six, as well as none of the volunteers. The
program provided documentation regarding attempts made to add the missing individuals to the
employee roster to no avail, showing an error in the Clearinghouse system. None of the twenty-
six staff had been Department staff or previous other provider company staff. All twenty-six staff
had a signed contraband attestation form.
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.)
Two staff were applicable for a five-year rescreening/renewal. Both staff had a five-year
rescreening/renewal completed every five years, no more than twelve months, and no less than
ten days prior to the staff’s five-year anniversary date. A rescreening/renewal was submitted to
the Department’s Background Screening Unit/Clearinghouse at least ten business days prior to
the five-year anniversary or retained prints expiration date.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 71 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to address abuse reporting. The program had three
incidents alleging staff physically, psychologically, or emotionally abused youth in the program’s
care during the annual compliance review period. All three were reported to the Department’s
Central Communications Center (CCC), and one was accepted by the Florida Abuse Hotline.
None of the three allegations were founded and none of the youth involved were potential
victims of human trafficking, child sexual exploitation, or labor trafficking. A review of five staff
records indicated each staff had signed a document acknowledging a review of the program’s
code of conduct. The program had the Florida Abuse Hotline and CCC telephone numbers
posted throughout the facility. The program completed a Trauma Responsive and Caring
Environment (TRACE) self-assessment on March 14, 2024.
All five youth interviews indicated they feel safe at the program, had never been stopped from
reporting abuse to the Florida Abuse Hotline or CCC and they knew where the Florida Abuse
Hotline telephone number was posted in the facility. All five youth interviews stated the staff are
always respectful toward them, and they had never heard staff use curse words when speaking
to them or other youth. All five youth said they had never exchanged emails, telephone
numbers, or social media contact information with staff. All five staff interviews indicated the
process for staff and youth to call the Florida Abuse Hotline or the CCC to report suspected
abuse was to notify the supervisor and the facility administrator, to allow youth to make the
telephone call, or the supervisor will make the call, and staff are also allowed to call. None of the
five staff had ever observed another staff telling a youth they could not call the Florida Abuse
Hotline. Four stated they had never heard another staff using profanity while speaking with
youth, the remaining one staff saying they heard a staff using profanity once. The facility
administrator (FA) interview indicated general standards of conduct and performance apply to
all staff and contractors. The standards are categorized into three levels: minor, major, and
critical offense. Failure to follow a standard of conduct may result in disciplinary action from a
verbal warning to termination of employment. The severity of the penalty depends on the
frequency and nature of the offense. These standards are not all-inclusive; however, they are
intended to be illustrative of the minimum expectations for acceptable work performance and
workplace behavior. The FA interview stated the program incorporates trauma-responsive
practices by ensuring each youth has a safety plan created upon youth admission, which is
reviewed by all staff, and is maintained in a general location for staff reference, and all staff are
in-service trained in trauma informed care. The FA interview indicated the program’s incident
reporting process includes the FA/designee being notified of any CCC reportable incident,
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determining if the incident is reportable, and if necessary, gather information and contact the
CCC within two hours. Any staff can contact the CCC with the FA being the primary reporting
person. Any youth eighteen years of age or older is permitted to contact the CCC. The program
has a Florida Abuse Hotline telephone and any youth requesting to call can do so immediately
in a private space. All staff are mandated reporters and can contact the Florida Abuse Hotline at
any time. The FA interview stated during general staff meetings the facility operating procedures
are reviewed, staff receive pre-service training during the onboarding process, as well as annual
training regarding the reporting process for the CCC and the Florida Abuse Hotline. Any CCC or
abuse incidents are reviewed and reported in the morning management meeting and are input
in the database for tracking. There are numerous postings of the CCC and Florida Abuse
Hotline telephone numbers throughout the facility for staff and youth access.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had three incidents alleging staff physically, psychologically, or emotionally
abused youth in the program’s care during the annual compliance review period. In all three
incidents there was evidence management took immediate action to address the allegations
and all three investigations were closed unfounded. The facility administrator interview indicated
anytime management is made aware of any allegations of abuse, an internal investigation is
immediately initiated, and the staff the named in the allegation is placed on suspension with no
youth contact pending the investigation. The Florida Abuse Hotline and the Department’s
Central Communications Center are contacted. During or upon conclusion of the investigation,
when deemed necessary disciplinary action will be issued up to termination of employment.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program had twenty-one reportable incidents to the Department’s Central Communications
Center (CCC) during the annual compliance review (ACR) period. Five CCCs were reviewed
and all five were reported within the required two-hour timeframe and documented in the
logbook. A review of documentation for the ACR period indicated there were no additional
internal incidents/grievances, which should have been reported to the CCC. The program has
experienced an increase in the number of reportable incidents to the CCC; however, the total
increase did not exceed five.
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1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. 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 RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program had nineteen Right Interaction (RI) incidents during the annual compliance review
(ACR) period. The program maintained monthly summaries of all RI incidents submitted to the
Department during the ACR period. The RI plan was updated on April 9, 2024, and approved by
the Department on May 3, 2024. The program had experienced an increase in RI incidents of
more than five from the previous ACR period, stating the Department’s residential services
instructed them to write reports for touch techniques and add them to their summaries. The
program stated those instructions are not congruent with RI/Protective Action Response Rule.
Additionally, the closure of another program resulted in a short-term increase in youth
admissions.. The program’s PAR rate during the previous quarter was 0, which is below the
statewide residential PAR rate of 1.71. The facility administrator (FA) interview indicated RI
reports are reviewed during morning management meetings and reported for tracking in the
morning meeting database. The assistant FA of operations conducts video reviews of RI
incidents to ensure proper procedures were followed, there was no use of excessive force, and
RI was necessary. The RI summary report is completed and reviewed for trends, as well as
submitted to the Department for tracking monthly. Five staff interviews indicated four used RI,
one did not. All four who use RI stated the RI process includes completion of an RI incident
report and to notify the supervisor. Three of the four staff stated to use verbal directions/de-
escalation techniques before using RI. One staff also stated to notify medical, and another said
to call a code for back-up. A review of five RI reports for the ACR period indicated the report
was completed by the end of the staff’s shift and included statements from all staff involved.
None of the five required mechanical restraints, no staff or youth were injured, no youth alleged
abuse, and no RI medical review was required. All five RI reports were reviewed by a supervisor
and a RI instructor, as well as reviewed by the administrator/designee within seventy-two hours
of the incident.
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. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program considers youth care workers, shift supervisors, recreational therapist, facility
administrator (FA), assistant FA, and administrative assistant to be direct-care staff and can be
counted in the staff-to-youth ratio. A review of documentation indicated the program’s instructors
were qualified to deliver training in cardiopulmonary resuscitation (CPR), first-aid, automated
external defibrillator (AED) and Right Interactions (RI). The program submitted a pre-service
training plan on December 30, 2022 prior to implementation, as well as on March 12, 2024. The
training plan was approved by the highest ranking official at the location, the assistant secretary
for residential services, and the director of the Department’s Talent, Leadership, and Culture. A
review of five pre-service training staff records indicated all training was completed within 180
days of hire and each staff had more than the required 120 training hours. All five staff
completed the required training prior to youth contact.. All remaining required training was
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completed within the 180 days of hire andwas documented in the Department’s Learning
Management System (SkillPro) or on an approved checklist due to SkillPro having been down.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
A review of five in-service training records indicated all five staff completed the mandatory
training topics and required twenty-four hours of annual training, with the exception of two staff
missing one training for the 2023 training year; one of the staff completed the missing training in
2024. Three of the staff were supervisory and had completed more than the required eight
hours of supervisor training in coaching, leadership and personal accountability. The five staff
had from 102.5 to 233.5 annual training hours documented in the Department’s Learning
Management System (SkillPro). A review of documentation indicated the program’s instructors
were qualified to deliver training in cardio-pulmonary resuscitation (CPR), first-aid, automated
external defibrillator (AED) and Right Interactions (RI). The program has an annual in-service
training calendar, which is updated as changes occur. The program submitted an in-service
training plan prior to implementation, and it was approved by the highest ranking official at the
location and the assistant secretary for residential services; however, the signature for the
director of the Department’s Talent, Leadership, and Culture was missing.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures to address the grievance process, including the three
phases of informal, formal and appeal, as well as training requirements. The program’s informal
phase indicates the staff shall make reasonable efforts to discuss the youth's concern or
complaint and assist the youth in informally resolving the issue; however, no youth is
discouraged from filing a formal grievance. The informal grievance shall be handled
expeditiously and no later than twenty-four hours after receipt. A youth can submit an informal
request at anytime as an alternative to filing a formal grievance. A review of documentation
indicated the program’s practice correlates with their process. The program maintained copies
of all sixty-five grievances for the last twelve months. A review of seven grievances indicated all
were handled within twenty-four hours of receipt during the formal phase and were resolved.
Four of five youth interviews indicated they were aware of the grievance process; the remaining
one stating she had never had to file a grievance. All five youth stated they could ask for
assistance in completing a grievance form. All five staff interviews indicated they could describe
the grievance process, including stating forms are placed throughout the program, youth can
request assistance in completing forms, the process has three phases with associated time
frames, and the supervisor and the facility administrator (FA) review grievances. The FA
interview indicated the program's grievance process includes all girls be treated fairly,
respectfully, without discrimination, and to enjoy all constitutional rights afforded to them under
both state and federal law. Filing a grievance shall not result in retaliation or barriers to services,
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there is no time limits for a girl to file a grievance, and there is no requirement prohibiting a girl
from filing a grievance without first using the informal complaint process. The grievance process
includes three phases, each with associated time frames.
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
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 does not have a specific policy and procedures to address life and social skills
activities provided to youth. The program indicated their entire focus of the program is to
develop life and social skills for all of the youth with the groups and daily activities they are
completing. A review of documentation indicated the program provided life and social skills
activities addressing communication, interpersonal relationships and interaction, non-violent
conflict resolution, anger management, critical thinking, and needs of the programs targeted
gender group. The program uses Dialectical Behavioral Therapy (DBT), and Moral Reconation
Therapy (MRT) group sessions to address life and social skill services, which was verified
through a review of sign-in sheets. The program has also offered Creating a Positive
Environment individual counseling sessions, yoga, mentoring, debate team meetings, string
music lessons, drum sessions, mentoring for prospected and verified human trafficking youth,
as well as cardio-pulmonary resuscitation and first-aid training during the annual compliance
review period. One of five youth interviews indicated she did not participate in any activities
related to life skills at this time. All other four stated they participate in life and social skills
groups and activities, mentioning MRT and Impact of Crime (IOC), substance abuse, process
groups, book club and individual counseling. The facility administrator interview indicated youth
participate in mental health groups five days a week facilitated by trained clinicians and licensed
therapists and delinquency groups are facilitated by case managers two days a week. The
program addresses the needs of a targeted gender group by utilizing the Empower model which
follows a gender responsive philosophy. They provide youth with personal items allowing
gender expression, including meeting the needs of youth who identify as the opposite gender.
The youth are encouraged and taught gender specific hygiene and health care, and a member
of the community advisory board is from the LGBTQIA+ community who provides feedback
when requested and is also willing to conduct staff trainings as needed. The designated mental
health clinician authority (DMHCA) interview indicated clinical services are provided by licensed
and master’s-level therapists. The clinical specialized groups include MRT, which are conducted
by a trained master’s-level clinical staff three times a week for mental health issues. IOC is a
delinquency intervention group designed to promote insight and understanding into how thought
patterns and conduct impact themselves and their community, which is delivered to all youth in
the program by a trained case manager one time a week. Process Group is a mental
health/substance abuse group delivered two times a week and DBT is a mental health
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intervention also provided two times a week. The interview also mentioned seeking safety as a
substance abuse group provided one time a week. The youth can practice skills in the daily
meetings, as well as part of the positive performance system, as co-facilitators of mental health
and substance abuse groups, and leading recreational activities.
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 has no specific contractually required restorative justice groups or activities. The
program provided restorative justice activities at least monthly during the annual compliance
review (ACR) period, including volunteering at the local Humane Society, assisting with food
donations, and back to school events, creating posters for back to school event, participating in
breast cancer awareness walk, packed Christmas boxes for young girls at a local church,
assisted with setting up for a local run, made Christmas cards for young girls at a local church,
and Christmas ornaments. A review of Department news articles and pictures verified the
provision of activities. The facility administrator interview indicated the program youth participate
in various restorative justice groups/activities, reiterating the reviewed documentation. Youth
participate in Impact of Crime which focuses on restorative justice and involves the youth
working on projects helping them understand the impact they had on their communities,
families, and themselves. Youth also participate in Moral Reconation Therapy which
incorporates skills training and addresses delinquency intervention. All five youth interviews
indicated they participated in IOC as a restorative justice group and they have practiced skills
they learned in group, mentioning how to approach people, effective communication, anger
management, coping skills, and relapse prevention skills.
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1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures to address how new alerts are identified,
documented, updated, and communicated to staff. The program’s policy indicated during
screening assessments identified alerts are entered into the Department’s Juvenile Justice
Information System (JJIS) and placed on the program’s alert board, which is updated daily when
changes occur. The alert board is reviewed during shift change with staff. Alerts are also
entered into the facility logbook regarding suicide risk. Removal from an alert is based on
assessments by professionals, like mental health and medical. During the annual compliance
review week youth who had open alerts were noted on the internal alert system and JJIS as
indicated by the program’s policy. A review of five youth records indicated all alerts were
entered, updated, and closed, if applicable as required. All suicide risk alerts were documented
in the logbook, as well as JJIS. All other open alerts were documented in JJIS, as well as on the
internal alert system. The facility administrator interview indicated the health service
administrator (HSA) and FA meet daily in the morning management meeting to discuss
important medical issues pertaining to youth at the program. The program also utilizes an
internal alert system to include an alert roster and alert board which details all applicable youth
alerts. Any change in a youth's alert status is updated on the alert board as well as documented
in the shift logbook. The outgoing shift supervisor will brief the incoming staff of any
new/changed alerts and they are also discussed during morning management meeting. Each
department head is responsible for managing alerts applicable to their department. The internal
alert board displays current alerts and is updated as needed. The nursing interview indicated
the registered nurse, the licensed practical nurse and the HSA are responsible for updating the
medical alert system. One of five staff interviews indicated the clinical staff will inform the floor
staff of any alerts. The remaining four staff stated youth alerts are provided during shift change.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program separates the youth records into two separate records: an Individual Healthcare
Record (IHCR), and an individual case management record with the IHCR being separated into
a medical and a mental health substance abuse record. Each individual management record
contained the youth’s name, the Department of Juvenile Justice Identification Number (DJJID),
date of birth, county of residence and committing offense. The individual management records
contained sections for legal information, demographics and chronological information,
correspondence, case management and treatment team activities and miscellaneous. All youth
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records were labeled “Confidential”, as well as the file cabinets to store the records. All records
were maintained in a locked room in a locked file cabinet.
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.
A review of agendas and meeting minutes indicated the program’s community advisory board
(CAB) met every quarter. A review of documentation indicated the facility administrator (FA)
actively solicited/recruited involvement from the business community, school board/district, faith
community, LGBTQIA+ community, victim/victim advocate, and a parent/guardian whose child
was previously involved in the juvenile justice system and other community partners. There was
no documentation regarding recruitment for a law enforcement representative or the judiciary
community. During the annual compliance review week, the FA called and sent letters to seek
involvement from the missing community partners. During an interview, the FA confirmed CAB
meetings are held quarterly and include a review of an agenda detailing program updates and
CAB member updates. Meeting minutes are shared with all CAB members to inform those who
were not been present during the meeting. The program sends out recruitment letters
periodically to solicit new membership and to ensure each position on the CAB is represented.
An interview was conducted with a CAB member who is a parent/guardian of a whose youth
previously involved in the juvenile justice system. The CAB member stated she participates
mostly on the telephone since she does not live in the immediate area. She reported she either
gets a text, email or telephone call from the FA to notify her of the CAB. She reported they
discusses family day, outings, mentors, and other events which serve to encourage the youth.
She stated she feels the CAB meetings are very beneficial to the program youth and a lot of
information is exchanged amongst the CAB members and the program staff.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures to address staff performance evaluations. The policy
indicates staff performance is evaluated after the first ninety days of hire and then at least
annually. A review of four different position descriptions indicated each staff’s performance
standards were clearly identified. A review of five performance evaluations indicated they were
completed as required, and the performance standards matched the position description for
each staff. All position descriptions for staff whose job function includes implementation of the
program’s behavior management system were reviewed, for a total of eighteen, and found they
encompassed implementation of the behavior management system. The program had all
contractually required positions filled during the annual compliance review(ACR) week, other
than the registered behavioral technician position which has been vacant since April 6, 2024.
The program provided documentation of all recruitment efforts since the vacancy has occurred.
During the annual compliance review week, the program had the required recreational therapist
position filled, as outlined in the contract. A review of documentation for the recreational
therapist confirmed all requirements were met. The program’s contract specifies two registered
nurses (RNs), as well as a health services administrator (HSA), who is a RN are required. At the
time of the ACR week the program had one HSA, one RN and one licensed practical nurse
(LPN). The program provided emails from the Office of Health Services allowing the LPN as a
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substitute for one of the RN positions. During an interview, the FA reported the program has
experienced turnover in each department in the past year, mainly due to promotion, as well as
direct care staff. The program conducts ongoing recruitment efforts and emphasizes staff
retention with emphasis on staff morale and engagement. The program hosts spirit weeks, staff
outings, and on-campus socials to improve morale and boost staff engagement. Four of five
interviewed staff reported receiving formal evaluation every six months and the remaining one
stated they have not received an evaluation yet.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s special contract conditions include to research, develop, and implement a plan
for animal exposure and/or animal volunteering for all interested youth. A review of
documentation indicated eight youth participated in volunteering at the local humane society
during the annual compliance review period. The program was to implement compliance
monitoring for thirty days after release from the program, to ensure each youth meet all of their
transition plan goals. A review of four closed records indicated each youth were contacted at
least once within the first thirty days of release, with all four being contacted for two and three
months, monthly or weekly. The contacts made were documented in the case management
chronological documentation. The program special contract condition encompasses if a board
certified behavior analyst (BCBA) services are necessary the clinical director shall generate a
referral to the provider’s outside contractor, who will provide BCBA services. The outside
contractor must complete an initial assessment and generate a detailed behavior analysis
services plan (BASP). The plan shall be included in the Individualized Treatment Plan and
approved by the designated mental health clinical authority (DMHCA). The BASP shall be
discussed with the DMHCA and the chief clinical officer to ensure program staff members are
aware and involved in the ongoing support and implementation of the plan. A review of
documentation indicated the program has a contract agreement with a BCBA who holds all
required credentials. The outside contractor agreement included recommendations of BCBA
services not to exceed twenty hours a week, to attend treatment team meetings as needed,
provide consultation to the treatment team, clinical and case management departments
regarding youth's behavior issues. The BCBA shall observe assigned youth, provide
assessments, draft functional analysis, and individual behavior plans, as well as train direct care
staff and clinical staff on the implementation of behavior plans and related issues. An interview
with the BCBA and review of documentation confirmed the BCBA conducts all required
services. A review of three applicable youth records for the annual compliance review period
indicated referrals were made by the program and assessments were conducted by the BCBA.
The facility administrator interview indicated the program is compliant with contract specific
requirements. There are numerous agreements in place to ensure the youth are provided with
yoga, drumming, prodigy arts and behavioral analysis. Additionally, the program ensures youth
participate in counseling, restorative justice outings, and accommodations are made for families
in need when warranted, such as hotel reservations and gas cards.
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1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program’s practice regarding data trend analysis includes the provider utilizing different
type of tools to collect data and analyze it. The data is accumulated through a program
dashboard, electronic records system, survey completion and use of the Department’s Juvenile
Justice Information System (JJIS). The program’s dashboard allows for daily data entry by the
program and is aggregated into weekly and monthly totals, displayed in interactive dashboard
specific to the program information, and is provided back to the provider’s corporate office, as
well as the program’s management for the purpose of tracking trends and risk management.
The dashboard is updated every Monday and the provider’s regional compliance manager
conducts on-site checks to ensure data integrity. Some of the data collected includes
components from operations, mental health, health services, support services and human
resources/business. The electronic records system the program utilizes allows the program to
run specific reports giving programmatic snapshots and department heads routinely use the
tracking features to assist in department management, as well as forecast staffing patterns and
meetings. JJIS is another tool the program uses, which includes measures of treatment quality
for every individual primary service delivered by the program, program outcomes, and trends in
completion rates, recidivism rates, and releases, to name a few. The program also has youth,
staff and families conduct surveys on Survey Monkey. Results are extracted and analyzed
quarterly, with the program receiving the feedback and changes being made accordingly. The
provider utilizes the data on a daily, weekly, monthly, quarterly, and annual basis, driving policy
development and programming. The information is shared with staff during the daily
management meetings, and monthly staff meetings, as well as data being shared with the
corporate office and stakeholders. The program utilizes the community advisory board
meetings, as well as quarterly Department meetings to share data trend with the stakeholders.
A review of meeting agendas for Department meetings, as well as TRACE meetings and emails
with education and Department residential staff, and staff meetings for the annual compliance
review (ACR) period were reviewed to confirm the practice. During tis ACR period the program
changed a food vendor after collecting data from surveys.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures addressing parent/guardian and court notification. A
review of five youth case management records were reviewed, and each contained
documentation indicating each youth’s parent/guardian was notified by telephone within twenty-
four hours of admission to the program. All five youth case management records included
documentation reflecting each youth’s parent/guardian was notified, in writing, within forty-eight
hours of admission into the program. Each record included written notification to the committing
judge and juvenile probation officer within five working days of admission. None of the reviewed
youth were applicable for written notification to the post-residential service case manager.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to address the youth orientation process. The
program provides orientation to each youth on the day of admission. The program provides a
youth handbook which includes a more detailed description of program services and guidelines.
A review of five youth case management records indicated orientation was provided to each
youth on the day of admission. Each applicable record contained documentation confirming the
youth completed the orientation process which included all required elements. There was one
admission observed by the reviewer during the week of the annual compliance review and all
elements of the orientation process were included as outlined by the program’s policy. Five
interviewed youth confirmed receiving an orientation to the program on the day of admission
into the program. All five youth stated orientation included program rules, procedures,
schedules, and other pertinent information. Documentation confirmed the youth signed an
orientation checklist confirming they had received an orientation on all required elements.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures to address consent for youth who are eighteen years
of age or older. Written consents are required for any youth eighteen years of age or older prior
to providing or discussing any information with the youth’s parent/guardian. One of five case
management records were applicable. Two more were requested. In all three applicable case
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management records each youth was eighteen years of age or older and contained a consent
form signed by each youth prior to any release of information.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a policy and procedures outlining the classification process for youth upon
admission to the program and completion of reassessments, as necessary. The program utilizes
a classification system to promote safety and security for which a youth’s classification is
determined by their individual needs and identified risk factors. A review of the program’s
classification form validated the form included all required elements. A review of five youth case
management records found documentation indicating each record contained an admission
classification form including all required elements. A review of the Department’s Juvenile Justice
Information System (JJIS) confirmed a new Victimization and Sexually Aggressive Behavior
(VSAB) was completed and entered prior to each youth’s room assignment for the five reviewed
youth. Each applicable youth was classified for the purpose of assignment to a living area,
sleeping room, and group. The program maintains a constant updated internal alert system in
JJIS documenting any medical, mental health, substance abuse, security risk factors, and/or
special needs identified during or subsequent to the classification process. The program also
maintains an alert board in the staff duty station, which is updated as needed. The program’s
policy and procedures also address reassessment and reclassification of youth prior to an
increase of a youth’s privileges or freedom of movement, participation on work projects or other
activities which involve the use of tools, or a youth’s participation in any off-campus activities.
One of the five reviewed youth case management records was applicable for a reassessment.
Two more records were requested for reassessments. All three applicable youth case
management records included documentation for the reclassification of the youth prior to
engaging in certain activities. An interview with the facility administrator confirmed the program’s
practice.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures to address gang identification including notification of
law enforcement. Five youth case management records were reviewed. One of the five
reviewed youth case management records was applicable for notification to law enforcement of
suspected gang association. The program confirmed there were no other youth applicable for
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gang notification during the annual compliance review period. The one applicable youth case
management record confirmed the program notified local law enforcement and the youth’s
home county law enforcement in writing of the youth’s gang status. Documentation confirmed
gang information was shared with the educational staff at the program and the youth’s juvenile
probation officer. The youth was not applicable for notification of a post-residential services
counselor. The program identifies youth who are suspected gang members at intake and enters
any applicable alert in the Department’s Juvenile Justice Information System (JJIS). Reviewed
documentation reflected a gang alert was maintained in JJIS and updated, as required.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures to address a youth’s participation in gang prevention
and/or intervention activities and to develop a plan to disaffiliate with a criminal street gang. The
program utilizes the ARISE curriculum and Impact of Crime intervention groups as part of the
gang prevention and intervention curriculum. Five youth case management records were
reviewed and one was applicable for participation in gang interventions. No other youth were
applicable for gang intervention during the annual compliance review period. The applicable
youth’s Individualized Performance Plan included relevant goals and objectives related to gang
intervention strategies for the youth to complete prior to release from the program. The program
maintains sign-in sheets to document youth participation in gang prevention and intervention
activities. An interview with the facility administrator confirmed the program’s gang intervention
and prevention strategies.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures to ensure a Residential Assessment for Youth (RAY)
is completed for each youth within thirty days of admission. A review of five youth case
management records indicated each record contained a RAY which was completed within thirty
days of admission. Each initial RAY was maintained in the Department’s Juvenile Justice
Information System. All five youth were applicable for reassessments. Four of the five youth had
RAY Reassessments completed, as required. The remaining one youth’s RAY reassessment
was two days late. Each initial RAY and reassessment were maintained in each youth’s 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 the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures to address the completion of a Youth Needs
Assessment Summary (YNAS) within thirty days of each youth’s admission. Five youth case
management records were reviewed for completion of a YNAS. Four of five records contained a
completed YNAS within thirty days of each youth’s admission into the program and documented
in the Department’s Juvenile Justice Information System. The remaining one record was an
administrative transfer youth and no YNAS was completed within thirty days of admission.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a policy and procedures addressing the development of the performance plan.
The treatment team members, including the youth, meet to develop an Individualized
Performance Plan (IPP) based on the findings of the initial assessment of each youth within
thirty days of the youth’s admission. Four of five youth case management records reviewed
were applicable. The remaining one youth was not applicable due to being an administrative
transfer from another residential program. Three of the four reviewed youth records documented
the IPP was developed within thirty days of youth admission and completed after the initial
Residential Assessment for Youth (RAY). The remaining one youth record documented the IPP
was developed two days late. Each reviewed IPP was developed and signed by the treatment
leader, youth, treatment staff and all parties who had significant responsibility in goal
completion. Each of the four youth records included signature sheets, which were attached to
the original IPP. Each of the four youth’s IPPs were mailed to the parent/guardian; however, one
signature sheet was returned. All reviewed IPPs included each youth’s individualized goals,
specific delinquency interventions with measurable goals, based upon the prioritized needs
reflecting the risk, and protective factors identified during the initial assessment process,
delinquency interventions, recreation plan, target court-ordered sanctions, identified transition
activities, youth’s responsibilities to accomplish goals, program staff responsibilities to enable
youth to complete goals, and target dates for goal completion. All four youth’s IPP’s contained
youth’s top three criminogenic needs. When applicable, court-ordered sanctions which can be
initiated and/or completed while the youth is in the program were documented. None of the
reviewed youth were in the care of the Department of Children and Families (DCF) upon
creation of the initial IPP. All four IPPs were sent to each youth’s committing court judge,
juvenile probation officer (JPO), and parent/guardian within ten days of completion. Five youth
were interviewed, and each reported they participated in the development of their performance
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plan and were knowledgeable of their current performance plan goals. Each of the five
interviewed youth stated they received a copy of their performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a policy and procedures in place regarding revisions to a youth’s performance
plan. The treatment team may revise the youth’s Individualized Performance Plan (IPP) based
on the Residential Assessment for Youth (RAY) Reassessment results, the youth’s
demonstrated progress or lack of progress toward completing a goal, or newly acquired or
revealed information. Five youth case management records were reviewed, and four were
applicable for IPP revisions. All four applicable records reflected revisions were completed
according to the RAY Reassessment results and newly acquired/revealed information. All four
reflected progress towards completing a goal. One youth was applicable for demonstrating lack
of progress toward completing a goal. Two of four youth IPPs were revised due to facilitating
transition activities during the last sixty days of each youth’s stay. All five youth’s IPPs included
additional plans.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a policy and procedures in place regarding the completion and transmittal of
Performance Summaries for each youth at ninety-day intervals, beginning ninety days from the
signing of the performance plan, or at shorter intervals when requested by the courts. Five youth
case management records were reviewed. One youth case management record was non-
applicable for the initial performance plan due to being administratively transferred from another
residential program. The remaining four youth case management records were applicable for
the completion of the Initial Performance Plan (IPP). Each of the four youth records included
Performance Summaries which were completed within ninety days of the completion of the IPP.
All five case management records maintained Performance Summaries including all required
elements. Each applicable record contained signed documentation confirming the youth read
and was allowed to add comments to their Performance Summaries. Each youth was provided
a copy of the signed summary and the original summary was filed in each youth’s case
management record. Each Performance Summary was signed and dated by the treatment team
leader, staff member preparing the summary, facility administrator, and the youth. Each
reviewed record contained documentation to support each Performance Summary was sent to
the youth’s committing court, juvenile probation officer (JPO), youth, parent/guardian, and the
Department of Children and Families (DCF), when applicable, within ten days of completion. In
one of the five a Performance Summary was prepared prior to the youth’s release/discharge
from the program. Three closed youth case management records were reviewed for release
summaries. Each record contained a copy of the signed original summary sent to the JPO along
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with the Pre-Release Notification (PRN)/discharge summary at least forty-five days prior to each
youth’s anticipated release date. Each summary contained a justification for release. The
program provided written notification of approval for release to each youth’s parent/guardian.
Documentation supported each record contained a completed exit Residential Assessment for
Youth (RAY). None of the youth were applicable for the sexually violent predator program
(SVPP) or notification to a victim.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to encourage and facilitate parent/guardian
involvement in case management services. The program makes efforts to include the
parent/guardian in the assessment process, participation in the development of the youth
performance plan, progress reviews, formal treatment team meetings, and transition planning.
An interview with the facility administrator validated the program’s practice. Five youth case
management records were reviewed. In each of the case management records, documentation
reflected the case manager sent an admission letter to the parent/guardian, which included the
dates and times for the youth’s treatment team meetings. If parent/guardians are unable to
attend the meetings in person, they are afforded the opportunity to participate by telephone or
conference call or can provide verbal or written input prior to the meeting. Five reviewed youth
case management records confirmed the parent/guardian participated in the assessment
process and development of each youth’s Individualized Performance Plans, progress reviews,
formal treatment team meetings, and transition planning, when applicable. An observation of a
treatment team during the week of the annual compliance review was completed. After several
telephone call attempts were made by the treatment team leader to contact the parent/guardian
they were not able to participate. Three of five interviewed youth reported the parent/guardian is
involved in their case management services. The remaining two youth reported their
parent/guardian is notified and invited to participate; however, does not always attend.
2.13 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.
The program has a policy and procedures outlining treatment team meeting requirements. The
program’s policy requires the treatment team to meet every thirty days to formally review each
youth’s performance to include Residential Assessment for Youth (RAY) Reassessment results,
progress on Individualized Performance Plan goals, and positive and negative behavior
including behavior which resulted in physical interventions. Five youth case management
records were reviewed and each included documentation reflecting formal treatment teams
were held once every thirty days. Each record contained documentation supporting informal
treatment team meetings were held biweekly alternating with formal treatment team meetings to
review the youth’s performance, progress on Individual Performance Plan goals, behavior, and
Individualized Treatment Plan, as well as to review RAY Reassessment results, when
applicable. Each youth’s record reflected formal treatment team and informal treatment team
documentation included all required elements and all informal treatment team meeting
documentation was contained in each youth’s record. All required parties were invited and
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present either in person or by telephone during the formal and informal treatment team
meetings. During the annual compliance review week, an observation of a treatment team
meeting was conducted. All required program participants were in attendance or provided
written input. There was a review of the Individualized Performance Plan to determine
anticipated release dates and youth were observed demonstrating skills acquired in the
program. Five youth were interviewed and indicated staff review performance plans and update
them, as needed. All five stated they were provided the opportunity to demonstrate skills
acquired in the program.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a policy and procedures addressing transition planning conferences and
Community Re-Entry Team (CRT) meetings being conducted sixty days prior to the youth’s
target release date. A review of three closed youth case management records found the
program held a transition conference at least sixty days prior to each youth’s anticipated release
date. The program invited all required members to the transition meetings through mail
correspondence or email. The transition conferences were attended by each youth,
parent/guardian, juvenile probation officer, facility administrator, treatment team leader, and
other treatment team members. None of the reviewed youth records required a human
trafficking specific service provider. During the transition conferences, the team discussed all
required topics including transition activities, completion dates, and parties responsible for
completion of goals. All attendees signed each transition conference form, and the forms were
mailed to all parties for their signature. There was documentation in each record to reflect a
CRT meeting invite, each youth and case manager participated, and confirmed the CRT
meeting was conducted prior to each youth’s release.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures outlining the requirements of the exit portfolio. Three
closed youth case management records were reviewed and documented each youth’s exit
portfolio was discussed during the transition conference. Each exit portfolio contained a
transition plan, calendar with all dates, time, and locations of each youth’s upcoming community
appointments, educational and/or vocational certificates, educational records, transcripts, and
résumé. All three youth records contained a sample employment application. Two of three youth
exit portfolios included a state issued identification card, birth certificate, and social security
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card. One youth’s exit portfolio did not include a state identification card, birth certificate, and
social security card due to the parent/guardian not providing the requested documents to the
program. The program reported they requested the required documentation from the
parent/guardian. Documentation confirmed multiple requests from the program to the
parent/guardian for the requested documents. Each youth’s exit portfolio included signed
documentation indicating each youth was given a copy of the exit portfolio upon release from
the program. Three youth closed case management records included documentation the
program staff forwarded the exit portfolio information to the juvenile probation officer. The
program’s contract requires additional items for the exit portfolio. Each youth’s exit portfolio
contained Career and Technical Education certifications, locations of Career Source Centers,
and health education materials.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures to ensure an exit conference is conducted to
coordinate release procedures and prepare each youth for re-entry back to the community.
Three closed youth case management records were reviewed. Each record documented an exit
conference was conducted at least fourteen days prior to the youth’s release date. Each exit
conference was conducted after the juvenile probation officer (JPO) was notified of the release.
Each record had documentation indicating the exit conference date, signatures, and a summary
of pending transition goals. Each record had documentation to confirm the treatment team
leader, parent/guardian, education representative, therapist, JPO, youth, and other pertinent
parties participated during the exit conference. Each record had documentation reflecting the
status of transition activities and finalized plans for the youth’s release, provisions for
continuation of education and/or employment, documentation each youth’s parent/guardian and
JPO were aware of the vocational plan for each youth, as well as each youth’s case manager
and parent/guardian were aware of the post-release discharge plans. The date of admission
and date of release correlated with the Department’s Juvenile Justice Information System for
each youth. Each exit conference was held separate from the transition conference and
Community Re-Entry Team meeting.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program maintains a policy and procedures to encourage formal constructive input by
youth. The program has a youth advisory board to promote a formal process for youth to have
constructive input regarding the program. Youth advisory board meetings are held biweekly, and
address issues initiated by youth in the program. Agendas, sign-in sheets, and minutes are
maintained in a binder for the youth advisory board. Documentation confirmed youth advisory
board meetings were held as required during the annual compliance review period. The
program also utilizes quarterly youth surveys, daily meetings, Trauma Responsive and Caring
Environment (TRACE) assessment, and My Voice Matters forms to solicit youth input. Five
youth were interviewed on how they provide input about what is happening at the program. Two
youth stated they provided input through My Voice Matters, two stated they can provide input
during the daily meeting with staff, and one stated they express their opinions at the advisory
board meetings. An interview with the facility administrator stated the program’s formal process
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to solicit input from youth is provided through My Voice Matters, grievance forms, daily
meetings, and youth advisory board.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program’s designated mental health clinical authority (DMHCA) is a licensed mental health
counselor (LMHC) with a clear and active license, which expires on March 31, 2025. The
DMHCA is a full-time employee at the program, working a minimum of forty hours a week,
Monday through Friday. The DMHCA is also available on call twenty-four hours a day, seven
days a week for clinical emergencies. The DMHCA provides specialized treatment services and
oversees the coordination and implementation of mental health and substance abuse services.
The DMHCA has a licensed mental health counselor who serves as the back-up DMHCA during
absences. The back-up DMHCA holds a clear and active license, expiring on March 31, 2025.
The DMHCA was interviewed and confirmed part of the responsibilities include ensuring
documentation is completed in a timely and accurate manner and meeting the requirements
outlined within the program's system. The DMHCA is responsible for reviewing the
Comprehensive Mental Health and Substance Abuse Assessment within ten calendar days of
completion. Individualized Treatment Plans and Treatment Plan Reviews are reviewed within
five days of completion. Additionally, the DMHCA oversees the review and approval of various
assessments, including suicide risk assessments, Crisis Assessments, Victimization and
Sexually Aggressive Behavior (VSAB), and Mental Status Examinations. Group sign-in sheets
are reviewed daily. Individual, group, and weekly progress notes are reviewed weekly in an
online tracking system to ensure services are provided as required. The DMHCA provides
weekly supervision to non-licensed clinical staff for a minimum of one hour a week. The DMHCA
also attends treatment teams, pre-classification, classification, needs assessment, transition
staffing, and exit conferences to ensure individualized treatment is consistent across the
multidisciplinary team. Additionally, the DMHCA conducts monthly group fidelity checks to
ensure the proper application of services within the guidelines. The DMHCA utilizes an internal
monitoring system, which is updated weekly to ensure fidelity of services. The DMHCA
maintains a caseload as needed, conducting individual and family therapy sessions. They also
provide coverage for group therapy and other assessments as necessary. The previous
DMHCA, who provided services during the annual compliance review period, was a licensed
clinical social worker with a clear and active license, which expires on March 31, 2025.
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3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures to ensure mental health and substance abuse
services are provided by staff with the appropriate qualifications. The program has contract
agreements with a psychologist and a certified behavior analyst to provide services to youth.
The designated mental health clinician authority (DMHCA) ensures the licensed clinical staff
working under their supervision are performing services they are qualified to provide based on
education, training, and experience. Psychologist and behavior analyst also participate in
supervision with DMHCA. The psychologist has a clear and active license which expires on May
31, 2026. The certified behavior analyst has an active certification which expires on August 31,
2025.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures to ensure mental health and substance abuse
services are provided by staff with the appropriate qualifications. The designated mental health
clinician authority (DMHCA) must ensure clinical staff working under their supervision are
performing services the staff are qualified to provide based on education, training, and
experience. An informal interview with the DMHCA confirmed these procedures were being
followed. The program has two non-licensed master’s-level therapists who provide mental
health and substance abuse services at the program. The Department’s Licensed Mental Health
Professionals and Certified/Licensed Substance Abuse Professionals Direct Supervision Log
was reviewed which verified each non-licensed mental health clinical staff working under the
direct supervision of the DMHCA received a minimum of one hour a week of on-site, face-to-
face direct supervision, by a licensed mental health professional, for the purpose of overseeing
and directing the mental health services provided in the program during the annual compliance
review period. The program has an active Chapter 397 license which expires on September 6,
2025. The Chapter 397 license is displayed in the program’s lobby. Non-licensed clinical staff
provide mental health and substance abuse services seven days a week, each working for forty
hours a week. A review of credentials of the non-licensed therapists confirmed both have
master’s-level degrees from an accredited university or college. One therapist has a master’s-
level degree in the field of human services and the other therapist holds a master’s-level degree
in the field of social work. The non-licensed substance abuse clinical staff provide substance
abuse services in the program, which is licensed under Chapter 397, and are working under the
direct supervision of a qualified professional. Documentation confirmed one of the two non-
licensed clinical staff has completed twenty hours of training and supervised experience in
assessing suicide risk, mental health crisis intervention, and emergency mental health services.
The training included administration of five Assessment of Suicide Risk (ASR) conducted on-site
in the physical presence of a licensed mental health professional. The remaining non-licensed
clinical staff member has not yet completed training to conduct ASRs.
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3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a policy and procedures addressing a standardized process for the screening
and referral of youth identified as needing further mental health and/or substance abuse
evaluation, staff training in mental health and substance abuse issues, and the administration of
the Massachusetts Youth Screening Instrument, Second Version (MAYSI-2). All youth are
screened upon intake through the administration of the MAYSI-2, within the Department’s
Juvenile Justice Information System (JJIS). The reviewed documentation in all five mental
health and substance abuse records confirmed assessments were completed on the day of
admission by a trained licensed mental health clinician (LMHC) and entered into JJIS, other
than two not being entered into JJIS due to JJIS being down. The five youth mental health
records reviewed all included a completed MAYSI-2. For all five youth, the MAYSI-2 results
indicated further assessment was required. Referrals for additional evaluations were made. In
all five the MAYSI-2 or other admission information indicated the need for a comprehensive
evaluation, an assessment, and the facility administrator (FA) or designee was notified and a
referral made to alert the designated mental health clinician authority (DMHCA). Three of the
five youth required an Assessment of Suicide Risk (ASR) and the FA ensured an ASR was
conducted within twenty-four hours. One youth was placed on precautionary observation. All
five documented the reason for referral. The program’s practice includes conducting further
evaluation for every youth admitted, regardless of MAYSI-2 results. The program ensures an
(ASR) and a comprehensive mental health and substance abuse evaluation is conducted for all
youth. The policy outlines a standardized screening process, which includes reviewing
commitment packet information, reports, and records, administering the MAYSI-2 within JJIS,
providing staff training in mental health and substance abuse issues, and implementing a
standardized referral process for youth identified as needing further evaluation. This may
include referral to a qualified professional or, when immediate attention is necessary, to a
hospital or Baker Act/ Marchman Act receiving facility. The FA interview indicated the program
utilizes the MAYSI-2 as a screening tool.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a policy and procedures to ensure youth identified by screenings, staff
observations, or behaviors post-admission as in need of further evaluation will be referred for a
combined Comprehensive Mental Health and Substance Abuse Evaluation. Five youth mental
health and substance abuse records were reviewed. Four of five youth were applicable for the
completion of a Comprehensive Mental Health and Substance Abuse Evaluation. The remaining
youth was an administrative transfer from another program and the youth’s evaluation was
completed at the previous program. All four applicable youth had a new combined
comprehensive evaluation completed within thirty days of admission. Each record contained a
substance abuse consent for services signed by youth. Two out of the four applicable youth had
a comprehensive evaluation completed by a non-licensed clinical staff. In both records, the
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licensed clinical staff reviewed and signed the comprehensive evaluation within ten calendar
days. Each youth’s comprehensive evaluation contained all required elements. None of the
reviewed youth were applicable for needing an updated comprehensive evaluation.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures to ensure youth determined to have a 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/Substance Abuse Treatment
Plan. Five youth mental health and substance abuse records were reviewed. Each youth had an
Initial Mental Health/Substance Abuse Treatment Plan completed on a program form which
contained all required elements within seven days of the beginning of treatment or within seven
days of the initial psychiatric interview for youth prescribed psychotropic medication. All five
Initial Mental Health/Substance Abuse Treatment Plans were signed by all members of the
treatment team who participated in the development of each plan. Two of five Initial Mental
Health/Substance Abuse Treatment Plans were completed by a non-licensed mental health
clinical staff, and each was signed by the licensed clinical supervisor within ten days of
completion; the remaining Initial Mental Health/Substance Abuse Treatment Plans were
completed by licensed clinical staff. Two of five Initial Mental Health/Substance Abuse
Treatment Plans addressed each youth’s psychiatric needs, including medication and frequency
of monitoring by the psychiatrist. The remaining three were not applicable; however, two of the
remaining youth did have psychiatric services added to their Individualized Mental
Health/Substance Abuse Treatment Plans after completing a psychiatric interview. Each youth
had an Individualized Mental Health/Substance Abuse Treatment Plan completed on a program
form which contained all required elements. One of the five reviewed youth had the incorrect
frequency for group therapy listed on her Individualized Mental Health/Substance Abuse
Treatment Plan. The program stated this was a typographical error and corrected the plan
during the week of the annual compliance review. Individualized Mental Health/Substance
Abuse Treatment Plan reviews were completed for each youth at a minimum of every thirty
days. All five youth had Individualized Mental Health/Substance Abuse Treatment Plans signed
by all required parties. A review of video camera observation of three groups, compared to
logbooks and sign-in sheets, confirmed groups are being held as scheduled. An interview with
the designated mental health clinician authority confirmed the program’s practice.
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3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program has a policy and procedures addressing treatment and discharge planning. Five
youth mental health and substance abuse records were reviewed. Each youth was assigned to
a treatment team, which contained all required members, on the day of admission to the
program. Four of five reviewed youth had a properly executed Authority for Evaluation and
Treatment (AET) in their record. The remaining youth was eighteen years old; therefore, an AET
was not required. Each record contained a signed consent for substance abuse treatment
services. All five records contained treatment progress notes which contained all elements of
the Department’s form. Documentation confirmed each youth was receiving individual therapy
and psychosocial skills training. All five reviewed youth received all services as stipulated on
their treatment plan. Three closed youth mental health and substance abuse records were
reviewed for discharge planning. Each record included a discharge plan on the Department’s
Mental Health/Substance Abuse Treatment Discharge Summary form which documented future
services needed. None of the reviewed youth were released while on suicide
precautions/mental health alert. Documentation confirmed the discharge plan was discussed
with each youth, parent/guardian, and juvenile probation officer (JPO) during the exit
conference. A copy of the Mental Health/Substance Abuse Treatment Discharge Summary was
provided to each youth, parent/guardian, and JPO.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program has a policy and procedures which requires specialized intensive mental health
treatment services to be provided to youth. The program’s required clinical groups according to
the contract are Dialectical Behavior Therapy Skills Manual for Adolescents and Moral
Reconation Therapy. Five youth were interviewed. All five youth confirmed they participate in
individual and family therapy. Five staff were interviewed. All five staff confirmed only clinical
staff facilitate mental health and substance abuse groups. An interview with the designated
mental health clinician authority (DMHCA) confirmed all youth receive intensive mental health
treatment services and substance abuse services according to their individualized treatment
plan. An interview with the facility administrator confirmed youth receive intensive mental health
treatment services. The DMHCA is on-site forty hours a week and clinical staff are on-site seven
days a week. A review of clinical staff caseloads confirmed clinical staff have no more than ten
youth to one therapist. A review of documentation confirmed the program provides weekly
individual therapy, biweekly family therapy, and psychiatrist is on-site weekly. Program has
contracted with a licensed psychologist and a certified behavior analyst to provide services
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weekly. Documentation confirmed program mental health and substance abuse groups are held
five times a week. The program did not have any youth applicable for needing services during
medical quarantine.
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 Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a policy and procedures to ensure the provision of psychiatric services which
includes psychiatric evaluation, psychiatric consultation, medication management, and medical
supportive counseling provided to youth with a diagnosed Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth receiving psychotropic
medication in the program. The program employs a psychiatrist through an independent
contractor agreement. The psychiatrist is scheduled to be on-site every week, for a minimum of
two hours, and on call for emergencies during the evening and on weekends and holidays. The
psychiatrist has a clear and active license which expires on January 31, 2026. The psychiatrist
briefs a representative of the treatment team regarding the psychiatric status of each youth
receiving psychiatric services who is scheduled for treatment team review. The psychiatrist’s
evaluation and recommendations for each youth are also incorporated into the mental health
clinical staff’s evaluations of the youth and the youth’s Individualized Mental Health/Substance
Abuse Treatment Plan. The program does not use a psychiatric advanced practice registered
nurse. A review was conducted of the sign-in/out logs for the psychiatrist’s weekly visits, which
confirmed the psychiatrist was at the program as required by the agreement with the program
and program’s contract with the Department. Documentation confirmed the psychiatrist actively
participates in, manages, and supervises psychotropic medication services at the program. The
program has a back-up psychiatrist who is a medical doctor with a clear and active license
expiring on January 31, 2026. Back-up psychiatrist has equivalent education to the psychiatrist.
Program does not utilize tele-psychiatry services. An interview with the psychiatrist confirms the
psychiatrist oversees psychiatric interventions, medication management, and completes
psychiatric evaluations for youth. The psychiatrist states he is on-site weekly and meets with
medical and mental health staff to discuss referrals and youth receiving services. The
psychiatrist had no concerns with the mental health and substance abuse services at the
program. An interview with the designated mental health clinician authority confirms the
program’s practice. Two of the five youth were applicable for entering the program on
psychotropic medication; however, it is the program’s practice to refer all newly admitted youth
for a psychiatric interview. Documentation confirmed all five youth had a psychiatric interview
conducted within fourteen days of admission. The initial diagnostic psychiatric interviews
included history of the youth, mental status examination, diagnoses and ensuring each
diagnosis is consistent with the treatment plan, treatment recommendations, prescribed
medications, explanation of the need for psychotropic medication, target symptoms, initial
treatment goals, potential side effects, risks, and benefits of taking the medication, and
frequency of medication monitoring. The initial psychiatric evaluations were completed on a
form developed by the program which contained all required elements of the Department’s
Clinical Psychotropic Progress Note (CPPN). The form was clearly identified as an initial
psychiatric interview. Two of the five youth entered the program on psychotropic medication and
two youth were prescribed psychotropic medication several months after admission, for a total
of four of five reviewed youth requiring psychiatric medication management. The four applicable
youth records review confirmed each youth received prescribed psychotropic medications and
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included documentation of face-to-face medication monitoring reviews being conducted every
thirty days. The psychiatric evaluations were documented on a form developed by the program
which contained all the required elements within the CPPN. The reviews were completed,
signed, and dated by the psychiatrist and included identifying youth information, diagnosis,
target symptoms of each medication, evaluation, and description of effects of prescribed
medication on target symptoms, the name, dosage and quantity of the medication, side effects,
youth’s adherence to the medication regimen, height, weight, blood pressure, and most recent
serum drug levels or laboratory findings. Three of the four reviewed youth had missing vital sign
information on the CPPNs. One youth had one of seven CPPNs missing vital signs, one youth
had two of five CPPNs missing vital signs, and the remaining youth had three of ten CPPNs
missing vital signs. The remaining youth had six CPPNs which all contained required vital signs.
One of the four applicable youth records required monitoring of Tardive Dyskinesia and
reviewed documentation supported the monitoring was conducted monthly.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a policy and procedures ensuring the program follows a suicide prevention
plan to safely assess and protect youth with elevated risk of suicide in the least restrictive
means possible. The program has a suicide prevention plan including identification and
assessment of youth at risk of suicide, staff training, suicide precautions, levels of supervision,
referral, communication, notification, documentation, immediate staff response, and review
process. The program’s review process for suicide attempts and mortality review includes
circumstances surrounding the event, facility program procedures relevant to the incident, all
relevant training received by involved staff, pertinent medical and mental health services
involving the victim, possible precipitating factors, and recommendations. The suicide
prevention plan was reviewed annually as required, on July 2, 2024, by the facility administrator.
The suicide prevention plan was reviewed by the previous designated mental health clinician
authority (DMHCA) on January 30, 2024. The program’s newly hired DMHCA had not yet
signed the suicide prevention plan as the DMHCA was still in training.
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3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
The program has a policy and procedures which governs suicide prevention services. This
policy defines suicide precautions as methods utilized for supervising, observing, monitoring,
and housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. It requires any youth exhibiting suicide risk behaviors to be placed on
suicide precautions, and a minimum of constant supervision. Five youth mental health and
substance abuse records were reviewed. Four out of the five reviewed youth were applicable for
suicide prevention services. Three of the applicable youth were determined to be at risk by staff
observation, the remaining youth self-reported suicidal ideations. Each youth had an
Assessment of Suicide Risk (ASR) completed on the Department’s form within twenty-four
hours of youth being determined to be at risk. Each youth was maintained on constant
supervision. Each record reflected the parent/guardian and juvenile probation officer were
notified about each youth’s potential suicide risk as indicated on the ASR. Documentation
confirmed each youth was provided supportive services by mental health clinical staff and each
ASR was completed by a licensed clinical staff member. Two of the four applicable youth were
continued on constant supervision after the completion of the ASR. The remaining two youth
were discontinued from precautionary observation and were stepped down to close supervision.
Documentation confirmed each ASR contained the actual date/time clinician conferred with
facility administrator (FA) or designee and licensed mental health professional recorded in the
date/time sections. Both records, for the two youth continued on constant supervision, contained
a Follow-Up Assessment of Suicide Risk (FASR) on the Department’s form completed prior to
the removal of each youth from precautionary observation. Both youth were maintained on
constant supervision until the completion of a FASR and were stepped down to close
supervision once it was determined each youth could be discontinued from suicide precautions.
All four applicable youth were maintained on close supervision until it was determined no longer
necessary by the designated mental health clinician authority (DMHCA) and a conference was
held between DMHCA and FA. A review of the Department’s Juvenile Justice Information
System (JJIS) reflected a suicide alert was initiated for each youth and closed upon the
recommendation of the ASR or FASR. A review of the program logbooks indicated
administration or supervisory staff provided instructions related to the suicide risk assessment
findings and suicide precaution decisions for each youth. While on Precautionary Observation,
each “at-risk” youth was allowed to participate in select activities with other youth in designated
safe housing/observation areas of the program. A review of video footage, which is maintained
for thirty days was able to be completed for two youth on precautionary observation and
confirmed staff were always with each youth while youth were on precautionary observation.
Precautionary logs and logbooks confirmed the length of time each youth was on precautionary
observation. The program only had two youth on precautionary observation in the thirty days
available for video camera review.
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3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program’s Suicide Prevention Plan requires staff to maintain one-to-one or constant
supervision of youth placed on suicide precautions. Five youth mental health and substance
abuse records were reviewed. Four of the five reviewed youth were applicable for suicide
prevention services. Documentation confirmed suicide precaution observation logs were
maintained for each youth for the duration each youth was on suicide precautions. Each suicide
precautionary observation log documented the appropriate level of supervision and
observations of each youth’s behavior in real time, not exceeding thirty-minute intervals, as well
as each log being reviewed and signed by each shift supervisor and mental health clinical staff.
Each log documented safe housing requirements. Each log documented warning signs
observed; and the facility administrator/designee and mental health clinical staff were notified,
which was documented on the log.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a policy and procedures which ensures 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 pre-service and five in-service staff training records
were reviewed for the completion of suicide prevention training. All five pre-service staff and five
in-service staff completed the required training. The program has two suicide response kits
which are co-located with first-aid kits in administration/master control and the duty station. The
suicide response kits each contain a knife-for-life, a needle nose plier, and wire cutters. A
review was conducted of the program’s mock suicide drills which confirmed the program
completed the required quarterly drills on each shift. An observation of video camera review
confirmed drills are simulated. All mock mental health drills scenarios were in response to a
suicide attempt and/or incident of serious self-injury. The program exceeded the required semi-
annual training on emergency response procedures which includes “mock” training in
emergency response to a suicide attempt or incident of serious self-inflicted injury to include
cardiopulmonary resuscitation. All staff who were not present during a quarterly drill had the
opportunity to review each drill scenario and procedures in an effort to understand the process
and receive the necessary training to respond to an incident of a suicide attempt or incident of
serious self-inflicted injury in the program. An interview with the facility administrator confirmed
the program has medical and mental health drills for every shift quarterly and drills are reviewed
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at the monthly staff meeting. Five staff were interviewed about what they would do if a youth
expressed suicide ideation. All five stated they would notify mental health clinical staff, place
youth on sight and sound, document supervision, and search room for sharp objects. All five
interviewed staff stated suicide response kits are located in master control. Three of five staff
stated a suicide response kit was also located in the duty station. Two of five interviewed staff
stated medical and suicide drills are held weekly, two staff stated they are held biweekly, and
the remaining staff member stated they were held monthly.
3.15 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 written crisis intervention plan for mental health and substance abuse
services, suicide prevention, crisis intervention, and emergency care. The plan includes
notification and alert system, means of referral, communication, supervision, documentation,
and review, as well as addressing youth in need of a mental status examination and the
completion of a crisis assessment. If needed, the program will utilize the Department’s Crisis
Assessment form.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a policy and procedures which requires a response to youth in crisis in the
least restrictive means possible to protect the safety of the youth and others, while maintaining
control and safety of the program. The program shall be able to differentiate a youth who has an
acute emotional problem or serious psychological distress from one who requires emergency
services. Five youth mental health and substance abuse records were reviewed. Two of the five
reviewed youth records were applicable for requiring a Crisis Assessment. One additional
record was requested for a minimal sample of three. All three reviewed youth had a Crisis
Assessment completed on the same day youth was identified as being in crisis. Each Crisis
Assessment included reason for the assessment, mental status examination and interview,
determination of danger to self and/or others, initial clinical impressions, supervision and
treatment recommendations, and recommendations for follow-up or further evaluation. Two of
three youth were applicable for parent/guardian notification of follow-up treatment and both
applicable youth had documentation confirming parent/guardian was notified. The remaining
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youth was eighteen and did not require parent/guardian notification. Each youth had a Crisis
Assessment completed by mental health clinical staff. None of the three youth were applicable
for requiring a mental health alert to be placed in the Department’s Juvenile Justice Information
System (JJIS) due to being placed on precautions after completion of the Crisis Assessment.
None of the three reviewed youth posed a safety and security risk. None of the three youth were
applicable for returning from an off-site Crisis Assessment. None of the three reviewed records
were applicable for having a Follow-Up Crisis Assessment completed by a non-licensed
therapist. Two of three reviewed youth were applicable for being the alleged victim of a Prison
Rape Elimination Act (PREA). Documentation confirmed a Mental Health and Substance Abuse
Referral Summary was submitted immediately for a Crisis Assessment and youth was offered
ongoing mental health services.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a policy and procedures which governs 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 Florida Administrative Code
and the program’s emergency response plan. The program has a written emergency response
plan which includes immediate staff response, notifications, communication, supervision,
authorization to transport for emergency mental health and substance abuse services, transport
for Baker and Marchman Acts, documentation, training, and review.
3.18 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program has a policy and procedures to ensure individuals who are believed to be an
imminent danger to themselves or others because of mental illness or substance abuse
impairment receive emergency mental health or substance abuse services. Five youth mental
health and substance abuse records were reviewed. None of the reviewed youth were
applicable for requiring a Baker or Marchman Act. The program had two Baker Acts and no
Marchman Acts during the annual compliance review period. The two youth records for the
incidents of Baker Act were reviewed. Each youth was referred to mental health clinical staff
immediately upon staff determining youth was at risk. Documentation confirmed each youth was
placed on one-on-one supervision at the time of discovery of risk. Both youth were assessed by
mental health staff and a Baker Act was authorized by the designated mental health clinician
authority (DMHCA) and facility administrator. Each youth was then transported to a local
receiving facility by law enforcement. Upon return to the program, both youth were placed on
constant supervision and a referral was completed indicating a Mental Status Examination was
to be conducted. Supervision was maintained until the DMHCA completed an appropriate
assessment.
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3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedures to 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 and substance abuse records were
reviewed. All five youth had a safety plan completed within fourteen days of admission which
contained all required elements. Each youth’s plan was jointly prepared by the youth,
parent/guardian or family member, and the program’s clinical staff, except for one youth who did
not have parent/guardian involvement in the initial safety plan preparation due to parental
incarceration. Documentation confirmed each safety plan incorporated any recommendations
from previous or current clinical assessments or screening instruments and incorporated trauma
responsive practices. All five youth had their safety plan reviewed and updated at least every
thirty days. None required an update following any significant behavioral or mental health event.
Safety plans were located in a binder in the duty station for direct care staff to review as well as
in each youth’s mental health and substance abuse record. Five youth were interviewed. All five
confirmed they participated in the development of their safety plan. An interview with the facility
administrator confirmed safety plans are updated during formal treatment team meetings
monthly and after any incident of mental health crisis.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a policy and procedures to ensure the designated health authority (DHA) shall
be clinically responsible for the medical care of all youth at the program. The program’s DHA is
a licensed physician who holds a clear and active license with an expiration date of March 31,
2025. The physician’s specialty training is in internal medicine, with experience in adolescent
health. The DHA does not have any disciplinary cases or public complaints on record. The
program does not utilize a physician assistant or advanced practice registered nurse. A review
of the sign-in/out logs for the annual compliance review period (ACR) confirmed the DHA was
on-site for two hours each week, as required by contract, with the exception of one visit on
October 7, 2024, which was rescheduled due to the evacuation for Hurricane Milton. The
program has a back-up physician in the event of the DHA’s absence who holds a clear and
active license with an expiration date of January 31, 2026; however, the DHA was not absent
during the ACR period. A review of the program’s contract found the program does not utilize
telemedicine or telehealth for medical services. The DHA was interviewed and stated they are
on-site weekly to conduct initial physical exams, periodic evaluations, sick call, and to refer
youth off-site as needed. The DHA indicated there is a tracking system in place to ensure all off-
site findings, instructions, and information are reviewed. The information is placed either in the
youth Individual Healthcare Records or the DHA’s folder. The DHA stated they are available to
review important medical issues with nursing staff by telephone or when on-site. The DHA
stated if they are on a scheduled absence, they notify the back-up DHA to assist with coverage.
The DHA stated they have no concerns with healthcare at the program.
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 a policy and procedures to address the designated health authority is clinically
responsible for all healthcare services provided to youth at the program. Daily clinical care shall
be performed by licensed medical staff, according to developed and authorized protocols. The
program’s contract indicates they will have a full-time health services administrator (HSA), who
works forty hours a week, and two full-time registered nurses (RN), who work eighty hours a
week. At the time of the annual compliance review, the program had one full-time RN, who
serves as the HSA, one full-time RN and one full-time licensed practical nurse (LPN) with a
licensed healthcare professional providing direction to the LPN and reviewing all medical cases
daily with the LPN. The two RNs and one LPN were meeting the required nursing hours for the
program. The program provided documentation confirming the Department’s Office of Health
Services (OHS) approval of the program’s use of the LPN. A review of nursing licensure
credentials confirmed each RN’s and the LPN’s license was clear and active. Each nurse has a
current cardiopulmonary resuscitation certification card.
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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.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The medical FOPs and healthcare protocols were signed by
the designated health authority (DHA), the psychiatrist, and the facility administrator (FA) on
July 10, 2024. A cover page indicating all FOPs and healthcare protocols were reviewed and
signed by the program’s health services administrator (HSA) and one licensed practical nurse
(LPN) on March 11, 2024, and by the other RN on June 9, 2024. The program had one newly
hired RN on May 6, 2024, who received a comprehensive clinical orientation to the
Department’s health care policies and procedures, given by a RN on June 9, 2024. Approval of
treatment protocols and standing procedures were written and authorized by the DHA and were
not delegated to any other person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures to 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. All five IHCRs
contained a valid AET form. Each AET was a copy and was stamped with the word “copy.” Each
AET was signed by a parent/guardian and a Department representative. One youth was
eighteen years of age and had a documented release of information in their IHCR. The nursing
staff interview indicated nursing staff review all projected intakes in the Department’s Juvenile
Justice Information System (JJIS) and validate each AET. New admissions are discussed with
case management, and if needed, a case manager will contact the juvenile probation officer to
obtain a new AET. Nursing staff indicated a release of information is signed by each youth when
they turn eighteen, or if they are eighteen when they arrive to the facility.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures ensuring parents/guardians are informed of
significant changes in youth’s conditions and to obtain consent when new medications and
treatments are prescribed. Five youth Individual Healthcare Records (IHCRs) were reviewed.
Four of the five IHCRs were applicable for parent/guardian notification, and the remaining youth
was not applicable. Three IHCRs were applicable for parent/guardian notifications for over-the-
counter (OTC) medications beyond those covered by the Authority for Evaluation and Treatment
(AET). All three HCRs contained documentation of parent/guardian notification and consent for
each OTC medication. The remaining youth did not receive any OTC medications beyond those
covered by the AET. New medication was ordered for all four applicable youth. Documentation
of notification to the parent/guardian for each new medication was in each youth’s IHCR. All
written notifications were sent utilizing the correct forms. Two youth were taking psychotropic
medications at the time of admission, and two additional youth were prescribed psychotropic
medications while at the facility. All four youth had a new psychotropic medication prescribed,
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discontinued, or had the dosage significantly changed while at the program. Documentation in
all four IHCRs found parent/guardian verbal consent was documented on page three of the
Clinical Psychotropic Progress Note (CPPN). A signature indicating a staff witnessed telephone
conversations for psychotropic medications was located on page three of the CPPN for all four
youth. All five reviewed youth had their vaccinations verified on the day of admission. None of
the reviewed youth received a vaccination at the program or required an exemption for a
vaccination. The interview with nursing staff indicated parent/guardian verbal consent is
obtained for doctor visits, off-site visits, and on-site medical appointments. Nursing staff stated
notifications are made within twenty-four hours with a written notification, and verbal consent is
obtained as soon as possible after an order is written by the physician. If a youth needs
emergency services, all attempts are made to verbally contact a parent/guardian prior to the
youth leaving for the emergency room. Parents/guardians are also contacted upon a youth’s
return to the facility with the results of the emergency visit. Nursing staff indicated a witnessed
verbal consent is obtained to initiate a new psychotropic medication, significantly change the
dosage, or discontinue the medication. Nursing staff indicated vaccinations are not provided on-
site. Immunization records are reviewed prior to and at each admission. If a parent/guardian is
requesting exemption from an immunization, they must provide the appropriate documentation
from the Department of Health and when applicable the exemption form is 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.
The program has a policy and procedures which ensure 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 the
Department’s Facility Entry Physical Health Screening (FEPHS) form. Three of five youth IHCR
contained a FEPHS form completed by a registered nurse (RN) on the day of their admission,
while the remaining two IHCR contained a FEPHS form completed by a licensed practical nurse
(LPN) on the day of their admission. None of the youth were applicable for a change in physical
custody for greater than twenty-four hours. The interview with nursing staff indicated each youth
is seen by a RN immediately following the initial search, normally within five minutes of
admission. Nursing staff are notified of new admissions through the commitment manager and
transportation informs medical when they are leaving to get a youth. If there is a change in
custody, a new FEPHS form is completed upon the youth’s return to the program.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures to ensure all youth are oriented to the general
process of healthcare delivery services at the program. Five youth Individual Healthcare
Records (IHCRs) were reviewed for healthcare orientation. Each youth received a general care
orientation on the day of admission. The program’s healthcare orientation included all required
topics. Each youth’s IHCR included a signed Health Care Services Orientation form indicating
they reviewed medical care education and were able to ask any questions. A Health Education
Record was also located in each youth’s IHCR. The program’s contract indicates they must
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provide health education monthly. Documentation in each youth’s IHCR indicated they receive
monthly education on the required topics.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to ensure the designated health authority (DHA) is
notified when an admitted youth requires emergency care or routine notification in accordance
with the Department’s requirements. The program’s practice is to notify the DHA of each
admission. Five youth Individual Healthcare Records (IHCRs) were reviewed. All five reviewed
youth had a known or suspected chronic condition upon admission. None of the reviewed youth
were identified as in-need of an emergency response upon admission. Each youth’s IHCR
contained documentation of notification being made to the DHA within twelve hours of
admission. Two of the five youth were taking psychotropic medication when admitted to the
program and the remaining three youth were not taking psychotropic medication when admitted
to the program. Both IHCRs included documentation of the psychiatrist being notified. The
interview with nursing staff indicated a nurse notifies the DHA, by telephone or verbally, if on-
site, of all admissions. The notification, includes each youth’s history and any chronic
conditions, is completed once the initial nursing assessments are done, and IHCRs are
reviewed. All notifications are documented in the nursing admission note and the DHA weekly
log.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures to ensure the standard Department’s Health-Related
History (HRH) form is used for all youth admitted into their physical custody. Five youth
Individual Healthcare Records (IHCRs) were reviewed for completion of an HRH form. A new
HRH form was completed on the day of admission for each youth. Each reviewed HRH form
was completed prior to the Comprehensive Physical Assessment and reviewed by the
designated health authority. Nursing staff stated a nurse completes an HRH form during the
initial nursing assessment for each youth, normally within five minutes of arrival to the program.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the standardized Department
Comprehensive Physical Assessment (CPA) form is used for all youth admitted into the
program. A review of five youth Individual Healthcare Records (IHCRs) found a new Department
CPA form was completed by the designated health authority (DHA), within seven days of
admission for each youth. Each youth’s Medical Grade was documented on their CPA. One
youth was identified as Medical Grade one, two youth were identified as Medical Grade two,
and two youth were identified as Medical Grade five. All sections of each CPA were marked with
an “O” or an “X.” Those sections marked with an “X” had comments by the DHA in the
comments section of the form for each youth. The clinician deferred the gynecological
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examinations for each youth and cited no symptoms at this time, which was documented on
each CPA. The Department’s Problem List was updated, as required, for each youth. All five
youth had at least one verified Tuberculosis Skin Test (TST) completed and documented within
the last year. Each youth’s results were documented on their CPA and Infectious
Communicable Disease (ICD) form, and each youth’s test results matched on both forms. The
nursing staff interview reflected CPAs are conducted by the DHA within seven days of
admission and annually thereafter. Nursing staff stated they review the Department’s Juvenile
Justice Information System (JJIS) for TST status prior to admission. A tuberculosis screening is
completed during the initial nursing assessment and a medical tracker is maintained to monitor
for TST due dates. Nursing staff stated TST documentation is located on the Facility Entry
Physical Health Screening form and the ICD form. Additionally, the nursing interview indicated
gynecological exams for female youth are not routinely completed.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures ensuring all youth are evaluated and treated, if
necessary, for sexually transmitted infections (STIs). Five youth Individual Healthcare Records
(IHCRs) were reviewed. Each youth’s IHCR contained documentation showing they were
screened and evaluated for STIs on the day of admission. The designated health authority’s
(DHA) standing admission orders require all youth to be screened for STIs regardless of their
risk. A referral for each of the five youth was documented on the STI screening tool, each youth
was referred to the medical doctor (MD), and testing was ordered and performed. The results
for all five youth were documented on the Infectious and Communicable Diseases (ICD) form in
their respective IHCR. None of the reviewed youth were out of the Department’s physical
custody or required a rescreen for any reason. Consent forms in all five reviewed IHCRs
reflected each youth was offered counseling, testing, and if indicated, treatment/referral for
human immunodeficiency virus (HIV). Each youth refused HIV testing and a refusal was
documented. The program’s policy and procedures indicate youth HIV test results are only
disclosed to entities as outlined in Florida Administrative Code. The program has a provider with
a 500/501 certification by the Department of Health who provides their HIV pre-test and post-
test counseling services. All five interviewed youth indicated they can ask for a HIV test. An
interview with nursing staff found each youth is screened for STIs. Each youth is interviewed
during the initial nursing assessment to obtain their history. If further evaluation is required, they
are referred for an off-site evaluation. All screenings, evaluations, referrals, and test results are
documented on the ICD form. Lab results are filed in the laboratory section of each IHCR.
Nursing staff stated HIV test results are kept in a sealed envelope, marked confidential, and
filed in the lab section of each IHCR. Results are given to the youth upon discharge from the
program. Nursing staff stated youth are asked if they want HIV testing during intake. A log is
maintained identifying each youth who has requested testing. Youth can request to be tested at
any time. They simply sign a consent, and a community provider comes monthly to provide
education and on-site testing. All pre and post-test counseling is documented on the Health
Education Record.
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4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures to ensure all youth can submit sick call requests and
have their complaints treated appropriately through the program’s sick call system. Five
Individual Healthcare Records (IHCRs) were reviewed, and four were applicable for sick calls.
None of the four applicable youth presented with a similar sick call complaint three or more
times within a two-week period. Each Sick Call Request form was completed by the youth
requesting a sick call and the nurse conducting the sick call. Reviewed documentation found
each sick call was completed by a registered nurse (RN) or a licensed practical nurse (LPN),
which was reviewed daily with the RN. Each youth’s Sick Call Request forms were filed in their
IHCR in reverse chronological order. Each Sick Call Request form was documented in
accordance with Florida Administrative Code. None of the youth were in restricted housing.
Each youth’s sick calls were documented on their Sick Call Index in their IHCR. Each sick call
was documented on the program’s Sick Call Referral Log. All dates listed on the Sick Call Index
corresponded to the completed Sick Call Request forms located in each IHCR. A review of the
daily schedule, posted schedule, and nurse interview found sick call is held Monday through
Friday from 7:00 a.m. to 8:00 a.m., 10:10 a.m. to 10:25 a.m., 5:30 p.m. to 6:00 p.m. and on
Saturday and Sunday from 7:30 a.m. to 8:00 a.m. and 5:00 p.m. to 6:00 p.m., which meets the
contract requirement of providing sick call seven days a week as indicated on the schedule.
Sick call hours are posted outside of the medical office. An exam table is located in the medical
clinic to utilize during sick calls and only licensed nurses conduct sick call. If there are no
nursing staff on-site, the program’s policy indicates Sick Call Request forms should be reviewed
by a supervisor within two hours. Sick Call Request forms are available to youth on the dorm, in
the supervisor’s office and with staff members who carry the forms with them. Five youth were
interviewed, and all five youth stated they see a nurse immediately when requesting a sick call.
The nursing staff interview indicated youth can submit a sick call at any time by completing a
form and placing it in the sick call box. The box is monitored by nursing staff (RN or LPN) at
regular intervals throughout the day, at least every two hours and then prioritized at the
scheduled time, and all youth are seen within twenty-four hours of making a request. If sick call
is conducted by an LPN, a daily review is conducted with either the RN or designated health
authority (DHA) to obtain approval for the implemented treatment plan. A referral is completed if
a youth has the same complaint three times within fourteen days or if the treatment protocol
appears to be ineffective. Nursing staff indicated the program does not utilize room restriction. A
sick call was observed during the annual compliance review week. The youth was escorted to
medical by direct care staff, who remained outside the door, within eyesight of the youth.
Observations confirmed the medical provider identified themselves and stated why the youth
was there. The youth was seen in a private area within the medical office, with no other youth
present to see or hear the examination by the RN.
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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.
The program has a policy and procedures showing they have a comprehensive process for the
provision of episodic care and first-aid care. The program’s policy also encompasses the use,
access, and inventory of Narcan. Five youth Individual Healthcare Records (IHCRs) were
reviewed and four were applicable for episodic care. A total of five episodic care or first-aid care
events were reviewed for the four youth. On-site care was provided by licensed healthcare staff
for each event. Each event was documented in the required subjective, objective, assessment,
and plan (SOAP) format. An episodic care event was not observed, as one did not take place
during the annual compliance review week. During an interview, nursing staff stated they
document episodic care on their nursing progress notes and on the Episodic Care Log. Non-
licensed staff can complete the Department’s required form to document and notify nursing staff
of youth who received episodic care while nursing staff were off-site. Off-site emergency care is
documented on the Episodic Care Log. The program maintains seven first-aid kits. Two first-aid
kits are utilized for transportation and are located in master control, two kits are in the cafeteria,
one kit is in the duty station, one is in dietary, and the last one is in administration. Medical staff
maintain weekly and monthly inspections, which include the inventories of each first-aid kit and
re-stock, if needed. Additionally, the first-aid kits are checked daily, during each shift by the
supervisor. A review of documentation for the annual compliance review (ACR) period found
first-aid kits were inspected monthly by nursing staff, as required. Three first-aid kits were
checked and were found to be fully stocked with designated health authority (DHA) approved
items. The interview with the nursing staff confirmed there are seven first-aid kits. The program
has one automated external defibrillator (AED), which is located in the administration hallway.
Instructions are located with the AED. On-site nursing staff check to ensure the AED batteries
and pads are operable. A review of documentation for the ACR found checks were conducted
monthly. Nursing staff conducted a self-test on the AED during the ACR week, with no issues
being noted. The green light was flashing on the AED. The batteries for the AED were last
changed in December 2024 and expire in December 2028. The pads on the AED expire on
March 8, 2026. The interview with nursing staff confirmed there is one AED in the facility and
instructions are kept with the AED. Nursing staff also confirmed they check to ensure the AED is
operable and confirmed the expiration dates for the batteries and pads. A list of emergency
numbers, including the Poison Information Control Center, was observed posted in medical, is
accessible for non-licensed and licensed staff, and the numbers are inaccessible to youth. A
review of emergency drill documentation for the ACR period found the program has conducted
drills, which simulate an episodic care event, called for immediate first-aid and/or administration
of cardiopulmonary resuscitation (CPR) techniques, and the initiation of the emergency
procedures to follow when a life-threatening emergency occurs, at least monthly on each shift. A
review of drill documentation found all direct care staff who have been at the program for at
least a year participated in at least one emergency “man-down” drill including the use of CPR
during ACR period. A video review of emergency drills confirmed drills were simulated. There
were no episodic care events which took place during the ACR week; therefore, an observation
of an episodic care event could not be completed. The program has Narcan on-site, which is
stored in a locked medical cart in the medical office, accessible by medical staff and
administration. Staff receive training on the use of Narcan when they receive CPR and first-aid
training. All non-healthcare staff received epinephrine autoinjector training by a registered
nurse. A review of five pre-service and five in-service staff training records found each staff was
trained in episodic, first-aid, and emergency care. The program inventories Narcan on a weekly
basis along with their Weekly Syringe/Sharps Count. The interview with nursing staff indicated
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drills are conducted monthly on each shift, with the use of CPR quarterly. Seven staff were
interviewed, and each indicated they are able to call 9-1-1 for a medical emergency. Five
interviewed youth stated they can see a doctor or dentist, 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.
The program has a policy and procedures ensuring the program provides for timely referrals
and coordination of medical services to off-site healthcare providers. None of the reviewed
Individual Healthcare Records (IHCRs) were applicable for off-site care. The program provided
the IHCRs for three applicable youth and each youth had one off-site care event, which was
reviewed. The Department’s Summary of Off-Site Care Consultation Report form was utilized
for each off-site care event. The off-site care events for two of the three youth were documented
on the Episodic Care Log and the program acknowledged the off-site care event was not
included for the remaining youth. Documentation of parent/guardian notification was located for
two of three youth off-site care events. The parent/guardian notification for the remaining youth
was not applicable because the youth was eighteen years of age. The designated health
authority (DHA) reviewed all off-site care findings, instructions, and information and signed each
Summary of Off-Site Care Consultation Report form acknowledging the review. All three youth
required follow-up care. Evidence indicating one youth received appropriate follow-up care was
provided, with the remaining two youth having follow-up appointments in the future, which are
tracked by the program. During an interview, nursing staff indicated youth who are sent off-site
for first-aid or emergency purposes are tracked utilizing the Episodic Care Log. Nursing staff are
notified of all off-site medical events which occur after nursing hours. Nursing staff indicated
they review all orders with the DHA upon each youth’s return. A checklist is completed to ensure
all steps are completed. The DHA’s folder is utilized for weekly review, and required
documentation is flagged in each youth’s IHCR for the DHA to review during their next on-site
visit. A medical tracker is utilized to track any follow-up care. An interview with the DHA
indicated all off-site care findings, instructions and information are placed in a folder for review
upon arrival to the program. The DHA stated he is informed of any new medical developments
of youth and meets with staff quarterly.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure youth who have chronic conditions receive
regularly scheduled evaluations and necessary follow-up. Five youth Individual Healthcare
Records (IHCRs) were reviewed. Three of the youth were applicable for chronic conditions. All
three reviewed youth were identified on the Department’s Facility Entry Physical Health
Screening (FEPHS) form as having a chronic condition. None of the reviewed youth had a
communicable disease. The three youth were taking prescribed medication on an ongoing basis
and were undergoing treatment for a physical health condition and two were classified with a
Medical Grade two and one a five. All three youth were placed on the program’s chronic illness
list. None of the youth were identified as pregnant. A review of progress notes found each youth
received periodic evaluations at least every ninety-days. There were no youth at the program
who were taking anti-tuberculosis medication. All periodic evaluations were conducted on-site,
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and periodic evaluations were completed prior to renewing any prescription medications which
expired. There were no instances of lapses in care or missed periodic evaluations for any youth.
The Department’s Problem List was updated, as required, for each youth. The interview with the
facility administrator (FA) indicated administration meets with medical staff daily to discuss any
medical issues pertaining to youth. The FA indicated discussions occur in morning management
meetings and the previous day’s documentation is reviewed. An interview with the designated
health authority (DHA) confirmed periodic evaluations are conducted every two months, or
sooner, if needed. Nursing staff have a tracker to ensure they are completed as required. An
interview with the nursing staff stated youth are placed on the medical tracker at intake, or once
they are determined by the DHA to have a chronic condition. The medical tracker monitors and
tracks due dates for periodic evaluations.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a policy and procedures indicating they shall receive, store, inventory, and
provide medication 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. Three youth were identified on the Department’s
Facility Entry Physical Health Screening (FEPHS) form and in the progress notes as admitted
with medication. Documentation in each youth’s IHCR confirmed each youth’s medications were
verified, utilizing the required Department form, prior to being admitted into the program. The
designated health authority (DHA) and/or psychiatrist was contacted to obtain an order to
resume the medication prescribed prior to admission for all three youth. The two remaining
reviewed youth were prescribed medication after their admission. All medications for all five
youth were observed to have a current, valid order, and were given pursuant to a current
prescription. Each time a medication was continued, discontinued, changed, or a new one was
ordered, the DHA placed an order on a Practitioner Order form. None of the youth were in
restricted housing. Three youth were applicable for over-the-counter (OTC) medications not
listed on the Authority for Evaluation and Treatment form. All OTC medications for the four
youth were administered in accordance with approved protocols or practitioner orders. The
program utilizes a preprinted pharmacy Medication Administration Record (MAR), which
includes all required elements; however, one medication for one youth had an incorrect dosage
documented, the program confirmed it was a writing error. A review of MARs confirmed staff
initialed each administered medication and side-effect monitoring was documented at least
weekly for each youth. There were no undocumented explanations for lapses or errors in
medication administration. Four youth refused medication and each youth signed a Refusal of
Treatment form for each refusal, and each refusal was clearly documented on the MAR. One of
the reviewed youth required parenteral medication and the medication was administered by
licensed healthcare staff. Two youth were prescribed psychotropic medication upon admission,
and the DHA and psychiatrist were notified the day of admission for both. The psychiatrist
conducted an Initial Diagnostic Psychiatric Interview with both youth within fourteen days of
admission. Two additional youth were prescribed psychotropic medication subsequently to
admission. All four youth received a medication monitoring/review every thirty days, as required.
There were no standing orders, emergency treatment orders, or pro re nata orders for
psychotropic medications. Medication pass was observed for two youth during the annual
compliance review week. Medication delivery was the sole responsibility of the nurse during the
time of administration. Each youth was escorted to medication pass by direct care staff and
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approached the nurse administering medication individually. The nurse identified themselves
and stated the youth was there for medication pass. The same staff prepared and administered
the medication. The nurse verified the youth’s allergy and alert status, and the staff initialed the
MAR. Staff observed the youth take their medication to ensure it was swallowed, and the nurse
had the youth cough for her and for direct care staff to ensure the medication was swallowed.
The medication was not pre-poured from original packaging and placed in another container for
subsequent administration. OTC medication administration was documented. The six rights of
medication delivery/administration were verified by nursing staff. Five youth were interviewed.
Four youth indicated they receive their medication from a nurse and were able to explain the
process for receiving medication. The remaining youth indicated they do not currently take
medication. The nursing staff interview indicated medications are verified upon admission with
the records which are sent from the detention center and are also verified with parent/guardian
and youth during intake. Nursing staff confirmed the program utilizes a pre-printed pharmacy
MAR. All non-healthcare staff who administer medication are trained by the health service
administrator (HSA) and the list of approved staff is kept in the medical office. Nursing staff
indicated medication pass takes place daily at 7:30 a.m., 12:00 p.m., and 7:00 p.m. Medications
are ordered through a vendor and are procured within twenty-four hours. Nursing staff
confirmed there is a psychiatrist on-site for medication management.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures which states 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. An observation of the programs medical area revealed medical
equipment classified as sharps, as well as stock medications, are secured and inventoried
utilizing a routine perpetual inventory. The program uses a descending count as each sharp is
utilized and disposed of, or when the medication is administered. Medications were identified
and secured in a locked cabinet designated for storage of medications. The program’s
medication cart was observed to be clean and organized with stock items separate from youth-
specific medications. The program did have an accurate and perpetual inventory of controlled
substances, which were maintained separate from other medications. All sharps and
medications were observed to be stored in a separate locked area, inaccessible to youth. The
program kept narcotics and other controlled medications stored in a cabinet behind two locks.
The program had medications which required refrigeration and were kept in a locked
refrigerator. The program has an agreement with a pharmacy to return any unused, expired, or
discontinued medications. The pharmacy consultant comes on-site and destroys the medication
at the program. A review of the programs internal medical logbook documented this process. A
review of weekly inventories of sharps and over-the-counter (OTC) medications confirmed the
program conducts perpetual and weekly inventories, with no noted exceptions. A review of shift-
to-shift inventory counts of all controlled substances confirmed the program is meeting the
requirements. A list was provided of the supervisory-level, non-healthcare staff trained in the
delivery of medication self-administration. Seven staff training records were reviewed during the
annual compliance review week and all had received training provided by a registered nurse
(RN). An observation, during the annual compliance review week, of the RN counting three OTC
medications, two controlled substances, and three sharps was completed with no exceptions.
All inventories reviewed matched the on-site inventory numbers. The programs policy and
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procedures stated the designated health authority (DHA), and the facility administrator (FA)
shall be notified when any discrepancies are found in the perpetual and/or weekly inventory
counts; furthermore, the Department’s Central Communications Center (CCC) is also notified.
An interview with the nurse described the process for disposal of medication which is done on-
site with the pharmacist, a nurse, and the FA. The practice in securing controlled substances
consists of keeping them in a lock box within the medical cart and when they are provided to
youth the nursing staff as well as a witness initial each time the medication is given; a daily
narcotic count is completed as part of this process. The program has an agreement with the
pharmacist consultant which includes on-site visits monthly, quarterly, and yearly to ensure
regulatory compliance.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has implemented infection control procedures which include prevention,
containment, treatment, and reporting requirements related to infectious diseases, as according
to Occupational Safety and Health Administration (OSHA) federal regulations and the Center for
Disease Control and Prevention (CDC) guidelines. The program’s Infection Control Plan and
Exposure Control Plan were reviewed and signed by the designated health authority on October
30, 2023, the facility administrator (FA) on October 31, 2023, and the health services
administrator on November 1, 2023. The program’s Infection Control Plan includes all required
topics. Hepatitis B immunizations are available for all staff and staff have access to protective
equipment, as needed. There were no instances in which the local county health department,
CDC, and/or the Department’s Central Communications Center (CCC) should have been
notified of an infectious disease or any facility or occupational exposure during the annual
compliance review period. The program’s Exposure Control Plan was written in accordance with
OSHA standards and is available to all staff in the medical office and the FA’s office. The
program has a comprehensive process for needle stick post-exposure evaluation. The program
is to document the route of exposure and circumstances of the exposure, identify and document
the source individual, collect and test the exposed individual with consent, provide post-
exposure prophylaxis when medically indicated, provide counseling, evaluate any reported
illness, and provide the OSHA standard, description of duties related to the incident,
documentation of the route of exposure and circumstances, results of blood testing, and medical
records relevant to treatment of the exposed individual. The FA was interviewed and indicated
the exposure control plan is located in the FA’s office, in the medical nursing office and is
reviewed with staff bi-annually. Nursing staff indicated the exposure control plan is available in
medical. Nursing staff provide infection control and exposure control plan pre-service training to
staff, youth receive infection control training upon admission and as scheduled on the monthly
education schedule, and healthcare staff complete training bi-annually.
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4.19 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
The program has not had any youth since the last annual compliance review requiring prenatal
care. A review of five youth Individual Healthcare Records (IHCRs) was conducted for the
inclusion of education relating to alcohol/drug use, smoking, nutrition, sexually transmitted
infections (STIs), and contraception. Each youth had education documented within the IHCR. All
non-healthcare staff involved in the supervision or treatment of pregnant youth received
education on girl’s healthcare, which was completed annually. The training was conducted by
the health services administrator (HSA). A review of training materials provided to staff included
observation and monitoring of emergency care needs and symptoms of possible miscarriage. A
review of on-site protocols noted the program has nursing protocols for pregnant youth. Nursing
staff were interviewed and stated pregnant youth are monitored by the designated health
authority (DHA) and are seen at regular intervals by an obstetrics provider. Pregnant youth also
receive weekly pregnancy education from the nursing staff. Female youth are routinely tested
for pregnancy upon admission, as required by policy. Youth are monitored daily for pregnancy
complications. Pregnancy monitoring is documented on the Medication Administration Record.
Pregnant youth receive double portions or double protein as part of a special diet, which is
ordered by the DHA. Pregnancy education is provided to non-healthcare staff by the HSA.
Pregnant youth are provided with education on the birthing process, post-partum care, basic
baby care, child/infant development, parenting skills, shaken baby syndrome, and related topics.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures addressing active supervision, which is required for
staff to maintain at all times, including interacting positively with the youth and engaging in a full
schedule of constructive activities. The program’s staff to youth ratio is one to six during awake
hours, one to eight during sleeping hours, and one to five while off-site. Staff were observed
during daily activities such as school, recreation, meals, groups, and line movement during the
annual compliance review week. There was positive interaction observed between youth and
staff. Three staff were interviewed and able to provide an accurate youth count upon request.
Proper ratio was maintained at all times. No youth were observed roaming freely without
supervision. The daily activity schedule was posted in the day area and living unit and was being
followed by staff. Youth were engaged in a full schedule of activities. Video observation indicated
staff were observing youth while in their sleeping rooms.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program has a policy and procedures addressing their behavior management system
(BMS), including staff are provided feedback regarding the implementation of the BMS. The
BMS was posted in the day area, living unit, and in the youth handbook. The program’s BMS
included rules governing conduct, and positive and negative consequences. All staff are
involved in the development, implementation, and ongoing maintenance of the BMS. The
cooperative agreement reflects classroom management between the program and the local
county school system. A training roster was provided which reflected BMS training was
completed with the teachers by the regional compliance manager. All five staff training records
contained documentation to support each staff was trained in the BMS. Five youth case
management records were reviewed and confirmed youth orientation included a review of the
program’s BMS. Eighteen staff position descriptions included implementation of the program’s
BMS. Positive behaviors are given at a four to one ratio, as indicated in the contractual
agreement. The BMS does not increase length of stay for the youth, deny youth of basic rights,
allow group punishment, allow discipline of youth by other youth, or allow isolation. The
program’s BMS contains all required elements, including a process wherein staff explain to each
youth the reason for any sanction imposed prior to the end of the staff’s workday and the youth
is given an opportunity to explain their behavior. Staff and youth discuss the behavior impact on
others, reasonable reparations for harm caused to others, and alternative acceptable behavior.
The program provides a variety of rewards/incentives. Staff and youth interactions were
observed and supported adherence to the BMS requirements. Five staff were interviewed and
each of the five staff indicated, during special treatment team they will discuss any
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consequences given to the youth and the youth are able to explain their behaviors. All five staff
were able to explain the BMS, as well as rewards provided, and all stated rights cannot be taken
as a consequence. Five youth were also interviewed; and each of the five indicated they all
receive incentives which include snacks, boutique, outings, and food. Youth stated staff are
consistent in what behaviors they give rewards and consequences, and no youth are allowed to
punish other youth. All five youth were able to explain the BMS and the process for moving from
level to level. The facility administrator (FA) was interviewed and reported the program utilizes a
BMS compiled of a series of levels. Youth complete each level by earning daily points to
achieve a positive day in the program. Earning positive days allows youth to participate in
nightly incentives. If a youth has a behavioral infraction, they will not earn points for the task.
After so many deducted points, youth will not earn enough points to make their positive day
which hinders their progression in the level. Additionally, youth can earn a special treatment
team referral for more serious behavioral violations. Youth will meet with their treatment team to
provide feedback and share their input on the situation and together they will determine an
appropriate consequence. The program utilizes a daily tracker to manage youth progress and
as a means of communication between staff regarding youth progress in the program. Point
cards are reviewed daily by the shift supervisor and youth, who initial acknowledging the points
earned. Any time a point is not earned, the reason is explained on the point card, so youth and
other staff are aware in the event a youth has a question. Staff are evaluated from
commendable to unacceptable in participation in the maintenance of the therapeutic milieu of
the living unit, enforcement of the level system, or other methods of the BMS. Performance
evaluations are completed at ninety days of employment or promotion and annually.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a forty-seven cameras, with forty-five operational at the time of the annual
compliance review (ACR). Video recordings are stored for thirty days. The program has one
living unit for youth, and the staff were on twelve-hour shifts. Ten-minute checks were reviewed
through video observation, which confirmed checks were completed with staff pausing and
looking in the youth rooms at least every ten minutes. Check sheets were reviewed from both
shifts on weekdays and weekends. A review of each month thirty-minute increment for the ACR
period showed documentation supported ten-minute checks were completed correctly. Five
staff were interviewed and each of the five staff indicated checks are conducted every five
minutes while youth are in their sleeping rooms.
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5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program has a policy and procedures pertaining to census, counts, and tracking of youth.
The facility administrator (FA) ensures the program develops, updates, and maintains a
Continuity of Operations Plan (COOP) which follows state law and the Department’s policy.
Facility logbooks were provided for the annual compliance review (ACR) period by the program
for review, which reflected facility population counts were completed as required. During the
ACR week, youth counts for movement to class, from class, from lunch, and to group were
observed to be conducted correctly. Five staff were interviewed and three staff indicated they
are notified to conduct a count by master control. Two staff reported counts are conducted at
least twice a shift, and they notify master control if there is a miscount. All five staff reported an
emergency headcount is conducted if a youth is unaccounted for and after every fire drill.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures to address logbook entries. A review of logbooks
during the annual compliance review period was conducted. Logbooks were bound with
numbered pages and all logbook entries were made in ink with no erasures or white-out areas.
There were no entries destroyed or removed and no eraser marks were observed. All entries
included the date and time of the event, the name of the staff and youth involved, brief
descriptions of the events, and the names and signatures of the staff making the entries.
Logbook entries included all required information. Reviewed documentation indicated each
incoming shift reviewed the logbook entries made during the previous shift then signed and
dated the logbook to acknowledge the information. Internal incidents reported to the Florida
Abuse Hotline and/or the Department’s Central Communications Center (CCC) were
documented in the logbook. The program maintains a logbook in master control.
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5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures to address key control which includes key
assignment and usage, restrictions on usage, inventory and tracking of keys, secure storage of
keys not in use, procedures addressing missing or lost keys, and reporting and replacement of
damaged keys. Program keys are maintained in secured key boxes located in master control
and the area is secured and inaccessible to youth. Staff secure personal keys in master control
within a locked key box. The key boxes located in master control are not accessible while
locked. Each set of keys has an assigned number and corresponding key ring. A review of the
key inventory matched the actual key rings in use. Keys are assigned to staff according to their
position. Keys are always locked in the key box when not in use. The facility administrator
assigns the permanent and restricted keys based on the position. An acknowledgment form for
permanent keys is completed for each permanent key assigned with signature, key number, and
return date. The physical plant manager replaces all damaged keys. A broken key report form
is completed for each broken/damaged key and the damaged/broken key is attached to the
form. The inventory and tracking of keys and distribution of program keys to staff was observed
during the week of the annual compliance review. The key tracking and distribution processes
were in accordance with the program’s key control process. An informal interview with the
master control staff validated they were aware of the process for restricting usage of keys. A
random check of five staff key rings confirmed the keys matched the inventory and each staff
was aware of the number of keys on their assigned key ring and the function of each key. There
were no reports made to the Department’s Central Communications Center (CCC) or
deficiencies in the Department’s Program Monitoring and Management (PMM) system this
annual compliance review period regarding key control concerns. Five staff were interviewed,
and each was able to explain the program’s key control process.
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5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a system to prevent the introduction of contraband through searches of the
physical plant, facility grounds, and youth, and identifies contraband items and materials, which
is clearly explained in the program’s policy and procedures, and resident handbook. The policy
also states any staff found to be in possession of contraband at the program will be subject to
disciplinary action up to and including, dismissal, as well as procedures regarding notification of
law enforcement for items considered illegal as defined in Florida Statute. During the annual
compliance review (ACR) period the program had to contact law enforcement once due to illegal
contraband found. Law enforcement did not pursue any charges. The program notified the
Department’s Central Communications Center (CCC). The programs policy and procedures and
the youth handbook define items and materials considered contraband when found in the
possession of youth, provides youth with a list of contraband which meets the required
elements, and informs youth of the consequences if found with contraband. The prohibited list
includes personal cellular telephones, and/or equipment, and/or electronic devices capable of
taking pictures, and/or audio/video recordings, which are prohibited in the secure area. The list
also includes unauthorized articles of clothing and food, controlled substances, prescriptions or
non-prescription drugs, and any firearm or explosive device. The program policy and the youth
handbook also explain the searching of the physical plant, facility grounds, youth and staff, and
incoming and outgoing mail to prevent contraband introduction. The program maintains room
search forms which document any contraband findings, which are also documented in the
program logbook. A review of contraband forms for the ACR period was completed. No illegal
contraband was found. Items not considered illegal contraband were documented on the
contraband search form as well as documenting the disposition of the item. Any item not
considered illegal contraband will be sent to the youth’s home or retained at the program until
the youth’s release. Five staff were interviewed, and each staff indicated random room searches
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are conducted twice a week. The contraband notice was posted, and state law enforcement will
be contacted for anyone bringing in contraband and a criminal report will be filed. This practice
was confirmed through an interview with the facility administrator (FA). The visitors log and
outside contractors sign-in form includes the contraband attestation statement. Twenty-six new
staff were hired since the last ACR and their personnel records were reviewed and all had a
signed copy of the contraband attestation. The FA stated in the event illegal contraband items
are discovered, the facility will immediately contact local law enforcement and the CCC. All
instances of contraband items and their disposal are documented appropriately after being
discarded or turned over to local law enforcement or the investigating agency.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures to address searches and full body visual searches to
ensure no contraband is introduced into the facility. Five interviewed youth reported being
searched for every movement, off-campus activities, meals, visitation, and education. Each of
the five interviewed staff stated youth are searched every movement. Visual observations were
made during the week of the annual compliance review (ACR) of youth searches before and
after groups, education, vocational instructions, recreational activities, transports, visitation, and
following access to tools and equipment. During searches youth were treated with dignity and
respect to minimize their stress and embarrassment and each observed search was conducted
by the appropriate number of staff and by a staff of the same gender as the youth. Youth
searches and instructions given to youth during searches were in accordance with the
program’s policy and procedures and the Right Interactions training manual. The program did
have one admission during the ACR week. The youth was searched as required. A video review
of five staff and visitor searches indicated all were conducted as required.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a policy and procedures to address vehicles and maintenance. The program
utilizes two vehicles for youth transport. Reviewed documentation validated the vehicles had
received an annual safety inspection, and all required maintenance records were documented.
An inspection of the program vehicles was conducted and found they contained a fire
extinguisher, the appropriate number of seatbelts, and the door to the youth passenger area
could not be opened from the inside. An approved first-aid kit is checked out of master control
with the vehicle keys for each transport, and a seatbelt cutter and window punch tool are
located on the key rings. Youth are not attached to any part of the vehicle by any means other
than proper use of a seatbelt. A check of five randomly selected program and personal vehicles
was conducted during the week of the annual compliance review; and all were locked when not
in use.
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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 has a policy and procedures to ensure the safety and security of youth transports
and driver eligibility. The review of the program’s policy and observation of a youth transport
confirmed a program cellular telephone and radio are provided to transportation staff, staff of the
same gender of the youth are present during transport, appropriate youth to staff ratio is
maintained, the youth are never left unsupervised in a vehicle, youth are not permitted to drive
program or staff vehicles, and youth and staff wear seatbelts. Reviewed documentation
confirmed the program maintains a monthly approved driver list; each month the program’s
human resources will ensure each approved driver has a valid driver license. Five youth were
interviewed, each youth reported they have never been handcuffed to any part of a vehicle or
seen anyone place contraband in a transport vehicle. Five staff were interviewed and were able
to explain how youth are secured within the vehicle, what type of communication devices are
used during youth transport, what the emergency response process includes, and the staff to
youth ratio. All five staff reported staff are not allowed to use their personal vehicle to transport
youth and the transport vehicles are searched prior to and after each use.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures outlining the audit or inspection process to include
the responsibility of the physical plant manager to conduct the weekly safety and security audits,
and develop and implement corrective action warranted, as a result of safety and security
deficiencies found during internal or external reviews, audits, or inspections. Weekly safety and
security audits were provided by the program for the annual compliance review period and a
review confirmed the practice, and the requirements were completed. An interview with the
facility administrator (FA) revealed the program’s physical plant manager and FA complete
weekly safety and security audits. Findings are then documented on the Weekly Safety
Inspection Report and provided to the FA for review. The report will detail identification of the
issue and tracks the correction of the deficiencies. All efforts are made to correct deficiencies in
a timely manner, dependent of the severity of the issue.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures ensuring youth do not use tools or equipment as
weapons or as a breach of security. Tools are classified as either Class A tools which are
hazardous with sharp edges or points, and with a high potential to be used as a weapon to
cause serious bodily harm, such as knives, hammers, screw drivers, and electric drills, or Class
B tools which do not have sharp edges or points, such as brooms, mops, and scrub brushes.
Observations of all tools, both Class A and B indicated they were secured, inaccessible to
youth, and stored in the program’s kitchen, hallway closet, laundry room, and maintenance
shed. All tools were labeled with an identification number, on a shadow-board or pegboard. The
physical plant manager inventories items daily, and documents this on the Master Inventory
form. Kitchen knives were observed behind a locked cabinet securely stored using a shadow-
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board system in the kitchen. All knives were accounted for according to the inventory forms
provided and observation of the cabinet. The dietary staff provided sign-in/out logs of the
sharps, which were completed as required. Class B items were secured in the south hall closet
and laundry room. These tools consisted of brooms, mops, mop buckets, scrub brushes, toilet
brushes, dust mops, and dust pans. There are pictures depicting the items in these areas, a
youth risk assessment list, and a sign-in/out log. The physical plant manager was interviewed
and confirmed youth are only allowed to use the items in the closet and laundry room with staff
supervision. Youth are never permitted to use tools from the maintenance shed. A review of ten
tools indicated all were secured, each had a marking, and they matched the inventory, The
program’s policy does not allow machetes, bowie knives, or other long blade knives. During the
annual compliance review period, the program had no missing or dysfunctional tools. A review
of five youth case management records and five staff training records revealed all were trained
on the intended and safe use of tools.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures addressing the supervision requirements when youth
use tools, including a one to five staff-to-youth ratio, issuing tools to youth and staff, a youth risk
assessment to determine a youth’s risk to self and others, and tool distribution, collection, and
search criteria during work projects. Clean-up is scheduled in the evening and was not able to
be observed during the annual compliance review week. Five youth case management records
were reviewed, and all had documentation of youth trained on the intended and safe use of
tools, and confirmed a risk assessment was completed prior to the use of tools. Five youth were
interviewed, and each youth indicated they only use mops and brooms. Five staff were
interviewed and stated youth only use mops and brooms.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures with guidelines for outside contractors which includes
tool control and restrictions. Vendors or outside contractors are provided a Written Notification
and Guidelines for Outside Contractors form, which is reviewed and signed by the contractor
and the facility administrator (FA) or the physical plant manager prior to being on-site. Providers
are made aware all tools must be checked and inventoried upon arrival, during the visit, and at
departure. They are also notified of the procedures to be followed if tools are missing. The
outside contractors form also references recording devices not being allowed in the program.
The outside contractor binder was provided and included the Written Notification and Guidelines
for Outside Contractors forms with invoices attached. The physical plant manager or designee
inspects all tools upon arrival of outside contractors and is responsible for providing approval if
such tools are required. The program’s guidelines for external work orders includes checking of
tools upon arrival and departure, searching of all vendors prior to entering the facility, tool
restriction while in the facility, missing tool follow-up, and restriction of youth from the work area.
A sample of three project invoices submitted to the program during the annual compliance
review period revealed the program inventoried the tools and equipment upon arrival and
departure of the vendor and matched the sign-in sheets of the outside contractor.
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5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a policy and procedures to address fire, safety, and evacuation drills. A review
of the program’s Continuity of Operations Plan (COOP) revealed the program conducts monthly
fire and COOP drills on a rotating basis on each shift. The program is on two twelve-hour shifts.
A review of drill documentation provided by the program for the annual compliance review
(ACR) period revealed monthly fire drills and COOP were completed as required with the
exception of one missing fire drill on the second shift for one month. The documentation for all
drills contained the type of drill, date and time, participants, brief scenario, findings, and
recommendations. A tour of the program during the ACR week found evacuation routes and
egress plans posted throughout the facility. The program provided documentation there are
fifteen fire extinguishers in the facility and reviewed documentation reflected all fire
extinguishers were inspected annually. Five staff were interviewed, and each indicated they
participate in fire drills, suicide drills, and medical drills. One of the five staff stated they
participate in active shooter drills, gang, and riot drills. Five youth were interviewed and all
stated they were instructed what to do in case of a fire. Four youth stated they conduct fire drills
weekly and one youth stated twice a week. An interview with the facility administrator revealed
COOP drills are completed monthly, across each shift. These drills include disturbances, riots,
threats, severe weather, evacuation, and escape. In addition, fire drills are conducted monthly
across each shift. Each drill is reviewed monthly in the general staff meeting.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program maintains a Continuity of Operations Plan (COOP) which is located in the facility
administrator’s (FA) office, and staff duty station readily available to all staff. The plan was last
updated on May 15, 2024, and signed by the Department’s residential operations staff on the
same date. The plan addresses relocation sites approved by the Department’s regional
director/designee staff. The Emergency Disaster Preparedness Plan and COOP are combined
into one plan. The program maintains supplies of water, flashlights, batteries, and dry goods in
the staff duty room closet clearly marked as COOP-related supplies and equipment. The
program maintains a separate record for each youth as an administrative hard copy which is
taken in large bins with staff in the event of an emergency or evacuation. Each record had the
required information. The FA validated the location of the COOP and accessibility to all program
staff.
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5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and 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 maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures regarding the storage, disposal, and inventory of
flammable, poisonous, and toxic items. The policy includes the procedure for cleaning up
chemical spills, notifications to master control and supervisory staff of the spill and the location.
In addition, the policies included procedures for the shutdown of all air handlers and ventilation
systems and closing off the facility if needed. An informal interview with the maintenance staff
indicated there have not been any chemical spills; however, assistance from outside the facility
shall be contacted as necessary. The program’s flammable, poisonous, and toxic items are
stored behind locked doors in a locked cabinet. The area is always secured and inaccessible to
youth. The program staff indicated only cleaning supplies are kept at the program. The program
maintains an inventory and a list of positions authorized to handle these items. A review of
seven items coordinated with the inventory log. Each item had a Safety Data Sheet (SDS) and
an SDS was maintained where the items were stored. Kitchen grease is disposed of by
contacting the appropriate disposal company who comes to the program to empty the grease
trap located outside the facility behind the kitchen. An informal interview with the dietary staff
and a direct-care staff indicated dirty mop water is poured down the mop sinks and floor drains.
The medical staff maintains a biohazard waste container clearly marked and secured in the
medical office. An interview with the facility administrator and maintenance staff indicated the
program utilizes a biohazardous waste contractor for the program’s hazardous waste disposal
practice in addition, the program participates in the local county solid waste management
division household hazardous waste program. Disposals can be made the first Saturday of each
month as needed.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures on the youth handling and supervision for flammable,
poisonous, and toxic items, and materials. The policy prohibits the youth from the use, handling,
or clean-up of dangerous, hazardous chemicals or bio-hazardous material, bodily fluids, or
human waste. The youth have no access to areas where chemicals and tools are stored. Staff
are required to spray or pour chemicals for youth for cleaning rooms or the unit and provide
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direct supervision of the cleaning activity. Youth daily cleaning activities occur in the evening
hours and were not observed during the annual compliance review week. Five youth were
interviewed, and each youth indicated they do not handle chemicals.
5.20 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.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures addressing visitation, youth correspondence, and use
of the telephone. The program’s visitation schedule is posted in the administrative hallway, day
room area, living unit, and is also available in the youth and parent/guardian handbook. The
program’s visitation hours are Saturdays and Sundays from 2:00 p.m. to 4:00 p.m. and
alternative visitation arrangements are available. A review of the visitation log and schedule
during the annual compliance review period confirmed visitation took place as scheduled.
Program case managers maintain an approved telephone log, mail, and visitation list for each
youth, in addition to the correspondence being reflected on the youth’s Admission Classification
Form. Reviewed documentation revealed the case managers request clarification from the
youth’s juvenile probation officer (JPO) for youth with history of human trafficking alert to verify
appropriate contact person for the youth to communicate with. All incoming and outgoing mail is
searched in the presence of the youth by staff. The program utilizes a third-party language
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service to assist in language translation for youth who have a language barrier. Five youth were
interviewed, and each youth confirmed they can call their parent/guardian and send letters
home.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a policy and procedures addressing recreation and leisure activities for youth.
The daily activity schedule was posted in the common areas of the program. The program
activity schedule contains at least one hour of supervised and structured indoor and outdoor
recreation and leisure activities, to include large muscle activity, for youth each day. Logbooks
were provided and reviewed for the annual compliance review period, which confirmed
recreation and leisure activities were conducted as scheduled. The program takes precautionary
measures to prevent overexertion, heat stress, dehydration, and exacerbation of existing illness
or physical injury. If the weather does not permit outside activities, youth would participate in
yoga, board games, or arts and crafts. The activities promote social and cognitive development,
creativity, teamwork, healthy competition, mental stimulation, and physical activity. The program
has a recreational therapist on staff as contractually agreed meeting all credential and other
requirements. Five youth mental health and substance abuse records were reviewed, and each
contained an individual treatment plan with recreational therapy goal(s). Five youth were
interviewed and all five youth stated they receive one hour of recreation each day. Five staff
were also interviewed, and confirmed youth are given at least one hour of recreational activity
each day. Each staff was able to provide a list of activity opportunities the program offers each
youth.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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Standard 6: Educational Services
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
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), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program has a policy and procedures which requires they implement career and technical
education (CTE) services, which are negotiated in the contract. A review of the contract
revealed the program is required to offer soft skills, Florida Ready to Work, Occupational Safety
and Health Administration (OSHA-10), first-aid/Cardiopulmonary Resuscitation (CPR) and
barbicide. The program offers a barbicide certification; however, no youth requested it. During
the annual compliance review period, fifty youth completed soft skills, Florida Ready to Work,
OSHA-10, and CPR/first-aid, eight youth completed ServSafe, seven youth completed My
Journey Career Success Workshop Series: Career Exploration, Career Planning, Job
Readiness and Career Navigation, and three youth received their high school diploma, and one
youth earned their general educational development (GED) certification. CTE services are
provided Monday through Friday from 6:15 p.m. to 7:15 p.m. A review of sign-in sheets
confirmed the CTE services were provided as required, according to the program schedule,
contract, and CTE requirements. The CTE services are provided by staff who are currently
certified and qualified to provide these courses. In addition, OSHA 10, Florida Ready to Work,
and Soft Skills are provided on-line by a certified CTE instructor. Sixteen youth are enrolled in
CTE course work towards earning industry certification. Five youth were interviewed and asked
how well the program is preparing them for their high school equivalency diploma (GED), high
school diploma, vocational school, and college. All five stated they were being prepared very
well. The facility administrator was interviewed and stated each youth is issued a career
assessment and overcoming obstacles to identify their individual vocational needs. Youth are
provided with the opportunity to complete job applications, obtain a state identification (ID), and
fill out job applications online prior to release. Youth are provided with CPR/Basic first-aid
certification and if appropriate, ServSafe Food Handling Certification.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide for educational access. The
program integrates education into the daily schedule. The reviewed scheduled coincided with
the education contract provider’s schedule times. A sample of three random days of videos and
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three random days of logbook reviews showed youth are being sent to class and returned from
class on time. In addition, randomly selected logbook entries over the past year were reviewed
and youth were moved accordingly with little deviation. In a review of the youth interviews, all
five-youth said no; there are no interruptions during the school day.
6.03 Educational Access (Education Contract Provider) Non-Applicable
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.
Education services are provided through a contract with Florida Virtual School (FLVS) which
ensures the integrity of the required minimum instruction time distributed over a twelve-month
period. The district approved calendar and daily school schedule were reviewed, which
incorporated the required 250 days of instruction, with twenty days used for teacher planning,
and a minimum of twenty-five hours of instruction weekly and was approved by the Department
on April 29, 2024. Youth are enrolled in academic courses through Florida Scholars Academy
and receive credit, as appropriate, when courses are completed. A sample of three random
days of videos and three logbook reviews showed youth started and completed class on time.
The Lead Teacher indicated the program’s education instruction schedule is as follows; 8:30
a.m.- 9:20 a.m. Period 1 ELA/MATH 9:20 a.m.- 10:10 a.m. Period 2 Science / Social Studies
10:10 a.m. - 10:25 a.m. Break 10:25 a.m. - 11:15 a.m., Period 3 Elective11:15 a.m.- 12:05 p.m.
Period 4 Elective12:05 p.m. -1:05 p.m. Lunch/Planning 1:05 p.m. - 1:55 p.m. Period 5
ELA/MATH 1:55 p.m. - 2:45 p.m. Period 6 Science / Social Studies.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The program has developed and implemented a vocational development program. The career
education program is appropriate for the educational abilities of youth in the program, and
appropriate for the length of stay in the program. The program offers type two vocational
competency development programming. Youth are provided with the opportunity to complete
job applications, obtain a state identification, and fill out job applications online prior to release.
The Lead Teacher was interviewed and stated Les Peters Academy provides career education
services.
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
According to the contract, the contracted educational provider is required to develop an
Education Transition Plan for each youth. Three closed case records were reviewed; none
contained an Education Transition Plan. Many youths entered the program before July 1, 2024,
when the new education provider Florida Virtual School (FLVS), began their contract, so they
would not have had an Education Transition Plan developed by the provider. In the lead
educator interview, it was reported each youth has an Entry Transition Plan upon entry.
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6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The contracted educational provider has procedures in place to provide for qualified
instructional personnel. After a review of the three teachers, as well as six flex teaches, and one
Exceptional Student Education (ESE) teacher, it was verified all hold active credentials as listed
on the Department of Education (DOE) website. A review of the three youth schedules
confirmed all teachers were accurately listed. A review of three records confirmed one teacher
was teaching an out-of-field course. There was no documented approval obtained by the school
board for out-of-filed teaching. Documentation in the three reviewed youth records indicated the
youth received education from the out-of-field teacher; however, parent/guardian notification
letters, were not sent out prior to October 14, 2024, and none of the letters accurately reflect the
classes, or teaching assignments outside of their field of expertise.
6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
The education provider shall complete the Florida Youth College referral process for each youth
which earns their high school diploma or high school equivalency diploma (GED). Each youth
will be assigned a Florida Youth College Career Navigator. Three closed youth records were
reviewed, and none of the three youth were applicable, two youth did not complete high school,
and one youth was too young. Three of the four youth who received their high school diploma,
received it prior to July 2024. Five youth were interviewed and stated the program is preparing
them well for GED, high school, employment, or collage. The lead educator and Florida
Academy Instructor were interviewed and stated all youth are referred to Florida Youth College
upon completion of school.
6.08 Florida Youth College (Post-Secondary Contract Provider) Non-Applicable
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session to
develop a career pathway plan. The career pathway plan shall include post-secondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming which leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
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their release. None of three youth records indicated they were applicable for a Florida Youth
College Career Navigator due to one being too young and two not completing school. Three of
the four youth who received their high school diploma, received it prior to July 2024. An informal
interview was conducted, and the facility school academy instructor stated all youth are referred
to Florida Youth College upon completion of school. All five youth stated the program is
preparing them well for a high school equivalency diploma (GED), high school, vocational
school, employment or collage.
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report_type: QI Residential

program_name_raw: Les Peters Academy