state: FL

facility_name: Deep Creek Youth Academy

summary: QI Residential - FY23-24 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Deep Creek Youth Academy- Mental Health Overlay Services (MHOS)
and Substance Abuse Overlay Services (SAOS)
Youth Opportunity Investments
(Contract Provider)
765 E Saint Johns Avenue
Hastings, Florida 32145
Review Date(s): March 26-29, 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:
Kamille Payne, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Jeff Campbell, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (Standard 3)
LeAnn Gruentzel, Office of Accountability and Program Support, Deputy Regional Supervisor
(Standard 2)
Kristine Harshaw, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Stephanie Patton, Alachua Academy, Health Services Administrator (Standard 4)
Miguel Roca, AMIkids Jacksonville, Behavior Interventionist (Standard 5)
Desiree Taylor, Office of Accountability and Program Support, Deputy Bureau Chief (Interviews)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Program Name: Deep Creek Youth Academy MQI Program Code: 1486
Provider Name: Youth Opportunity Investments, LLC Contract Number: 10677
Location: St. Johns County / Circuit 7 Number of Beds: 40
Review Date(s): March 26-29, 2024 Lead Reviewer Code: 161
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Failed
Limited Ratings
Ratings
5.01 Youth
Supervision *
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 64 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
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 5 of 64 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 64 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 64 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 64 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Limited
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
5.25 Controlled Observation Non-Applicable
5.26 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 64 (Revised September 2022)
Program Overview
The Deep Creek Youth Academy is a forty bed program, for twelve to nineteen year old males,
located in Hastings, Florida. The program is operated by Youth Opportunity Investments, LLC,
through a contract with the Department. The program provides services including Mental Health
Overlay Services (MHOS) and Substance Abuse Overlay Services (SAOS). In addition, the
program fosters each youth by providing Skillstreaming the Adolescent, Moral Reconation
Therapy, Living in Balance, and Impact of Crime. Additional treatment services provided include
individual and family therapy, animal assisted therapy, and recreational therapy. Program
administration is comprised of a facility administrator and two assistant facility administrators.
Case management services are provided by a director of case management, three transition
services managers, and six case managers. Mental health staff at the program include a
designated mental health clinician authority (DMHCA) who is a licensed psychologist, two
assistant clinical directors, one licensed therapist, and nine non-licensed therapists. Medical
services are offered twenty-four hours a day and are provided by a designated health authority
(DHA), psychiatrist, health services administrator (HSA), and four registered nurses.
Educational services are provided by TrueCore Behavioral Solutions through an agreement with
the St. Johns County School Board. The layout of the program includes one main building which
houses administration, master control, education, medical, kitchen and dining areas, and multi-
purpose space, and two buildings housing a total of four youth modules. The program has 166
operating security cameras providing coverage. There were thirteen cameras not operational at
the time of the annual compliance review; however, each area provided by a non-operational
camera was covered by another program camera at a different angle. At the time of the annual
compliance review, the program had twenty-six vacant positions; one licensed therapist, three
non-licensed therapists, one recreational therapist, one nurse, two case managers, four
supervisors, one master control operator, two transporters, and eleven safety and security
specialists.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 64 (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.
A review of the staff roster found fifty-five staff were hired during the annual compliance review
period. Each staff received a clear and eligible background screening in the Clearinghouse
system and their criminal history reports were reviewed prior to contact with youth or
confidential youth records. None of the staff required an exemption. None of the staff were
applicable for a break in service and five staff were applicable for being hired from another
provider. Each of the five applicable staff had a new background screening completed as
required. Each applicable staff was administered a pre-employment assessment tool and a
passing score was obtained and documented in their personnel records. Fifty-one of fifty-five
staff were added to the program’s roster in Clearinghouse, the remaining four staff were added
during the annual compliance review week. After hire, one staff received disqualifying charges
and was removed from youth contact. The charges were dropped and the paperwork was
submitted to the Department’s Office of Residential Services (ORS). The staff returned to the
floor; however, the paperwork was not submitted to the Department’s Background Screening
Unit (BSU). The staff’s eligibility in Clearinghouse was changed to ineligible, which was not
discovered until the annual compliance review week at which time the Department’s Central
Communications Center (CCC) was contacted. Following discussion with the ORS and BSU it
was determined the staff should have been eligible to work the floor and a new background
screening was initiated and received as eligible while the annual compliance review team was
on-site. The program did not have any volunteers, mentors, contract staff, or interns who
required a background screening. The Annual Affidavit of Compliance with Level 2 Screening
Standards was submitted for the program on January 19, 2024 and for the teachers who are
provided by TrueCore Behavioral Solutions through a contract with the St. Johns County School
Board on January 18, 2024.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures to ensure all staff are administered background
rescreenings every five years of employment. A review of the staff roster found no staff were
eligible for a five-year background rescreening.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 64 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
 The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
 All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
 Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
 The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
 A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to ensure an abuse-free environment which outline
the staff code of conduct, which they are required to sign upon hire, in addition to the program’s
abuse reporting procedures. The abuse reporting procedures indicate youth shall have
unhindered access to the Florida Abuse Hotline and the staff are to notify the supervisor, who
will notify the facility administrator, and immediately allow the youth to make the call. Ten
personnel records were reviewed and confirmed the staff signed their code of conduct upon
hire. A program tour confirmed the program has postings for the Florida Abuse Hotline and
Department’s Central Communications Center (CCC) throughout the program in areas
accessible to youth. The program last completed a Trauma Responsive and Caring
Environment (TRACE) self-assessment in April 2023. The program had nine incidents of alleged
abuse during the annual compliance review period, five of which were reviewed and one of
which was substantiated. Each of the five reviewed incidents was reported to the CCC and
Florida Abuse Hotline. None of the reviewed incidents involved allegations of human trafficking
or exploitation. An interview with the facility administrator confirmed the program follows the
abuse reporting procedures and ensure youth have unhindered access to the Florida Abuse
Hotline. Three youth were interviewed and confirmed they have never been stopped from
reporting abuse and know where the Florida Abuse Hotline number is posted. Two of the three
youth reported feeling safe in the program, one youth reported staff are trying to press charges
on the youth; however, the youth then made self-harm statements. The youth was offered and
declined an abuse call and the program staff were notified and provided mental health services
to the youth. Two of three youth reported staff use profanity at youth and are not respectful to
youth. None of the youth had ever exchanged contact or social media information with staff.
Three staff were interviewed and each reported in the event a youth wants to report an
allegation of abuse they are allowed to make a call or allow the youth to call the Florida Abuse
Hotline. Two of the three reported they would call the supervisor and allow the supervisor to
make the call. One of three would also call the facility administrator. Each staff reported they
have never witnessed another staff deny a youth the opportunity to call the Florida Abuse
Hotline or use threats, profanity, or intimidation when speaking with youth. Each staff knows
where the Florida Abuse Hotline number is posted. Results of the interviews were shared with
the program who responded any staff found to use profanity toward youth would be written up in
accordance with the program’s code of conduct.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 64 (Revised September 2022)
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had nine allegations of abuse against staff reported the Florida Abuse Hotline and
Department’s Central Communications Center (CCC) during the annual compliance review
period, five of which were reviewed. Incident reports were provided which confirmed the
program took immediate action and placed staff on no youth contact pending the investigation
into each incident. Corrective action was taken based upon the results of the investigations and
one incident was founded which resulted in the termination of the staff. The facility administrator
confirmed the program takes immediate action and places staff accused of abuse on no youth
contact pending an investigation.
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 seventy-two incidents reported to the Department’s Central Communications
Center (CCC) during the annual compliance review period, seven of which were reviewed. Each
reviewed incident was called into the CCC within two hours of the incident occurring or
discovery of the incident and was found in the program’s master control logbook. There were no
additional incidents found which should have been reported to the CCC and were not. The
program had an increase in reports from the previous annual compliance review period and
reported the increase was due to the increase in bed capacity and thirty-five incidents were
medical incidents, of which eleven were in regard to one youth’s chronic condition.
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program had seven Protective Action Response Right Interactions model (PAR/RI)
incidents during the annual compliance review period, five of which were reviewed. Each
reviewed PAR/RI incident report was completed with statements from all staff before the end of
the staff’s workday. Each PAR/RI included documentation a post-PAR/RI interview and PAR/RI
medical review were completed and the PAR/RI was reviewed by all required parties. One of
the PARs/RIs resulted in an injury to the youth and the incident was reported to the Florida
Abuse Hotline and the Department’s Central Communications Center (CCC). None of the
incidents involved the youth of mechanical restraints. Each PAR/RI Report was placed in a
centralized record and the program submitted their monthly PAR/RI Reports to the Department
as required. The program’s PAR/RI plan was last updated and submitted to the Department on
November 6, 2023 and approved by the Department on November 28, 2023. The program’s
PAR/RI rate during the previous quarter was 0.43, which is below the statewide Residential
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 64 (Revised September 2022)
PAR/RI rate of 1.76. The program experienced an increase in PAR/RI incidents since the last
annual compliance review period and the program reported this was due to an increase in the
program’s census and transfer of youth into the program. The facility administrator was
interviewed and reported the PAR/RI matrix should be used and physical intervention should be
used when all alternatives have been exhausted. One of the three interviewed staff reported
they have utilized PAR/RI and the one applicable staff reported they attempted to verbally de-
escalate the youth prior to utilizing PAR/RI.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
Five staff records were reviewed for pre-service training requirements. Each of the five staff
completed an excess of 120 hours of training in the first 180 days of hire. Each staff completed
all essential skills training prior to contact with youth and all additional required training to be
certified within 180 days of hire. All training was documented in the Department’s Learning
Management System (SkillPro). None of the staff were applicable for re-certification training of
staff who were separated from employment. All staff who could be responsible for the
supervision of youth received the required training. All instructors were qualified to deliver
trainings provided.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
Five staff records were reviewed for in-service training requirements. Each staff completed an
excess of the required twenty-four hours of annual in-service training, which included training in
all required topics. Each staff maintained required certifications. Two staff were applicable for
supervisory training and one staff completed ten hours of supervisor training in coaching,
leadership, and personal accountability. The remaining staff completed six of the required eight
hours of supervisory training. All training was documented in the Department’s Learning
Management System (SkillPro). All instructors were qualified to deliver trainings provided. The
program has an in-service training plan which was approved by the Department on December
23, 2023, and an in-service training calendar which is updated as changes occur.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures which outline the grievance process and required
staff training. The program’s grievance process includes informal, formal, and appeal phases
and associated timelines. All grievances are reviewed at morning management meetings and
assigned to administrative staff for response. A review of the program’s grievance
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 64 (Revised September 2022)
documentation confirmed the program maintains grievances for the past twelve months, which
included eight grievances across all program youth for the annual compliance review period.
Five of the grievances were reviewed and four of the five grievances were responded to within
the required time frame, one grievance was responded to four days late. Each grievance was
resolved during the formal phase. Six youth were interviewed, three youth from each side of the
program. Five of the six youth knew the grievance process included completion of grievance
forms, the remaining youth had not needed to complete a grievance. Each of the six youth
reported they could ask for assistance in completing a grievance. Six staff were interviewed,
three representing each side of the program. Each of the six staff reported the forms are posted
on the dorms, five staff reported the supervisor reviews grievances, four staff reported youth can
request assistance in completing the forms, and two staff indicated there were time frames
associated with the grievance process.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
A review of the program’s contract found all groups provided are either clinical or primary
services; therefore, delinquency intervention groups were not reviewed as part of the annual
compliance review. The program’s activity and group schedules confirmed groups are being
offered as required and in accordance with the program’s contract. The activity schedule
reflected youth are engaged in structured activities more than sixty percent of their awake
hours. The facility administrator was interviewed and reported the program provides Moral
Reconation Therapy, Impact of Crime, Skillstreaming the Adolescent, and Living in Balance. All
groups are provided by trained therapists or case managers. The designated mental health
clinician authority (DMHCA) was interviewed and confirmed the groups offered by the program
and indicated the clinical director provides supervision to therapists and conducts fidelity
monitoring of interventions.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures which outline life skills training shall be provided to all
youth and youth are assigned to life skills groups based on the specialized services they
receive. The program provides Skillstreaming the Adolescent as a life skills curriculum which is
a practice with demonstrated effectiveness. Skillstreaming the Adolescent is a primary service
for all youth components with the exception of the Intensive Mental Health (IMH) youth. The
Skillstreaming the Adolescent group addresses all required topics and is facilitated by trained
clinical staff. A review of group sign-in sheets verified the program is providing the group as
required for the IMH youth. The group is monitored by the Department’s Office of Programming
and Technical Assistance for the remaining youth components. In addition to Skillstreaming the
Adolescent, the program reported they offer Barbershop Talks for youth in which they invite
community partners to speak with youth in an informal barbershop setting to discuss different
life skills topics, utilize assessment tools to determine skills the youth need assistance with, and
include independent living goals on the treatment plans. The facility administrator was
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 64 (Revised September 2022)
interviewed and verified youth participate in groups facilitated by trained clinicians and
Barbershop Talks. The designated mental health clinician authority (DMHCA) was interviewed
and reported youth are able to practice skills learned throughout the day. Three youth were
interviewed and each reported they are given the opportunity to practice skills. Two of the three
youth also reported they complete substance abuse and Moral Reconantion Therapy (MRT)
groups and one youth reported they are given life skills packets.
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 offers Impact of Crime (IOC) groups for all youth which is a primary service for all
program components. The program facilitated restorative justice projects as a part of the Impact
of Crime groups, such as cleaning up the facility, victim letters, and picking up trash. The
program’s contract did not require additional restorative justice programming and the program
reported no additional restorative justice activities. Observations of restorative justice activities
were unable to be conducted during the annual compliance review week. The facility
administrator was interviewed and reported the youth participate in IOC and a restorative justice
project at the end of the group. The designated mental health clinician authority (DMHCA)
reported IOC is offered four times a week. Three youth were interviewed and each youth
verified they participated in IOC.
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 regarding the alert process which outline alerts shall
be consistent in the internal alert system and the Department’s Juvenile Justice Information
System (JJIS) and only authorized staff shall update or close applicable alerts. The program
utilizes an alert board in the staff break room to track all internal alerts. Five youth records were
reviewed with fourteen applicable alerts between them. Each alert was placed on the program’s
internal alert system and entered in JJIS on the same day the alert was initiated. Each
applicable alert was found in the program’s logbook. Only authorized staff entered, downgraded,
and closed alerts. The nurse was interviewed and reported nurses update medical alerts as
changes are made and the alerts are reviewed weekly. The facility administrator (FA) was
interviewed and reported alerts are reviewed at the morning management meetings. The FA
verified the program utilizes an alert board and all alerts should be reflected on the alert board,
in JJIS, and in the logbook. Three staff were reviewed and each reported learning of alerts in a
different manner, one reported master control knows the alerts and the supervisor will tell the
staff if a youth is not allowed to participate in something, one staff reported they would learn as
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they go, and the remaining staff reported medical tracks them. Two of the three staff also
discussed shift briefings cover alerts. One staff stated communication at the program is good,
one stated it is fair, and the remaining staff stated communication is very poor.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains separate individual management records, mental health records, and
Individual Healthcare Records. Five youth records were reviewed and each record is labeled
confidential and maintained in locked cabinets and offices marked as confidential. Each
individual management record includes all required information and is separated into required
sections.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program operates a Community Advisory Board which included representatives from all
required community partners. A review of sign-in sheets and meeting minutes confirmed
meetings were held hybrid in-person and by video conferencing at least quarterly during the
annual compliance review period. The facility administrator was interviewed and verified
meetings are held quarterly with all required parties and invitations are sent to solicit active
involvement from board members. A board member was interviewed and reported they work
with youth who have been discharged from the program and are over the age of eighteen. The
board member utilizes their role on the board to update the board on the youth and seek out
opportunities for the youth.
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 which outline performance evaluations will be
conducted ninety days after hire and annually thereafter. Position descriptions for four different
position types were reviewed and compared with the ten staff records reviewed and confirmed
staff were evaluated based on established performance standards. A review of the program’s
staff roster and contract confirmed all required positions were maintained with the exception of
three non-licensed therapists, which were added positions with the addition of two program
components, and one licensed therapist which has been vacant five months. The program
reported this position is being covered by the state clinical director. The facility administrator
was interviewed and reported turnover has decreased and the program’s staff morale
committee has implemented multiple initiatives to improve morale and recognize staff
performance. Three staff were interviewed and each reported they receive performance
evaluations every six months.
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1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s contract was reviewed for contract-specific requirements. Documentation
confirmed the program is providing each of the fifteen contract-required activities. The program
has agreements, sign-in sheets, and picture documentation of activities with Friends In Blue
through the St. Johns Sheriff’s Office, mentoring through Compassion St. Augustine, animal
assisted programming through the Hands and Feet Foundation, and First Coast Technical. The
program maintains spaces for youth to utilize as part of their behavior management system
including an enhanced basketball court, arcade, barbershop, diverse media center and music
studio. The nurses taught two classes with an infant simulator to instruct youth in caring for an
infant. Youth are provided required clothing, salad bowls with their meals, opportunities to
receive the iHope patch for fitness achievement, and input through the youth advisory board.
The program provided documentation they have leases for four passenger vans, exceeding the
contract requirement of three. A review of the program’s staff roster confirmed they have a
medical clerk and a physical plant worker with certifications in heating, ventilation, and air
conditioning (HVAC). The program utilizes recruitment and retention efforts confirmed through
their staff handbook. The facility administrator confirmed the contract-specific opportunities
offered to youth. Three youth were interviewed and none of the youth reported participating in
contract-specific activities; however, sign-in sheets, pictures, and agreements confirmed the
program is providing the activities as required.
1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
A review of youth records, certificates, sign-in sheets, and the program’s contract confirmed the
program is providing all required career and technical education (CTE) certifications. During the
annual compliance review period twenty-four youth received their Florida Ready to Work soft
Skills certification through online training. Certified program staff facilitated training in which 110
youth achieved their certification in first-aid/cardiopulmonary resuscitation (CPR). The Core
Group was utilized for 136 youth to complete their Occupational Safety and Health
Administration (OSHA)-10 certification. Seventy-two youth completed ServSafe through trained
SafeStaff facilitators. Sixteen youth completed Self Advocacy through EmployU. Seventeen
earned certifications through C-Tech programming which is facilitated by the program’s physical
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plant manager who is certified to facilitate the training. An additional five youth are currently
enrolled. Thirteen youth completed Express Yourself training in the music studio, facilitated by
the vocational instructor. One youth completed Integrative Behavioral Health through a referral
with vocational rehabilitation services. The program reported vocational services are completed
during youth leisure time or during the school day for EmployU and Florida Ready to Work
courses. The facility administrator confirmed the program’s CTE services. Three youth were
interviewed and none of the youth reported participating in the CTE services; however, sign-in
sheets and certifications confirmed the program is providing the CTE activities as required.
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 quality assurance program includes data collection, review and internal fidelity
monitoring and verification processes which address all components of the program including
but not limited to management accountability, living and treatment environment, case
management, delinquency interventions, mental health and substance abuse services, safety
and security, and health care services. Within these respective areas, routine reviews and
evaluations of youth care and services, client records, staff development, facility safety and
maintenance are conducted. Fidelity monitoring, peer review, and utilization reviews are also
completed. The program uses reporting systems to track key performance data and ensures the
timely review and communication of system data with program and corporate leadership teams
as well as the Department. Data collection includes daily management meeting reports, monthly
incident reports, corporate leadership data review, and monthly key performance indictor (KPI)
data. The data is utilized to make decisions within the program and improve performance in the
KPI data and performance standards.
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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 in place to address initial contact with each youth’s
parent/guardian, courts, and juvenile probation officer (JPO). Five youth case management
records were reviewed, each provided documentation which indicated contact with the
parent/guardian was initiated within twenty-four hours of youth arrival to the program. Reviewed
documentation also verified written notification was initiated with parent/guardian within forty-
eight hours of admission. Written notification was sent to the JPO and committing courts within
five working days of each youth’s admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures in place to address youth orientation. Five youth case
management records were reviewed, all five youth were oriented to the program on the day of
their admission. The program’s orientation topics included all required elements. The orientation
process was unable to be reviewed during the week of annual compliance as no youth were
scheduled for admission. Three interviewed youth stated their orientation began within twenty-
four hours of admission to the program which included program rules, procedures, and
schedule, and each was able to explain the orientation process.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures in place to address written consent of youth who are
eighteen years of age or older. A review of five youth case management records found only
one youth was applicable for youth eighteen of age or older. A request for two additional youth
case management records was made and provided by the program. All three applicable
reviewed records contained a signed written consent from each youth prior to providing or
discussing with the parent/guardian applicable information related to their mental health,
physical health, assessments, and treatments provided.
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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 in place detailing the classification process and
reassessments for each youth, which promotes safety and security, as well as effective delivery
of treatment services, based on determination of each youth’s individual needs and risk factors.
Five youth case management records were reviewed for classification requirements. The
program classification forms included all required elements. None of the five records were
applicable for having suicide or escape risks. One record was applicable for medical risk, as
was documented accordingly on the classification form. Documentation confirmed the
Department’s Juvenile Justice Information System (JJIS) alert list was reviewed for any alerts
affecting classification for all applicable records. All five records reflected youth were classified
for purposes of assigning them to a specified living area, sleeping rooms, and group. Risk
factors identified during admission screening or thereafter were immediately entered into the
program’s internal alert system and JJIS. Reassessments were completed for all five case
management records reviewed. Each record documented reassessment prior to increase in
youth privileges, and/or participation in work projects or other activities involving tools. None of
the youth reviewed were approved for off-campus activities. The facility administrator was
interviewed and was able to summarize the program’s classification system.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures in place to address gang identification and notification
to law enforcement of youth with gang affiliation or suspected gang affiliation. Five youth case
management records were reviewed and two were applicable for gang identification and
notification requirements. An additional record was requested and provided by the program. All
three applicable records included documentation of local law enforcement being notified of
suspected gang activity. Law enforcement was notified of gang affiliation in each youths’ home
county. Gang alerts were entered into the internal alert system and the Department’s Juvenile
Justice Information System (JJIS) upon identification. Information for each applicable youth’s
gang status was shared with the education provider and juvenile probation officer (JPO). None
of the three reviewed youth were applicable for having a post-residential counselor.
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2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures in place to address gang prevention and intervention
strategies, which include providing youth the opportunity to develop a plan to disassociate with a
criminal street gang, if one so desires. Five youth case management records were reviewed and
two were applicable for gang prevention and intervention activities. An additional record was
requested and provided by the program. All three applicable youth records reviewed had
evidence each youth participates in gang prevention and intervention strategies. Each of the
youth performance plans included goals and objectives related to gang intervention strategies
for youth to complete prior to program release. The program utilizes the Gang Resistance and
Drug Education (G.R.A.D.E.) curriculum as the gang intervention strategy, verified by group
sign-in sheet documentation, with no discrepancies noted. The program also includes goals and
activities on each youth’s performance plan associated to gang prevention and awareness as
well. The facility administrator was interviewed and stated the program facilitates monthly gang
intervention groups.
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 in place to address the Residential Assessment for
Youth (RAY). Five youth case management records were reviewed for completion requirements
of the RAY and reassessments. All five records reviewed had evidence of a RAY completed
within thirty days of each youth admission. Initial assessments were maintained in the
Department’s Juvenile Justice Information System (JJIS). Reassessments were completed for
four of five case management records reviewed. One was not applicable for needing a
reassessment. All four applicable reassessments were completed at least every ninety-days
after completion of the initial RAY. The program maintained all reassessment documentation in
each youth’s official case record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
The program has a policy and procedures in place to address the Youth Needs Assessment
Summary (YNAS). Five youth case management records were reviewed for completion
requirements of the YNAS. All five records reviewed had evidence the YNAS was completed
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within thirty-days of the youths’ admission. Each YNAS was documented in the Department’s
Juvenile Justice Information System (JJIS) as required.
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 in place for performance plan development. Five
youth case management records were reviewed for performance plan development, goals, and
transmittal documentation. Each record reviewed had evidence the Individualized Performance
Plan (IPP) was developed within thirty-days of the youth’s admission, and after the development
and completion of the initial Residential Assessment for Youth (RAY) and Youth Needs
Assessment Summary (YNAS). All applicable intervention and treatment team members were
present during the development of each IPP. Signatures of all required representatives were
documented, including the intervention and treatment team leader, youth, administration
representative, living unit representative, and treatment and education staff. Parents/guardians
participated by telephone during treatment team meetings. Signature sheets completed by
treatment team member representatives were filed in each youth’s official case management
record. A parent/guardian signature sheet was provided by mail to all parent/guardians;
however, none of the five youth records reviewed had evidence the youths’ parent/guardian
returned the signed signature sheet in the pre-stamped envelope provided by the program. All
five youth plans had individualized goals based on prioritized needs of each youth, reflecting
their risk and protective factors identified during the initial assessment process, and addressed
the youths’ top three criminogenic needs and delinquency interventions based on results from
the Residential Assessment for Youth (RAY), which are designed promote youth strengths and
skills while decreasing criminogenic risk factors. Target court-ordered sanctions were also
identified for all five youth IPPs reviewed. Each reviewed plan included transition activities
targeted for the last sixty days of the youth’s anticipated stay, as well as youth responsibilities
and target dates to accomplish their goals. Within ten working days of plan completion, there
was evidence a transmittal letter and copy of the plan were sent to all required parties and
stakeholders for each of the five youth records reviewed. Three youth were interviewed. Two of
three youth stated they participated in the development of their plan, knew their goals, and
received a copy of their performance plans. One youth stated they did not, however,
documentation in the youth record indicated they did participate in the development of their plan
and signed the plan acknowledging they reviewed and received a copy of their IPP.
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2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
Five youth case management records were reviewed for performance plan revision
requirements. Revisions were documented as completed for each youth to show demonstrated
progress towards goal completion as well as Residential Assessment for Youth (RAY)
Reassessment results. None of the five youth records reviewed were applicable for revisions
due to transition activities during the last sixty days of the youth’s commitment.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
Five youth case management records were reviewed for Performance Summary and transmittal
completion requirements. Three of the five youth had evidence of a Performance Summary
completed every ninety calendar days following the signing of the performance plan. The
remaining two youth were not applicable for completion of a Performance Summary due to not
enough sufficient time having passed since the signing of their initial performance plan and the
annual compliance review week. The three applicable Performance Summaries included all
required elements such as performance goal status, youth overall progress, level of motivation
and readiness to change, academic status, significant events, and interaction with staff and
peers. Reviewed documentation reflected in each of the three applicable records the youth were
allowed to read and add comments prior to signing and was provided a copy of the Performance
Summary. Each of the three records included evidence the original summary was filed in the
youth’s case management records. All Performance Summaries included signatures and dates
from all required parties. Within ten working days, a copy of the Performance Summary was
sent to the judge, juvenile probation officer, and parent/guardian or counselor in all three
records. Two closed youth records were reviewed for release summary requirements. In both
closed records there was evidence the original summary, along with justification for release,
was sent with the Pre-Release Notification (PRN) to the assigned juvenile probation officer
(JPO) at least forty-five days prior to the youths’ planned release. A signed copy of the PRN
was retained in both records. No court objections to release were documented. Once both of the
approved PRNs were received, the program provided written notification to the youth’s
parent/guardian regarding the planned release. For these two applicable records, the program
completed a Residential Assessment for Youth (RAY) exit assessment. Neither record was
applicable for victim notification.
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2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program encourages parent/guardian participation in case management services provided
for youth. A review of five case management youth records verified the program encouraged
and facilitated parent/guardian involvement in the assessment process, development of the
performance plan, progress reviews, and transition planning. If unable to attend scheduled
meetings, parents/guardians are given the opportunity to participate by telephone or video
conferencing, provide verbal and written input prior to meetings, and participate in family
visitation and family days. A treatment team meeting was unable to be observed as the program
informed there were none being conducted during the week of the annual compliance review.
Three interviewed youth confirmed their parent/guardian is involved in their case management
process, such as treatment planning and treatment team meetings. The facility administrator
was interviewed and stated families are encouraged to participate in monthly treatment team
meetings, quarterly held family days, monthly family forums, and weekly visitation.
2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
Five reviewed youth case management records included additional plans for academic and
treatment planning. All five performance plans referenced these applicable plans. Each
reviewed record referenced the mental health treatment plan. None of the records reviewed
were applicable for having a support plan through the Department of Children and Families
(DCF) and/or Agency for Persons with Disabilities (APD).
2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
Five youth case management records were reviewed. Each record indicated formal treatment
team meetings were held at least every thirty days. Reviewed documentation regarding formal
treatment team meetings process contained all required elements. Five records indicated
informal bi-weekly treatment team meeting were held as required. Documentation regarding
informal treatment team meetings included all the required elements of the process. All records
indicated youth’s parent/guardian, juvenile probation officer (JPO), and any other pertinent
party, through advanced notification, was invited and encouraged to participate and provide
input for each treatment team. A treatment team was not observable due to none being
scheduled during the week of the annual compliance review. Three youth were interviewed and
two stated they are given an opportunity to demonstrate the skills they have learned in the
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program and staff review performance, including progress on goals, positive and negative
behavior and treatment progress, during treatment teams. One youth reported staff did not
review performance or give them the opportunity to practice learned skills, however,
documentation verified the youth signed each treatment team review form indicating
demonstrated skills and performance were reviewed.
2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
A review of one case management record and two closed records was conducted to ensure the
intervention and treatment team planned for each youth’s successful transition to the community
upon release. Each record indicated the transition conference was held at least sixty days prior
to the youth’s targeted release date. Documentation also revealed the youth, treatment team
leader, and facility administrator attended the transition conference. Documentation indicated
the treatment team leader invited and encouraged participation from each youth’s juvenile
probation officer (JPO), parent/guardian, education staff, and any other pertinent party, if
applicable. All records indicated during the transition conference the youth’s revised
performance plan was reviewed for transition activities, which identified target dates and the
individual responsible for completion. Documentation indicated the treatment team leader
obtained signatures from all attendees to represent their acknowledgment and accountability of
transition goals. Documentation did reveal a copy of the plan was sent to non-attendees with a
request for return signature. Reviewed records indicated a copy of the returned email
acknowledgment receipt was printed and filed along with the plan for plans transmitted
electronically to the JPO. Documentation reviewed in each record evidenced an invitation to the
Community Re-Entry Team (CRT) for participation was received. The CRT meeting was
conducted prior to youth’s release and the youth and case manager participated.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The youth in the program were not admitted until after September 2023 when the contract was
amended to add the program components; therefore, only two closed youth records were
applicable for review of exit portfolios during the annual compliance review period. Both records
indicated the exit portfolio was discussed and initiated during the transition conference. A
records review indicated the youth’s exit portfolio contained a birth certificate, state issued
identification, copy of the transition plan, a calendar with all dates, times, and locations of
upcoming community appointments, educational/vocational certificates earned in the program,
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all education records, school transcripts, a résumé, and a sample employment application.
Documentation indicated the exit portfolio was verified during the exit conference as well as
completed and given to the youth upon release. Both records reflected program staff did forward
exit portfolio information to the juvenile probation officer (JPO). The program’s contract included
two additional requirements of an i-Home Experience Exit Portfolio for each youth and weekly
follow-up checks for thirty days after release. The program provides each youth with an i-Home
Experience Exit Portfolio binder at admission to capture all requirements and accomplishments
while in the program. Observations confirmed all youth are provided with a binder to transition
home with once released. Documentation confirmed the transition specialist or case manager
conducted post-release weekly follow-ups for both youth released during the annual compliance
review period.
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The youth in the program were not admitted until after September 2023 when the contract was
amended to add the program components; therefore, only two closed youth records were
eligible for review of exit conferences during the annual compliance review period. Both records
indicated the exit conference was held after the program notified the juvenile probation officer
(JPO), at least fourteen days prior to youth release, and contained signatures of attendees and
date the conference was held. Records confirmed each youth’s date of admission and date of
termination correlated with the Department’s Juvenile Justice Information System (JJIS).
Documentation indicated transition activities and plans established at the transition conference
were finalized during the exit conference. A review of both records verified the exit conference
was held separately from the transition and CRT meetings and was attended by the youth, JPO,
parent/guardian, educational representative, and treatment team leader.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program’s formal process to promote constructive input from youth consists of a variety of
youth surveys, including quarterly and exit surveys, weekly meetings, monthly youth advisory
board meetings, Speak-Out forms, and the Trauma Responsive and Caring Environment
(TRACE) assessment. Documentation confirmed the program completed quarterly and exit
youth surveys and the TRACE assessment to gather input information. A review of Speak-Out
forms, weekly house meetings, and bi-weekly youth advisory board meetings verified the
program’s process to promote input from the youth, with the exception of one weekly house
meeting, which could not be verified through a sign-in sheet. Three interviewed youth reported
they provide input about what happens at the facility through speak-outs. The facility
administrator was interviewed and confirmed the program’s policy.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures to provide career education based on age and is
appropriate for the educational abilities of the youth in the program. The program provides Type
2 career education development. An interview with the facility administrator and lead educator
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indicated the program provides career education services through Employ-U, Florida Ready to
Work, C-Tech, and Upper Iowa University. They also provide certifications in first-
aid/cardiopulmonary resuscitation (CPR)/automated external defibrillator (AED), Occupational
Safety and Health Administration (OSHA) 10, and ServSafe. One closed youth record was
reviewed and included a job application, résumé, and contact information with the local Career
Source Center. There was documentation in the record indicating the youth's parent/guardian
and juvenile probation officer (JPO) were aware of the vocational plan for the youth. The record
also included a state identification card (ID) and contained certifications in ServSafe and first-
aid/CPR. No additional records were available for review as the youth in the program were all
admitted after September 2023 and no youth had been discharged. One additional youth was
discharged during the annual compliance review week; however, the record was not available
for education to review while they were on-site.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide educational access. The center provides
education services through TrueCore Behavioral Solutions and the 250-day calendar,
distributed over twelve months, and includes ten days used for teacher training and planning. A
review of the daily school schedule revealed the center provides six fifty-minute classes fulfilling
the weekly requirement of twenty-five hours of instructional time. The interview with the lead
teacher indicated all the youth receive credit for a completed course. The lead teacher also
reported the school schedule is adhered to. Three youth were interviewed, two reported there
were no interruptions in school, and one reported there were interruptions due to youth fighting.
The Department’s Office of Education noted an issue with the educational access due to the
school provider having teacher vacancies. This issue was addressed through the Department’s
Office of Education, the program, and the school provider; therefore, all reviewed logbook and
video samples were after the issue was corrected on March 1, 2024. A review of seven
randomly selected days in the logbook indicated that education classes started on time on two
days. The other days showed classes started two to eighteen minutes late. On those days the
school day was extended. It should be noted the logbook entries for all the days reviewed were
missing documentation of class movement throughout the school day. Observations of the
program video on three days indicated school started and ended on time and classes followed
the school schedule.
2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program has a policy and procedures requiring an Education Transition Plan to be
developed upon each youth’s admission. One closed youth case management record was
reviewed. There were no additional youth discharged during the annual compliance review
period to review as none of the program youth were admitted until after September 2023. The
youth record included an individual Education Transition Plan developed upon entry, including
the youth’s post-release goals, meeting the required elements. The youth record contained an
Exit Plan indicating the case manager, parent/guardian, and youth were all aware of the plan.
Included in each record was an Electronic Educational Exit Plan (EEEP) which identified the
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next educational placement information and input from the post-release school district
representative. Three interviewed youth reported they participated in the planning of their
Education Transition Plan. Two of the three interviewed youth reported the program was not
preparing them well when it came to high school, high school equivalency diploma GED),
vocational school, employment, and/or college due to not doing work for their age. One youth
reported the program was preparing them well.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program has a designated mental health clinical authority (DMHCA) who is a psychologist
with a clear and active license with an expiration date of May 31, 2024, as required by the
program’s contract. A review of the position description confirmed the DMHCA is a full-time staff
who works at least forty-hours a week and is responsible for the coordination and
implementation of clinical services at the program. The program utilizes a back-up DMHCA who
is the assistant clinical director (ACD). The back-up DMHCA is a licensed mental health
counselor (LMHC) with a clear and active license in the State of Florida which expires March 31,
2025.
The DMHCA indicated they provide clinical supervision for non-licensed mental health
professionals, provide weekly group schedules, and monthly fidelity and feedback. The DMHCA
submits a monthly service calendar of scheduled individual and family sessions to the clinical
director or designee. During the intake process, the licensed mental health professional (LMHP)
gathers current information from the youth and within the first five days of admission. The LMHP
also confirms youth reports by referring to collateral information obtained in the Department’s
Juvenile Justice Information System and completes the Brief Behavioral Health Status Exam.
The LMHP completes and/or reviews all Assessments of Suicide Risk (ASRs). The LMHP also
provides any group therapy, individual/family therapy, and any needed clinical service in the
absence of a therapist.
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 maintains a policy and procedures ensuring mental health and substance abuse
services are provided by individuals with appropriate qualifications. The clinical supervisor
ensures the licensed clinical staff working under their supervision are performing services they
are qualified to provide based on education, training, and experience, which was determined by
a review of job descriptions and an informal interview with the designated mental health clinician
authority (DMHCA). The licensed mental health and substance abuse clinical staffing is in
accordance with the current contract and Florida Administrative Code. Copies of the licenses
were available on-site. Licenses of all licensed mental health professionals and licensed
qualified professionals employed at the program during the annual compliance review period
were reviewed and found to be clear and active. The program’s contract requires two assistant
clinical directors and one additional licensed therapist. A review of the staff roster and licenses
found the program had two assistant clinical directors; however, the licensed therapist position
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has been vacant since October 3, 2023. The provider’s director of mental health is currently
assigned to the program providing coverage.
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 maintains a policy and procedures ensuring mental health and substance abuse
services are provided by individuals with appropriate qualifications. The clinical supervisor
assures the non-licensed clinical staff working under their supervision are performing services
they are qualified to provide based on education, training, and experience based on a review of
job descriptions and an informal interview with the designated mental health clinician authority
(DMHCA). The program had seven non-licensed master’s-level clinical staff at the time of the
annual compliance review. The program had three vacancies for therapist positions which were
open for twenty-eight, fifty, and eighty-one days. During the annual compliance review period,
the program had six additional non-licensed master’s-level clinicians who provided services but
were no longer with the program. A review of the clinician’s credentials found each was qualified
to provide services based on their education, training, experience, and the contractual
requirements. The reviewed documentation reflected each non-licensed mental health clinical
staff working under the direct supervision of a licensed mental health professional received a
minimum of one hour a week 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, as required. Direct
supervision was recorded on a form which included all elements of the Department’s Licensed
Mental Health Professionals and Licensed/Certified Substance Abuse Professionals Direct
Supervision Log form. The program has a Chapter 397 license which expires April 1, 2025. The
program’s staffing roster was reviewed and showed the program employs two recreational
therapists. Both recreational therapist’s credentials, schedule, and services provided to youth
were reviewed and requirements were met as outlined in the contract. The non-licensed mental
health and substance abuse clinical staffing is in accordance with current contract to include the
number of hours.
All seven non-licensed mental health clinical staff hold a master’s-level degree from an
accredited university or college in the field of counseling, social work, psychology, or related
human services field. The non-licensed substance abuse clinical staff provide substance abuse
services in the program which is licensed under Chapter 397, Florida Statute. All seven
employed non-licensed mental health clinical staff who conducted Assessments of Suicide Risk
completed twenty hours of training and supervised experience in assessing suicide risk, mental
health crisis intervention, and emergency mental health services, as required. A review of the
six non-licensed staff no longer employed at the program confirmed they also completed twenty-
hours of training and supervised experience in assessing suicide risk, mental health crisis
intervention, and emergency mental health services, as required.
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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.
Five youth mental health records were reviewed. All five youth had a Massachusetts Youth
Screening Instrument, Second Version (MAYSI-2) completed during admission. The screener
reviewed available information to include the commitment packet, and reports and/or records for
existing documentation of mental health or substance abuse problems or history of human
trafficking in all five records. All five records included the date of completion. For three records,
the screenings were completed in full. The remaining two records did not include the name of
the staff completing the form, but included all other elements required in the form. Screenings
were completed in the Department’s Juvenile Justice Information System (JJIS) on the day of
admission, in a confidential manner, for all five records. Three of the records were verified to be
completed by trained staff, the two records which did not include a staff name were unable to be
verified for completion by a trained staff. All five MAYSI-2s indicated further assessment was
required and a referral was made for further evaluation which included the referral reason in all
five records. When the MAYSI-2 or other admission information indicated the need for an
assessment, crisis intervention, or emergency services, the facility administrator (FA) or
designee was notified, and a referral was made to alert the DMHCA in all five records. None of
the youth reviewed had a hit on the MAYSI-2 for suicide ideation. All five records had a referral
for a comprehensive assessment and documented the reason for referral.
The FA is responsible for developing written facility operating procedures for the implementation
of a standardized admission/intake mental health and substance abuse screening process. The
program’s policy addresses the standardized screening process which includes review of
commitment packet information, reports, and records; administration of the MAYSI-2 in JJIS or
Clinical Mental Health Screening by a licensed mental health professional and Clinical
Substance Abuse Screening by a qualified professional, and referral of juvenile offenders
identified by screenings as in need of further evaluation or immediate attention. The policy also
includes staff training in mental health and substance abuse issues and administration of the
MAYSI-2, and a standardized process for referral of youth identified as in-need of further mental
health and/or substance abuse evaluation to an appropriate service provider/professional or,
when immediate attention is needed, to a hospital or Baker Act or Marchman Act receiving
facility.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
Five youth records were reviewed for mental health and substance abuse
assessments/evaluations. The program completed a new, combined mental health and
substance abuse evaluation for all five youth. The new evaluations were completed within thirty
days of admission for all five records. Non-licensed mental health clinical staff or non-licensed
substance abuse clinical staff completed the evaluations. All five evaluations were reviewed and
signed by a licensed mental health professional or licensed qualified professional respectively,
within ten calendar days after the evaluation was conducted. All five new combined mental
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health and substance abuse evaluations included identifying information, reasons for the
evaluation, methods of assessment, patterns of alcohol and drug use, impact of alcohol and
drug use on major life areas, risk factors, relevant background information, behavioral
observations, Mental Status Examination, interview or procedures administered, discussion of
findings, diagnostic impression/formulation including diagnosis, and recommendations. Consent
was obtained for all five youth for substance abuse services.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
Five youth records were reviewed for mental health and substance abuse treatment. All five
youth had an initial treatment plan developed within seven days of the initiation of treatment on
a form which included all elements of the Department’s Initial Mental Health/Substance Abuse
Treatment Plan form. The initial combined mental health and substance abuse treatment plan
was developed within seven days of the onset of treatment, or for youth prescribed psychotropic
medication, within seven days of the initial psychiatric diagnostic interview in all five records. All
five initial treatment plans were signed by the mental health or substance abuse clinical staff
completing the form. All five plans were completed by non-licensed clinical staff. All five plans
were reviewed and signed by the clinical supervisor within ten days of completion. All five plans
were also signed by all treatment team members who participated in the development of the
plan, the youth, and parent/guardians who participated by telephone. Initial treatment plans
included the youth’s psychiatric needs (when applicable), including medication and frequency of
monitoring by the psychiatrist in all five records. Four of five individualized treatment plans were
developed for the youth within thirty days of admission. The remaining individualized treatment
plan was completed four days late. The individualized treatment plans were developed on a
form which included all the elements of the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan form in all five records. All five individualized treatment
plans were signed by the mental health or substance abuse clinical staff completing the plan. All
five plans were completed by a non-licensed staff, and the plans were reviewed and signed by
the licensed supervisor within ten days of completion. Individualized treatment plans were
signed by all treatment team members who participated in development of the plan, the youth,
and parent/guardian in all five records. The individualized treatment plans included psychiatric
services, including psychotropic medication and frequency of monitoring by the psychiatrist for
youth who received psychotropic medication in all five records. Individualized treatment plan
reviews were completed on a form which included all the elements of the Department’s
Individualized Mental Health/Substance Abuse Treatment Plan Review form in all five records.
Treatment plan reviews were completed every thirty days for all five records, as required. Goals
and objectives were individualized for each youth to include individual, group, family, and
psychiatric services/medication monitoring, for all five records. A comparison of video to the
logbooks and sign-in sheets showed groups were conducted for the required group time/length
and documentation and video review verified the facilitator remained constant.
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3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
Five youth records were reviewed for treatment and discharge planning. All five youth were
assigned a treatment team upon arrival to the program. Reviewed documentation reflected the
youth, program administration, residential living unit, education, medical, mental health and
substance abuse staff, vocational staff when applicable, and parent/guardians were in
attendance in all five records. Four of five youth were determined in need of substance abuse
treatment and receive individual, group, and/or family counseling provided by a licensed
qualified professional or a non-licensed substance abuse clinical staff in accordance with the
youth’s initial or individualized substance abuse treatment plan. All five youth receive mental
health treatment and had a properly executed Authority for Evaluation and Treatment (AET)
form in their record. Four of five youth were receiving substance abuse treatment, but all five
provided consent for substance abuser services through a signed Youth Consent for Substance
Abuse Treatment form. Mental health treatment notes or substance abuse treatment notes were
documented on the Department’s Counseling/Therapy Progress Notes form in all five records
reviewed. Mental health and substance abuse group therapy included individual psychotherapy
or counseling and psychosocial skills training which includes therapeutic activities designed to
address specific skill deficits or maladaptive behaviors and promote skill development and
improved functioning of youth with mental disorders for all five records reviewed. A review of
progress notes determined all five youth received services as stipulated on the treatment plan.
Only two youth have been discharged from the program during the annual compliance review
period, as such, the program had no additional records for review. The two available records
were reviewed and showed both discharge plans were documented on the Department’s Mental
Health/Substance Abuse (MHSA) Treatment Discharge Summary form. Neither youth was
released while on suicide precautions. The MH/SA Treatment Discharge Summary documented
the services needed for daily maintenance of the positive improvement in behavioral, emotional,
and social skills made by the youth during treatment for both records reviewed. A review of
documentation reflected both discharge plans were discussed with the youth, parent/guardian,
and juvenile probation officer (JPO) during the exit conference, and a copy was provided to all
three parties.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program provides mental health overlay services (MHOS) and substance abuse overlay
services (SAOS) to youth. The program’s contractually required clinical groups include Moral
Reconation Therapy (MRT), Skillstreaming the Adolescent, and Living in Balance. A review of
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documentation confirmed the program provides MHOS which includes individual, group, and
family therapy at least five days a week, and are conducted an average of seven days a week.
The program provides individual, group, and/or family counseling to each youth as part of the
individualized treatment plan. Daily therapeutic activities such as psychosocial skills training,
psychoeducation, and supportive counseling are provided by mental health clinical staff. Youth
with co-occurring substance abuse disorders receive substance abuse services. The program
maintains a psychologist on staff to provide services as needed. Counselor caseloads are
limited to no more than sixteen youth, as required by contract, with an average caseload of ten.
Therapy groups are limited to ten or fewer for mental health treatment groups. Substance abuse
groups are provided by the clinical director, assistant clinical director, psychologist, or
therapists. Staff are qualified to provide substance abuse education.
As part of SAOS, the program provides urinalysis drug testing, with positive tests followed by
appropriate clinical intervention and sanctions including drug screening upon the youth’s initial
intake into the program. The program provides substance abuse treatment services to include
individual, group, and family therapy as part of each youth’s treatment plan. Each youth
receives individual, group, or family therapy at least five times a week. Group therapy is limited
to no more than fifteen participants. Each youth receives daily therapeutic activities such as
substance abuse education, relapse prevention, substance refusal skills, and coping skills.
Youth with co-occurring mental health disorders also receive mental health treatment. A
licensed psychiatrist provides psychiatric evaluations and medication management, and
participates in treatment planning. Substance abuse clinical staff are on-site seven days a week.
Counselor caseloads are limited to no more than sixteen youth for SAOS.
Three interviewed youth stated they participate in family counseling monthly, and two of the
youth additionally stated they participate in individual counseling services weekly as well. Three
interviewed staff denied direct care staff facilitate groups and confirmed therapists or counselors
conduct the groups. An interview with the designated mental health clinician authority (DMHCA)
confirmed the program provides MHOS and SAOS. The facility administrator stated the youth
are provided group, individual, and family counseling sessions.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
Psychiatric services are provided by two psychiatrists who both possess a clear and active
license in the State of Florida, both expiring January 31, 2026. The psychiatrists are available
for emergency consultation twenty-four hours a day, seven days a week. The psychiatrists
providing psychiatric services brief a representative of the treatment team regarding the
psychiatric status of each youth receiving psychiatric services who is scheduled for treatment
team review. The psychiatrists’ evaluations and recommendations for the youth are
incorporated into the mental health clinical staff’s evaluations of the youth and the youth’s
individualized mental health or substance abuse treatment plan. A review of sign-in/out logs
confirmed visits during the annual compliance review period were conducted as required by the
contract for both psychiatrists. The psychiatrists actively participate in, manage, and supervise
psychotropic medication services in the program. The program did not use a back-up
psychiatrist during the annual compliance review period.
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An interview with one of the psychiatrists confirmed their role at the program is to perform initial
psychiatric evaluations and diagnoses for youth within thirty days of arrival or within two weeks
of arrival if the youth is on medication at the time of admission. Collateral information is obtained
with informed consent, when necessary, from the parent/guardian or adult youth for any new
medication or for any significant change in dosage. If medications have adverse side effects,
non-compliance, or are no longer necessary, the psychiatrist will attempt to inform/discuss with
the parent/guardian prior to discontinuation when possible. Youth on medications are seen by
appointment at least monthly and more often than monthly when clinically indicated. The
psychiatrist also confirmed they perform diagnostic evaluation services, psychiatric care and
treatment, provide consultation and approve treatment plans. Medication management is
provided for youth who arrive to the program on medication or are placed on medication. The
psychiatrists also provide in-service training when designated by the facility administrator or
clinical director. The psychiatrists meet with the clinical director at least weekly and attend a
clinical staff meeting with the entire clinical staff and clinical director bi-weekly or monthly.
Formalized procedures are in place with the healthcare staff to review the important medical
issues pertaining to youth at the program receiving psychiatric services. The psychiatrists
communicate face-to-face with therapists at least once on each clinical day and are available
twenty-four hours a day, seven days a week by phone when requested. The psychiatrist did not
have any concerns with mental health or substance abuse services at the program during the
review. An interview with the designated mental health clinician authority (DMHCA) determined
the licensed mental health professional meets with the psychiatrists two times each week.
Five youth records were reviewed for psychiatric services. Four youth were admitted on
psychotropic medications, but all five received a diagnostic interview within fourteen days of
admission. One youth was prescribed medications after the initial interview. All five initial
diagnostic interviews included the youths’ history, Mental Status Examination, Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) diagnosis consistent with the
youth’s treatment plan, treatment recommendations, prescribed medications, explanation of the
need for psychotropic medication related to the youth’s diagnosis, target symptoms, initial
treatment goals, potential side effects, risks and benefits of taking the medication, and
frequency of medication monitoring/management. The initial diagnostic psychiatric interview
was documented on the Department’s Clinical Psychotropic Progress Note (CPPN) form in all
five records reviewed. The CPPN forms were clearly identified as an “Initial Diagnostic
Psychiatric Interview” in all five records. When the initial psychiatric diagnostic interview resulted
in the prescription of psychotropic medications or changes to the youth’s existing psychotropic
medication regimen, page three of the CPPN was completed, regardless of the format used to
document the psychiatric interview, for all five records. All five youth were receiving medication.
Medication reviews were conducted monthly as required for four of five youth. One youth had
one medication review which was three days late. The psychiatric evaluation was documented
on the Department’s CPPN form and included all three pages in all five youth records. When the
psychiatric evaluation resulted in the prescription of psychotropic medication or changes to the
youth’s existing psychotropic medication, page three of the CPPN was completed in all five
records reviewed. None of the youth had an updated psychiatric evaluation completed; all youth
had a new evaluation. When psychotropic medication was prescribed/dispensed/administered
by the psychiatrist, identifying data, diagnosis, target symptoms of each medication, evaluation
and description of the effect of prescribed medication on target symptoms, prescribed
psychotropic medication information including the name, dosage and quantity of the medication,
normal dosage range, ordered dosage, frequency and route of administration, and reasons for
changes in medication and/or dosage were documented in all five records. The youth’s
adherence to the medication regimen, height, weight, blood pressure, most recent serum drug
levels or laboratory findings, when appropriate, telephone contact with the youth’s
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parent/guardian to discuss medication, signature of the psychiatrist and date of signature were
also documented in all five youth records. The psychiatrist and nursing staff have documented
monitoring for Tardive Dyskinesia on a monthly basis as indicated on the CPPN in all five
records reviewed. The program did not use tele-psychiatry.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a written plan detailing suicide prevention procedures. The plan includes
identification and assessment of youth at-risk of suicide, staff training of six hours annually
including two hours of web-based and four hours of instructor-led training, drills for all staff on
each shift, suicide precautions, levels of supervision including one-to-one supervision, constant
supervision, and close supervision, referrals, communication, notification, documentation,
immediate staff response, and a review process. The review process for suicide attempts and
mortality review includes circumstances surrounding the event, facility procedures relevant to
the incident, all relevant training received by involved staff, pertinent medical and mental health
services involving the victim, possible precipitating factors, and recommendations, if any, for
changes in policy, training, physical plant, medical or mental health services, and/or operational
procedures. The Suicide Prevention Plan is reviewed annually and was last reviewed March 25,
2024, by the designated mental health clinician authority (DMHCA), facility administrator, and
corporate staff.
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 include completing a thorough review of
existing and available documentation and administering a Massachusetts Youth Screening
Instrument, Second Version (MAYSI-2) and Suicide Risk Assessment at admission. Five youth
records were reviewed for suicide prevention services, but none were applicable. No youth were
placed on precautionary observation during the annual compliance review period, as such, there
were no records available for review.
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3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program has a policy and procedures which outline when a youth is placed on suicide
precautions, they shall be maintained on one-to-one or constant supervision. The staff assigned
to observe the youth shall provide the appropriate level of supervision and record observations
of the youth's behavior at intervals of thirty minutes, at a minimum. Five youth records were
reviewed for suicide prevention services, but none were applicable. No youth were placed on
precautionary observation during the annual compliance review period, as such, there were no
records available for review.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a policy and procedures for suicide prevention training for staff. Twenty
staff training records (ten pre-service and ten in-service) were reviewed for suicide prevention
training. All twenty staff received suicide prevention training. The program maintains three
suicide kits in the program. All suicide kits are located on the youth living modules. Two dorms
have suicide kits co-located with first-aid kits. One dorm only has suicide kits. Revewied
documentation confirmed the program is conducting mock suicide drills, at least once a quarter
on each shift for all staff who come in contact with the youth. The program conducted mock
suicide drills each month for each shift during the annual compliance review period. All mock
mental health drills included a suicide attempt or serious self-injury. No youth were used during
the mental health drills. After each drill, the program provided training on the emergency
response procedures. The program documented on each drill form “areas of improvement”. This
information was then reviewed with the staff who participated in the drill and during all staff
meetings as documented on the reviewed drill forms. If there were staff who were not present
during a quarterly drill, they did have an opportunity to review the 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. The facility
administrator reported they maintain a monthly drill calendar which includes mental health drills
and response to suicide attempts. A review of each drill is also completed during the monthly
all-staff meetings. Three staff reported staff are to notify mental health staff and the youth is to
be put on constant sight and sound if a youth expresses suicidal thoughts. Two staff reported
the staff document the supervision. One staff additionally reported the staff talk with the youth
and go over coping skills. Two staff reported the suicide kits are in medical and all three staff
reported the kits are on each of the dorms. All three staff reported drills are conducted on a
monthly basis. One staff went on to state, drills may be conducted twice a month or more.
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3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has an integrated mental health crisis Intervention and emergency mental health
and substance abuse services plan which includes notification and alert system, means of
referral, including youth self-referral, communication, supervision, documentation, and review.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has an integrated mental health crisis intervention and emergency mental health
and substance abuse services plan which was reviewed and approved by the facility
administrator and designated corporate staff on March 25, 2024. None of the five reviewed
youth mental health and substance abuse records were applicable for requiring a Crisis
Assessment. The program reported there were no applicable Crisis Assessments conducted
since the last annual compliance review.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has an integrated mental health crisis intervention and emergency mental health
and substance abuse services plan which includes immediate staff response, notifications,
communication, supervision, authorization to transport for emergency mental health and
substance abuse services, transport for emergency mental health evaluation and treatment
under Chapter 394, Florida’s Baker Act, transport for emergency substance abuse assessment
and treatment under Chapter 397, Marchman Act, documentation, training, and review.
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3.17 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a policy and procedures addressing the safety planning process. A
review of five youth safety plans showed all five plans included warning signs, youth’s baseline
behavior(s) as gathered from collateral contacts, parent/guardian input, youth’s history, and
evaluations, if applicable. All five plans also included crisis recognition, intervention strategies,
debriefing preferences, and crisis recognition. All five safety plans were developed on the day of
admission; therefore, meeting the fourteen-day time frame. All five plans were jointly prepared
by the youth, program’s clinical staff and other applicable staff involved with the treatment of the
youth. None of the youth’s parents/guardians provided input on the youth’s safety plans,
however, the program provided a means for the parents/guardian to provide input. All five safety
plans incorporated recommendations from previous or current clinical assessments or screening
instruments and incorporated trauma responsive practices. All five plans were reviewed and
updated as necessary at least every thirty days. All five plans were reviewed and updated as
necessary following any significant behavioral or mental health event identified by the youth’s
intervention and treatment team. The safety plans are reviewed by staff who have contact with
the youth and are maintained in the youth’s mental health record and in a binder in master
control. Three youth were interviewed. All three youth confirmed they contributed to their safety
plans. Three staff were interviewed, one staff stated they reviewed plans when they were first
hired and during their evaluation last week, one stated two to three months ago, and one stated
three months ago. An interview with the facility administrator confirmed safety plans are updated
during each treatment team, or as needed.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program’s designated health authority (DHA) is a licensed physician who holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
Florida. The DHA’s license expires on March 31, 2024. The DHA’s specialty training is in family
practice with experience in adolescent health. The DHA does not have any disciplinary cases or
public health complaints on record. According to the contract, the DHA is required to be on-site
one hour each day five days a week. A review of the sign-in sheets for the annual compliance
review period indicated the DHA was on-site, as required. If the DHA has a scheduled absence,
the program has an agreement with another licensed physician to provide medical care to the
youth. The back-up physician holds a clear and active unrestricted license, which expires on
January 31, 2026, and meets all requirements for independent and unsupervised practice in the
State of Florida. The back-up physician was not utilized during the annual compliance review
period. The DHA reviewed facility procedures, as documented by signature and date. There
were no inclusions of telemedicine in the facility’s contract. The DHA was interviewed, and
responsibilities include performing Comprehensive Physical Assessments upon intake, review
health related history, chart review, lab review, provides medical care, and reviews policy and
procedures.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has two licensed practical nurses (LPNs) and five registered nurses (RNs), and
one of the RNs serves as the health services administrator (HSA). A review of each RN’s
license credentials reflected each of the nurses have a clear and active license, in the State of
Florida, according to the Florida Department of Health Medical Quality Assurance website with
current expiration dates. In addition, each of the LPNs and RNs have current cardiopulmonary
resuscitation (CPR) certifications. The required on-site hours according to the contract are
seven days a week for a total of 220 hours. The nursing staff is in compliance with the
contractual requirements and nursing coverage is provided twenty-four hours a day as required
by the program’s contract.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has a policy and procedures for all health-related protocols utilized at the program.
The designated health authority (DHA) and facility administrator (FA) signed and dated all
treatment protocols. The DHA and FA reviewed and signed protocols and facility operating
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procedures (FOPs) on January 19, 2024. FOPs and protocols related to psychiatric services
and psychotropic medication management are developed and reviewed by the program’s
psychiatrist. The psychiatrist reviewed and signed the psychiatric protocols on January 19,
2024. The nursing protocols were signed by the nursing staff on January 26, 2024. There were
no new policies or changes in policy made during the annual compliance review period. An
annual review of all FOPs and protocols were signed by the respective individuals from each
discipline on February 6, 2024, signifying their understanding of the FOPs and any new health-
related Department policies. All newly hired medical staff receive a comprehensive clinical
orientation to the Department’s healthcare policies and procedures conducted by the registered
nurse (RN). The DHA had written and authorized approval of treatment protocols and standing
procedures which 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.
Five youth Individual Healthcare records (IHCRs) were reviewed for completion of the Authority
for Evaluation and Treatment (AET), three of which were applicable. Each of the three
applicable IHCRs included a valid AET which was signed by the youth’s parent/guardian and
Department representative and cleared marked as a copy. One youth was eighteen and signed
a consent for release of information. The remaining youth was in the custody of the Department
of Children and Families (DCF) and the youth’s IHCR contained a valid court order authorizing
treatment. An interview with the registered nurse (RN) advised if the AET is not included,
contact is made with the juvenile probation officer (JPO) to obtain it. Once a youth turns
eighteen, a release of information is completed.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
Five youth Individual Healthcare Records (IHCRs) were reviewed for parental consents. Three
youth were applicable for new medications and one youth was applicable for an over-the-
counter (OTC) medication beyond what is covered on the Authority for Evaluation and
Treatment (AET). Each youth’s parent/guardian authorized the medication and was mailed a
written notification on the required Department form. Four youth were applicable for being
admitted with psychotropic medications and one youth later received psychotropic medications.
Two of the youth’s IHCRs included documentation the parent/guardian gave verbal consent by
telephone, which was written, and were mailed a copy of the Clinical Psychotropic Progress
Note (CPPN), page three. One youth was in the custody of the Department of Children and
Families (DCF) and treatment was authorized by a court order, and the remaining youth was
eighteen years of age. There was no documentation in the remaining applicable youth’s IHCR
the program received consent from the youth’s parent/guardian or they were mailed a copy of
the CPPN, page three. Each of the five reviewed youth IHCRs contained copies of the youth’s
vaccination records which were reviewed by nursing staff within the required time frame. Two
youth were applicable for vaccinations and consent was obtained; however, the immunizations
were not administered within thirty days of admission. One youth’s vaccination was
administered fifty-six days late and the remaining youth’s vaccination was administered forty-
four days later. None of the youth were applicable for religious exemption from immunizations.
An interview with the registered nurse (RN) confirmed verbal consent is required when youth
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are starting a new medication, which is witnessed by another nurse. Parental/guardian
notification is sent as well. Written consent is required for any invasive dental procedures,
surgeries, and vaccines. Parental/guardian notifications and verbal notifications are also made
when a youth has a psychiatric medication change, is seen by an off-site provider, or has
imaging completed. The RN reported a parental/guardian notification and a copy of the CPPN,
page three are mailed to the parent with any change to psychotropic medications and the
psychiatrist contacts the parent/guardian for verbal consent and documents.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
Five youth Individual Healthcare Records (IHCRs) were reviewed for Facility Entry Physical
Health Screening (FEPHS) forms. Each IHCR contained a FEPHS completed on the day of
admission by a registered nurse (RN). One youth was applicable for a change in physical
custody beyond twenty-four hours and a RN completed a rescreening as required. An interview
with the RN advised notification is received by email when a youth is admitted to the program. A
nurse completes the FEPHS on the day of admission.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
Five youth Individual Healthcare Records (IHCRs) were reviewed for healthcare orientation and
each youth received an orientation within the required time frame as verified by the youth’s
signature on the Health Education form. The healthcare education included all 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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for notification to the
designated health authority (DHA). Three youth were applicable for chronic conditions and none
of the youth were in need of emergency care. Each of the three applicable youth’s IHCRs
documented the DHA was notified on the day of admission. Three youth were applicable for
taking psychotropic medications upon admission and the psychiatrist was notified of each
youth’s admission as required. The registered nurse (RN) was interviewed and reported the
DHA is notified by phone or while on-site once the youth’s intake is completed.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
Five youth Individual Healthcare Records (IHCRs) were reviewed and each IHCR included a
Health-Related History form which was completed on the day of each youth’s admission by a
registered nurse (RN). Each HRH was reviewed by the designated health authority (DHA) prior
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to the Comprehensive Physical Assessment (CPA) as indicated by the checkbox on the CPA.
An interview with the registered nurse (RN) confirmed the HRH is completed upon intake. It is
reviewed annually and updated when necessary.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
Five youth Individual Healthcare Records (IHCRs) were reviewed for a Comprehensive Physical
Assessment (CPA). Each record included a new CPA which was documented on the
Department form within seven days of the youth’s admission by the designated health authority
(DHA). Each CPA was completed as required with the youth’s Medical Grade indicated on the
form. All sections of the CPA were marked with “O” or “X” and any parts of the exam refused
were clearly documented on the form and accompanied by a refusal form signed by the youth.
Each youth had at least one verified Tuberculosis Skin Test (TST) which was documented on
the CPA and matched the youth’s Infectious and Communicable Disease (ICD) form. Two youth
were applicable for updates to their Department Problem Lists, which were updated as required.
The registered nurse (RN) was interviewed and confirmed a CPA is completed upon admission
and annually, and youth receive a TST annually.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures for sexually transmitted infection (STI) and human
immunodeficiency virus (HIV) screening and testing. The policy reflects results of HIV testing
are only released to authorized parties as defined in Florida Administrative Code. Five youth
Individual Healthcare Records were reviewed and each youth was screened for STIs on the
date of admission and referred to the designated health authority (DHA) for further evaluation,
which was documented on the required form. Testing was ordered and performed for each
youth and the results filed in the lab section of the IHCR. None of the youth were out of the
custody of the program requiring a rescreening. Each youth’s IHCR documented the youth was
offered HIV testing. One youth consented to testing and the youth’s IHCR documented the
youth received testing and was provided pre and post-test counseling. The youth’s results were
filed in the IHCR in a sealed envelope marked as confidential. The DHA signed the envelope
indicating their review and the youth’s HIV status was not documented on the program’s alert
system. Pre and post-test counseling services are provided by the DHA. Three youth were
interviewed and all three advised they can request testing. An interview with the registered
nurse (RN) confirmed youth provide a urine sample upon admission and if requested later for
STI testing. Results are documented on the Infectious and Communicable Disease form and the
Health Education Record is updated.
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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 for the sick call process, which include procedures for
non-licensed staff reviewing sick call requests in the event healthcare staff are not on-site. The
program offers sick call twice a day, seven days a week as required by contract. Postings for
sick call times were found on each module, in the school area, and in medical during a program
tour. Five youth Individual Healthcare Records (IHCRs) were reviewed and three were
applicable for sick call encounters. None of the applicable youth presented with a similar
complaint three or more times. Each sick call encounter was documented on the Sick Call form
completed by the youth and the nursing staff in the required time frame and filed in reverse
chronological order in the youth’s IHCR. Each encounter was completed as required and
documented on the youth’s Sick Call Index, and the program’s Sick Call Log, all of which
corresponded with the Sick Call form. Each encounter was conducted by licensed nursing staff,
one of which was completed by a licensed practical nurse (LPN) and the registered nurse (RN)
conducted a review on the same day and documented it on the form. None of the youth were in
restricted housing. Sick call is performed in the medical clinic in an exam room where youth can
receive privacy where supervision is maintained by direct care staff. No youth submitted a sick
call request during the annual compliance review week; therefore, sick call was unable to be
observed. Three youth were interviewed and two reported they can be seen for sick call within
one day, the remaining youth reported three days. The RN confirmed all youth will be re-
educated on the sick call process. Three staff were interviewed and each confirmed the nursing
staff conducts sick call. The nurse advised youth are seen for sick call, and the visit is
documented and placed on the list to see the designated health authority (DHA). The program
provides twenty-four-hour medical care.
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 addressing episodic and emergency care. Five youth
Individual Healthcare Records (IHCRs) were reviewed and four were applicable for requiring
episodic/first aid care. Each applicable youth’s IHCR documented all episodic care was
administered by licensed nursing staff and documented in problem-oriented charting. None of
the youth were applicable for episodic care administered by non-healthcare staff. The program
has a total of ten first-aid kits located in designated areas throughout the program. The kits are
in the kitchen, maintenance, alpha, bravo, charlie, delta (dorms), multipurpose room, and four
are stored for transport. The program has a process for ensuring contents of the first-aid kits are
maintained and stored in accordance with guidelines to prevent expiration or deterioration. An
observation of three first-aid kits confirmed the kits were fully stocked with designated health
authority (DHA) approved contents. The registered nurse (RN) monitors the first-aid kits weekly
and checks for expired contents, which is documented on the first-aid kits logs. The program
has two automated external defibrillators (AEDs) located in medical and charlie dorm. The AED
procedures are located with the AEDs. The AED batteries and pads are checked by the RN
once a month. Documentation confirmed the RN monitored the AEDs as required. The RN
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checked the expiration dates of the AEDs in the presence of the Monitoring and Quality
Improvement regional monitor. The nurse conducted a self-test of the AEDs in front of the
regional monitor, with no issues noted. The batteries of the AED were last changed in July 2023
and expire in March 2027. The AED pads were changed December 2023 and expire in
February 2029. A review of the emergency drills confirmed the program conducted an
emergency drill to include cardiopulmonary resuscitation (CPR)/AED annually. The emergency
medical drills simulated an episodic care event which called for immediate first-aid, and/or
administration of CPR techniques, and the initiation of emergency procedures to follow when a
life-threatening emergency does occur. The program had a list of emergency numbers which
were inaccessible to youth. The emergency numbers are posted in master control, medical, and
administration. A review of ten training records confirmed all staff were trained in episodic, first-
aid, and emergency care, and the administration of the epinephrine auto-injector. The program
has a facility operating procedure (FOP) regarding Narcan. The policy states all newly employed
provider staff and admitted youth shall receive education on recognizing and treating symptoms
of Opiod overdose. Training includes risk factors for overdose, strategies to prevent overdose
deaths, and overdose recognition and response. The training and prevention plan also includes
emergency response procedures. Narcan is stored in medical and inventoried along with other
medication. Supervisors are trained on the use of Narcan. Three interviewed staff confirmed
they knew what to do in an emergency and two reported they could call 9-1-1 in the event of an
emergency, the remaining staff reported they would call master control to contact 9-1-1. Two of
the three interviewed youth confirmed they can see a doctor if needed. The remaining youth
said they cannot. The RN reported they would re-educate all youth on requesting healthcare.
The RN advised episodic care is documented on an episodic note and in the episodic logbook.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
Five youth Individual Healthcare Records (IHCRs) were reviewed and each youth required off-
site care while at the program. Each off-site care incident was documented on the required
Department form, which was reviewed along with any discharge documentation by the
designated health authority (DHA) upon each youth’s return. Three youth were applicable for
parent/guardian notification which was documented in the youth’s IHCR. Each of the three
applicable emergency off-site incidents were documented on the Episodic Care Log. Four youth
required follow-up testing. One youth’s IHCR indicated the follow-up care was tracked and
provided, the remaining applicable youth’s follow-up care is scheduled for a future date. The
registered nurse (RN) confirmed all off-site care completed forms are flagged for DHA review,
youth are tracked utilizing a medical tracking log and a white board within the medical area.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
Five youth Individual Healthcare Records (IHCRs) were reviewed and three were applicable for
a chronic condition and taking medication on an on-going basis. Each of the three applicable
youth’s chronic conditions were documented on their Facility Entry Physical Health Screening
(FEPHS) form. None of the youth were undergoing treatment for additional conditions. Each of
the three youth were placed on the chronic illness list and their Medical Grades accurately
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reflected their status. Two of the three youth received periodic evaluations at least every ninety
days, the remaining youth had not been at the program long enough to receive a periodic
evaluation. Both applicable youth received a periodic evaluation prior to renewing prescriptions
and all evaluations were documented in the youth’s progress notes. None of the youth were
applicable for requiring care for Tuberculosis and the program is an all-male program. None of
the youth received an off-site evaluation. There were no indications of a lapse in care for any of
the youth. Each youth’s Department Problem List was updated as required. An interview with
the facility administrator (FA) advised meetings with healthcare staff are held daily. The FA
meets daily with medical staff to discuss all medical issues pertaining to youth. The designated
health authority (DHA) interview confirmed youth with chronic conditions are seen every ninety
days and tracked with a chronic tracker at the program. The nurse confirmed the appointment
dates are kept on a medical tracker and on a calendar in the DHA binder.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
Five youth Individual Healthcare Records (IHCRs) were reviewed and found three youth were
taking medication upon admission, as indicated on their Facility Entry Physical Health Screening
(FEPHS) form. Each of the youth medications were verified prior to the youth being admitted
into the program, and the prescription notification was documented and in the youth’s
Chronological Progress Notes. The designated health authority (DHA), and when applicable, the
psychiatrist was contacted to obtain an order to resume the specified medications prescribed
prior to admission for each youth. Each of the five youth IHCRs documented the youth received
medication while in the program and all medications were continued, discontinued, changed, or
new medications ordered utilizing the Practitioner Order Form. Each medication had a current
and valid prescription or order. None of the youth were in restricted housing of any kind. Two of
five youth were applicable for over-the-counter (OTC) medications and were administered
according to approved protocols. The program utilizes the Department’s Medication
Administration Record (MAR) to document all medications and treatment. The MAR clearly
indicated medication start and stop dates of the youth’s medications. In all applicable IHCRs,
the staff initialed each administered medication entry. There were no undocumented
explanations for lapses or errors in medication administration for any of the reviewed IHCRs.
The registered nurse (RN) documented side-effect monitoring weekly on the MAR for all five
reviewed IHCRs. The MAR contains all required elements. There were no medications
administered by non-healthcare staff. There were no indications of lapses or errors in
medication administration. Each reviewed youth had refusals which were clearly documented on
the MAR. Three youth were applicable for psychotropic medications and the psychiatrist was
notified for each youth upon admission and the youth received a psychiatric evaluation within
fourteen days. Two youth were applicable for psychotropic medications subsequent to
admission and one of the two youth received required monitoring. One youth’s monitoring was
not conducted at the time of the annual compliance review and was three days late. There were
no standing orders for psychotropic medications, emergency treatment orders for psychotropic
medication, or any pro-re-nata (PRN) orders for psychotropic medications. A medication pass
was observed. The youth were escorted by the direct care staff and approached the nurse
individually. The medical provider identified themselves and confirmed the reason each youth
was present. The medical provider prepared the medication and verified the youth’s allergies
and alert status. The medical provider and youth initialed the MAR, and the medical provider
observed to ensure the medication was swallowed. The Six Rights of Medication
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Delivery/Administration were maintained in each of the youth records. Three staff were
interviewed and each reported the nurse provides medication. Three youth were interviewed
and each knew the medication administration process and confirmed the nurse provides
medication. An interview with the nurse confirmed the pharmacy utilized, and advised two
nurses destroy all medication, except controlled medication which is destroyed by one RN and a
pharmacy inspector.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures to ensure medical equipment classified as
sharps/medications are secure and inventoried utilizing a routine perpetual inventory. A review
of the medical equipment classified as sharps confirmed the items were securely stored and
inventoried utilizing a routine perpetual inventory descending count. All medications were
identified and secured in a locked medication cart designated for storage of medications. The
medication cart was secured, clean, and organized with stock items separate from youth-
specific medications. All medications were stored in a separate, secured area, inaccessible to
the youth. Narcotics and other controlled medications were stored behind two locks, refrigerated
medication was stored in a secured refrigerator only used for medication. The program has a
process for the destruction and disposal of medications. Two nurses destroy all medication
except controlled medication which is destroyed by one registered nurse (RN) and a pharmacy
inspector. The program conducts a perpetual and weekly inventory of all sharps and stock over-
the-counter (OTC) medications which did not indicate any discrepancies. The nursing staff
maintain a shift-to-shift inventory of all controlled substances, in the event a youth is prescribed
a controlled substance, it is documented on the youth’s Individualized Controlled Medication
Inventory Record. The number of pills, tablets, or dosages remaining were documented on the
youth’s Individualized Controlled Medication Inventory Record after each administered dosage.
Six supervisory level staff were trained in the delivery and oversight of medication self-
administration. The training was provided by the RN. Observations were conducted of inventory
counts of three controlled medications, three OTC medications, and three sharps. All inventories
were correct with no discrepancies. The RN reported if there is a discrepancy in the count, the
health services administrator (HSA), designated health authority (DHA), and facility
administrator (FA) shall be notified immediately, and a call to the Department’s Central
Communications Center (CCC) will be placed. The interview with the nurse confirmed
medications are secured behind two locks and inventoried weekly and perpetually.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a policy and procedures related to Infection Control and an Exposure Control
Plan. The Infection Control and Exposure Control Plan is signed annually and was reviewed and
signed by the designated health authority (DHA) on February 2, 2023, and facility administrator
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(FA) on February 2, 2023. The program’s infection control procedures include prevention,
containment, treatment, and reporting requirements related to infectious diseases, as according
to Occupational Safety and Health Administration (OSHA) federal regulations and the Centers
for Disease Control and Prevention (CDC) guidelines. The plan addresses common infectious
diseases of childhood, self-limiting, episodic contagious illnesses, viral and bacterial infectious
diseases, tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus (HIV), infectious
diseases caused by blood-borne pathogens, other outbreaks or epidemics caused by any other
infectious agent, outbreaks of lice or scabies, Methicillin-Resistant Staphylococcus Aureus
(MRSA) and other antibiotic resistant micro-organisms, food-borne illnesses, bio-terrorist
agents, and chemical exposures. The program’s Exposure Control and Infection Control Plan is
written in accordance with the OSHA standards. The program offers Hepatitis B immunizations
to staff. Staff have access to personal protective equipment. The program has a comprehensive
process for needle stick post-exposure evaluation. The program has a separate file containing
all documents of youth and staff who have experienced a program or occupational exposure. An
interview with the PD confirmed the plan is located in the staff station. An interview with the
nurse confirmed exposure control training is provided by the registered nurse (RN).
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program therefore is indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Limited 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 stating how the program shall maintain active
supervision of youth at all times. Active supervision is described as interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of youth
and changes in behavior, and consistently applying the behavior management system.
Additionally, program staff shall be able to account for the whereabouts of youth under their
supervision at all times. Observations of staff during the annual compliance review week found
staff supervising youth appropriately during all observed activities. According to the policy and
procedures provided to the annual compliance review team, staff-to-youth ratios are one staff to
eight youth during awake hours, one staff to ten youth during sleep hours, and one staff to five
youth for off-site activities. Observed activities made during the four-day annual compliance
review week were supervision of youth during school hours, in the dining area, recreation,
supervised cleaning activity, and youth movement through the program. The daily schedules
were posted in the dormitories, common areas, and cafeteria. Youth were observed to be
supervised at all times during the annual compliance review week. Positive interactions were
observed between youth and staff. Youth were observed while they were in their sleeping
rooms. Three interviewed staff confirmed their understanding of the procedures when there is a
discrepancy with the count. Three staff indicated movement is stopped and the count is
reconducted until the count is reconciled. Observations found the counts were conducted at
scheduled and unscheduled times and the shift supervisor was able to give an accurate count
when asked.
During the annual compliance review period the program had an escape which resulted in an
outcome based corrective action plan (OBCAP) for youth supervision. As a result, this indicator
will be rated as limited compliance.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program maintains a policy and procedures addressing the implementation and training of
the program’s behavioral management system (BMS), which has not changed since the last
annual compliance review and contains all the required elements. The program utilizes the
iChoose System BMS which is a coordinated system of promoting, monitoring, recognizing, and
rewarding a youth’s progress. It is a program of incentives and consequences which promote
individualized skill building, appropriate behavior, and accountability. Staff use point cards to
monitor how well the youth are progressing in the program. Youth earn points daily for
complying with the program rules. At the end of each day, the points are totaled, and the youth
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are rewarded based on the number of points earned. Each youth enters the program on an
orientation level prior to starting the BMS and progresses their way up the four levels. Six
interviewed youth, three from each program, were able to explain how the level system of the
BMS works. A review of the BMS confirmed it is not used solely to increase a youth’s length of
stay, deny basic rights or services, promote the use of group punishment, allow youth to punish
other youth, or include disciplinary confinement. All three interviewed youth reported youth are
not allowed to punish other youth. Youth learn about the BMS during the orientation process.
Each youth is provided a program handbook which describes the BMS. A review of the youth
handbook indicated the BMS is included and clearly written. A review of five staff training
records indicated staff were trained on the BMS. Additionally, education staff are TrueCore
Behavioral Solutions staff, and each received BMS training by the regional training manager
within the last year. A review of five youth case management records indicated each youth
participated in orientation upon arrival to the program and received a copy of the youth
handbook. Observations found the BMS was posted throughout the program. Observations of
staff and youth interactions verified staff were adhering to the BMS by utilizing a ratio of four-to-
one positive to negative consequences when redirecting the youth as indicated in the program’s
policy. Three staff were interviewed, and all three reported they were trained in the BMS. Three
staff stated the BMS consists of a point system, with two of three reporting it includes rewards
and consequences, and one stating the BMS includes a level system. The interviewed staff
stated the BMS rewards youth with daily and weekly incentives including snacks, game nights,
pizza night, ice cream, off-site activities, and canteen. Each of the three interviewed staff stated
nothing can be taken away from a youth as a consequence, youth are informed of the
consequences of their behavior, and are able to explain the reason for their behavior. The three
interviewed staff reported the supervisors inform staff on how the BMS should be utilized and
provide feedback during shift briefings and after reviewing youth point cards. Three youth were
interviewed, and each youth stated the consequences included level freezes and early bedtime.
Three youth reported they receive daily and/or weekly incentives such as special meals, snacks,
reward parties, and canteen. Each youth was familiar with the program’s BMS level system and
each stated youth are not allowed to punish other youth. All three youth report staff use rewards
the same. One youth said the BMS is good, one said poor, and one said very poor. An interview
with the facility administrator (FA) confirmed the program utilizes the iChoose System BMS and
reiterated the program’s BMS policy.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program’s policy, procedures, and practice confirm the program does not use room
restriction; therefore, this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures in place to conduct and document ten-minute checks
during sleep hours or at other times, such as during an illness. The program has a total of 177
video cameras capable of storing thirty-days of video footage. During the annual compliance
review week, 166 of the cameras were operational. Prior to conducting checks, staff are
positioned where they are able to see any movement within the living unit. Staff are required to
conduct room checks every ten-minutes and document the time of the check on the Ten-Minute
Check Log when youth are sleeping. The program’s practice is to complete checks at eight
minute intervals. A video review of ten-minute checks, including samples from each of the living
units, verified staff were conducting checks every eight minutes and documented the times
accurately on the Ten-Minute Check Log. In addition, the Ten-Minute Check Logs since the last
annual compliance review were reviewed. A sample of various days, times, and shifts indicated
the ten-minute checks were completed within the required frequencies. Three interviewed staff
verified room checks were conducted every eight to ten-minutes when a youth is placed in their
room for sleeping or non-punishment reasons. In a formal interview, the facility administrator
(FA) stated the program has 177 cameras with video recording storage capabilities for thirty-
days.
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 maintains a policy and procedures to ensure youth are always accounted for
through a system of physically counting youth at various times throughout each day. The
program conducts formal head counts each hour and after outdoor activities. The program’s
policy indicates counts are conducted during power outages, escapes, program disturbances, or
any other disruptions which may occur. A review of the policy and procedures and well as the
Continuity of Operations Plan (COOP) verified program staff must always account for the
whereabouts of the youth in the care and custody of the program. This includes the need for
continual head counts to be conducted minimally at the beginning of each shift, during any
emergency situations, and at regular intervals. A review of twelve randomly selected dates and
times in the program’s logbook since the last annual compliance review validated head counts
were conducted at the beginning of each shift, hourly, after outdoor activities, during emergency
situations such as program disturbances, and during actual and/or simulated drills. In addition,
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the program logbooks included documentation of new admissions, releases, transfers, and
youth temporarily away from the program. Observations made during the annual compliance
review week indicated it is the program’s practice to conduct hourly youth counts and to
announce youth counts before all movement. Three interviewed staff explained formal counts
are conducted every hour. Each staff stated emergency counts are conducted anytime a code is
called which includes escapes, if there is a discrepancy in the count, and during drills. During
the annual compliance review week, the youth census was eighty-six youth. Two of the three
interviewed staff knew the youth census during the annual compliance review week, one staff
stated eighty-four youth.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a policy and procedures to ensure the maintenance of a chronological
record of events, incidents, and activities in a central logbook. The program maintains a bound
logbook with numbered pages for each month. Observations and a review of logbooks since the
last annual compliance review found the back covers of some logbooks were missing or falling
off. The logbooks daily pages were limited in space, if additional entries were needed, a blank
entry page was stapled to the book to add additional information. A review of logbook entries
confirmed they were documented in ink with no erasures or white-out areas. Errors were
struck through with a single line, dated, and initialed by the staff correcting the error.
Reviewed documentation of randomly selected days within the logbooks reflected each entry
included the date and time of the event, the name of the staff and youth involved, as well as a
brief description, the name, and signature of the staff making the entry. Logbooks included
entries for emergency situations, population counts, law enforcement access to youth, perimeter
checks, and youth movement. In addition, admissions and releases were documented as well
as transports away from the program. A review of precautionary observations (POs) reflected
the start of the POs were not entered into the logbook, however, the step-down in supervision
was logged. A review of the activity schedule and logbook documentation verified there was
minimal interference of education instruction. Logbook entries for education included youth
movement to and from the classrooms and school start and end times. Logbook entries and
observations verified recreation was conducted as scheduled. A review of internal incidents
reported to the Florida Abuse Hotline and/or the Department’s Central Communications Center
(CCC) verified each was documented in the logbook. The program ensures direct care staff,
including each supervisor, are briefed when coming on duty. Each staff signs the shift briefing
section of the logbook to acknowledge receiving the information.
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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 for assignment, inventory, tracking, and storage of
program keys. Keys are bound on a tamper resistant ring which includes a brass-colored tag
with the number of keys and a tracking number. The facility administrator (FA) is responsible for
inventory and tracking of all program keys including issuance, verification activities, and tracking
of keys including retrieval of keys from permanent staff. Shift supervisors with the assistance of
the master control operator are responsible for the inventory, issuance, and return of keys from
shift to shift. Observations verified program keys and staff personal keys are maintained in
master control in a secured cabinet with a lock. The program has a Daily Key Log to track keys.
The log indicates the name of staff and what type of key they are to be assigned according to
their position. The program maintains a master inventory list of program keys. A random check
of five different sets of program keys compared to the inventory list indicated the keys were
accounted for. The program identifies keys as active and restricted which are kept in a locked
drawer below the key cabinet in master control. Active keys are assigned to direct care staff
while restricted keys are designated for medical staff, kitchen staff, case managers, and
therapists. The program’s practice is when staff arrive at the program, personal keys are
collected by master control and placed in the key cabinet. Active program keys are given to staff
by master control who also document in the key logbook. A review of the key logs since the last
annual compliance review verified this practice. In addition, the program has a list of staff who
are assigned permanent keys. Permanent keys are issued, and staff sign an acknowledgment
form indicating the key identification number and the number of keys issued. A review of the
signed acknowledgment forms indicated each staff signed for the use of permanent keys. A
random check of three staff indicated they had program keys, knew the number of keys on the
key ring, and knew the function of each key. If a key becomes damaged, a Broken Key Report
is filled out which includes the date, reporting staff, key hook number, key number, description,
and attach the broken key with tape. The shift supervisor and key control manager sign the form
and the key is replaced. If the key is stuck in the lock, a Maintenance Work Order form is filled
out for maintenance staff to remove the broken key. A review of the Department’s Central
Communications Center (CCC) reports since the last annual compliance review indicated there
were no incidents related to key control. Three staff were interviewed, and each stated program
keys are assigned to staff and there is a daily tracking of keys. Two staff also reported staff and
visitor keys are given to master control upon entry, personal keys are securely stored, they are
to notify master control of missing keys, and the facility is searched when keys are missing. One
staff reported youth do not have access to keys, and the youth are searched when keys are
missing.
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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 maintains a policy and procedures to identify materials considered to be
contraband, to prevent contraband from entering the program, and consequences when found
in the possession of youth in the program. The program has a system in place to prevent
contraband entering the facility which includes defining items/material considered contraband,
exemptions, providing youth with a list of contraband, informing youth of consequences if found
with contraband, and searches of the physical plant, program grounds, youth, and incoming and
outgoing mail. The facility visitor log and all ten sampled staff personnel records contained a
signed contraband attestation statement. All ten of the new hire staff records contained the
contraband attestation statement. The attestation statement addresses any staff who is found in
possession of contraband in a program will be subject to disciplinary action up to and including
dismissal as outlined in Florida Administrative Code. The policy also states law enforcement will
be contacted if any found item is considered illegal as defined in Florida Statutes, or if there is
evidence of any type of unlawful activity. The program clearly delineates those items considered
contraband and keeps a contraband log documenting the focus of the search, items found, and
the disposition of any items found. There were no incidents of illegal contraband turned over to
law enforcement or reported to the Department’s Central Communications Center (CCC) during
the annual compliance review period. The program logbooks, search and contraband logs, and
incident reports were reviewed to determine frequency and quality of searches and the results
of each search, and each was found to be in compliance with policy. In an interview the facility
administrator (FA) stated any suspicion of youth, staff, or visitor having contraband shall be
dealt with immediately to ensure the safety and security of the program. The FA reaffirmed the
program’s policy shall be followed, to include preserving evidence for law enforcement and
required outside reporting procedures. Three staff were interviewed and each reported weekly
contraband searches, done on a rotation and on random days, are completed for youth rooms.
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5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a policy and procedures to ensure searches, including full body visual
searches, are conducted according to Florida Administrative Code at the time of admission,
after off-site activities, and visitation. Parents/guardians are notified of searches during
visitation by way of the parent/guardian intake letter, which is mailed at the time of each youth’s
admission. Youth are searched after school, group, outdoor recreation, and meals. Youth who
are a new admission, readmission, returning from visitation, returning from off-site activities
and/or appointments, suspected of contraband, or are a security risk are full body searched.
Observations made throughout the annual compliance review week validated youth are
provided instructions regarding the search, youth searches were conducted by staff of the same
gender as the youth, were conducted in a manner so as not to degrade the youth, and were
based on the Protective Action Response (PAR)/Right Interactions (RI) training manuals.
Searches observed during the annual compliance review week verified youth were searched
after every movement. Youth searches were observed following the use of cleaning tools,
verifying searches are conducted according to policy. Observed searches were completed
thoroughly and respectfully. Youth appeared to be comfortable and accustomed to the process.
Three staff were interviewed, and each reported youth are searched after every movement by
same gender staff. Three youth were interviewed, and all indicated searches occur prior to all
movement from one location to another.
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 center maintains a policy and procedures for transportation, operation, and maintenance of
each vehicle used to transport youth. The center has a total of five vehicles of which four are
used to transport youth. Two of the vans are Department issued and three are provider-owned.
Each vehicle had an annual safety inspection conducted by a certified automobile mechanic.
Observations of the four program vehicles were conducted, the remaining vehicle is not used for
youth transports. Observations verified each vehicle was locked when not in use. The four youth
transport vehicles have the appropriate number of seatbelts, a safety screen, a seatbelt cutter, a
window punch, up-to-date fire extinguishers, and an assigned first-aid kit with approved items by
the designated health authority (DHA). First-aid kits are stored in master control until the vehicle
is in use. Weekly visual vehicle inspection checks are conducted on all vehicles as required and
documented on the preventative maintenance check sheets. The four observed vehicles had
working seatbelts and the passenger doors could not be opened from the inside. A random
check of five staff personal vehicles and five program vehicles during the annual compliance
review week found all the vehicles were locked and secured when not in use.
Three staff were interviewed, and each stated youth are secured in the vehicle with
handcuffs, leg shackles, and by wearing the seatbelt. Three youth were interviewed. Two youth
reported they are required to wear seatbelts and the third youth reported never being on a
transport.
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5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a policy and procedures to ensure the safety and security of youth and
the community when youth are transported outside of the program. Reviewed documentation
verified all approved drivers had a valid driver’s license. The program assigns a ratio of one staff
to five youth during transport, not including the driver. The program provides secure
transportation for secure high and maximum-risk youth determined to be at greater risk. An
observation of a transport was unable to be conducted, as there were no off-site events or
appointments planned for the annual compliance review week. Logbook entries with names of
staff transporting youth reflected at least one staff of the same gender as the youth is on each
transport. Three staff were interviewed, and each staff confirmed they are not allowed to use
personal vehicles to transport youth. Three interviewed staff verified staff bring cellular
telephones during transports and two also stated two-way radios. Two interviewed staff stated
the safety equipment in the transport vehicles included a first-aid kit and a fire extinguisher. Staff
also reported each vehicle contains a logbook, wheel lock device, handcuff key, jack and spare
tire, and a window punch. All three interviewed staff stated the transport vehicles are searched
for contraband prior to and after each use. Each of the three staff know what to do in case of an
emergency during a transport. The three staff reported a minimum of two staff are required for
transports. Three interviewed youth stated they are secured in the vehicle using seatbelts. Each
interviewed youth stated they never witnessed anyone placing contraband in a transport vehicle
and they indicated staff were driving transport vehicles safely.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a policy and procedures to ensure safety and security is maintained.
The policy addressed who is responsible for conducting weekly audits, procedures to implement
corrective actions for deficiencies, and an internal system to verify deficiencies are corrected.
Weekly safety and security audits are conducted by the maintenance manager or designee
and documented on the Safety and Security Audit Inspection form. Any deficiencies are
addressed on the form and a work order is submitted to the appropriate staff for corrections. In
addition, deficiencies are discussed during the morning management meeting. A review of the
safety and security inspection forms since the last annual compliance review indicated
inspections were completed, as required. The program’s Preventive Maintenance Checklist was
reviewed and ensured maintenance schedules and repairs were conducted as required. In a
formal interview, the facility administrator stated weekly safety and security inspections and
daily perimeter checks are conducted, and any deficiencies identified are discussed amongst
the management team and addressed, as necessary.
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5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures to have a tool management system which
ensure youth do not use tools or equipment as weapons or for security breaches. The policy
addresses the issuance, inventory, and control of equipment and tools. A review of inventory
logs and observations verified tools are securely stored when not in use, easily marked for
identification, inventoried prior to, and following work activities. All sharp edged and pointed
tools are inventoried daily when in use. A review of six unique tools in the maintenance area
and four unique tools in the bravo dorm verified the inventory matched the inventory list. The
maintenance staff are responsible for conducting the inventories and securely maintaining all
Class A tools and equipment. The maintenance staff complete a tool inventory list which
documents each tool in inventory. All maintenance tools were inaccessible to youth and were
observed to be secured in the maintenance area. Observations of the tool storage area found it
was organized and secure. Class B tools including mops, brooms, and buckets are maintained
in locked closets by each dormitory and in a locked closet in the kitchen area. The items are
used by staff and youth when performing daily cleanup activities. Staff are required to complete
a sign-out and sign-in log when items are taken and are returned to the designated storage
room. A review of five staff training records and five youth case management records indicated
staff and youth are trained in the safe use of Class B tools. Reviewed documentation verified
there were no instances of missing or lost tools since the last annual compliance review.
Prohibited tools at the program include machetes, bowie knives, and other long bladed knives.
According to the program policy, if a tool is broken or inoperable, the maintenance staff is
alerted and makes a notation on the inventory log. The maintenance manager is responsible for
replacing the broken tool. If a tool is missing, staff shall notify administration, fill out an incident
report, document the incident in the logbook, place a tag on the shadow board, call the
Department’s Central Communications Center (CCC), and the program shall be searched until
the tool is found.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. A review of the program’s procedures verified staff
are required to complete a sign-out and sign-in log when Class B tools are taken and are
returned to the designated storage room. A risk assessment is completed by the case
manager prior to youth using any tools. Five youth case management records were reviewed,
and each youth had a Youth Risk Assessment completed by the case manager. The
program’s staff-to-youth ratio during a work project is no less than one staff to five youth.
Program staff search youth after a work detail has been completed. An observation of youth
using a broom to sweep the common area of the dormitory verified the youth were properly
supervised while sweeping and searched before returning to regular activities. Three youth were
interviewed. All three youth stated they use mops and brooms, with one youth reporting they
use scrub brushes. Three staff were interviewed, and each stated youth are allowed to use
mops, brooms, and scrub brushes.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 58 of 64 (Revised September 2022)
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures establishing guidelines for outside contractors who
come on-site to complete repairs. The program's policy stipulates the facility administrator (FA)
is responsible for providing approval and permissions if a personal cellular telephone and/or
equipment/electronic devices capable of taking pictures and/or audio or video recordings,
including smart watches, are required. The program’s procedures specify tools are restricted to
only the
tools needed for the job, tools are checked upon arrival and departure, and youth are restricted
from the work area. When a contractor arrives on-site, they sign the Outside Contractor On-Site
Work Project Log which includes the vendor’s name, date, time in, a list of tools needed for
the job, the beginning quantity of tools and ending quantity of tools, staff name checking the
tools, and date and time out. The form states the vendor must report any lost tools to
administration immediately. A review of vendor sign-in sheets since the last annual compliance
review confirmed tools and other equipment were inventoried when the vendor arrived and
inventoried when they left. Three reviewed project invoices showed the date of the project
matched the vendor sign-in sheets. Outside vendors are accompanied by staff to the work area
and youth access is restricted from the work area. Staff must supervise vendors in the work
area where youth are located. An observation of vendors cutting the facility grass was
conducted and youth were restricted from the work area.
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’s Continuity of Operations Plan (COOP) addresses fire, safety, evacuation
emergency processes, and the frequency of conducting drills at random times and under varied
conditions. Reviewed documentation validated fire drills were conducted for all shifts each
month, as required. In addition, the program conducted emergency drills on each shift ensuring
fire, riot, severe weather, flooding, terrorist threats, chemical spills, medical situations, and
bomb threats were covered on a rotating basis. Drill documentation included the type of drill,
date and time, participants, a brief scenario description, deficiencies identified during the drill,
and applicable corrective actions. Observations of the program during the annual compliance
review week indicated there were thirty-eight annually inspected fire extinguishers, and egress
plans are posted throughout the program. Three interviewed staff all reported they have
participated in fire and escape drills since the last annual compliance review. In addition, two of
the three staff reported they have participated in weather, major disturbance, bomb threat,
hostage situation, chemical spill, flooding, and terrorism drills. Three youth were interviewed,
and two stated they have been instructed on what to do in the case of a fire, one youth stated
they have not participated in a fire drill. One interviewed youth stated fire drills were conducted
monthly and one youth reports there has only been one since he was admitted. An interview
with the facility administrator (FA) indicated the program maintains a drill calendar which
includes drills for fire prevention, mental health, medical emergencies, severe weather, bomb
threats, and hostage situations. Drills are conducted randomly, and on each shift, at least
monthly for fire and quarterly for the remaining drills.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 64 (Revised September 2022)
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program maintains a Department approved Continuity of Operations Plan (COOP) available
for all staff to review. The COOP was submitted on February 1, 2023, and approved by the
Department on February 21, 2023. The COOP provides for basic care and custody of youth in
the event of an emergency or disaster. The COOP also addresses phases of a disaster plan as
well as emergency management including preparedness, response, and recovery. The COOP
addresses emergencies including fire prevention, bomb threats, evacuations, chemical spills,
severe weather, and terrorist attacks. A review of the plan indicated alternative housing has
been identified should the program require an evacuation due to an emergency or disaster. The
program also has provisions of equipment and supplies maintained in the kitchen, the
maintenance building, and the assistant facility administrator’s (AFA) office to ensure a
continuous operation of services during emergency or disaster situations. In addition, the
program has a generator to provide continuous power from ten to fourteen days. The program
maintains identifying information on each youth in the program, and in the event the program
has to evacuate the youth record accompanies the youth to the temporary location. A review of
five youth records indicated each has the youth’s name, Department identification number,
admission date, gender, race, contact information, emergency contact, assigned juvenile
probation officer (JPO), committing judge, victim information, physical description, health status,
and a photograph. The interviewed facility administrator (FA) reported the copy of the COOP is
maintained in master control and the FA’s office.
5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program has a policy and procedures for the storage and inventory of flammable,
poisonous, and toxic materials. Toxic items are stored outside of the program in a locked shed.
Cleaning supplies are located in the locked closets by each dormitory and in a locked closet in
the kitchen area. A list of staff which includes the facility administrator (FA), assistant facility
administrators (AFAs), supervisors, and maintenance staff designates they are authorized to
handle flammable, poisonous, and toxic materials. All flammable, poisonous, and toxic materials
are stored according to type and use. A Safety Data Sheet (SDS) binder is located inside the
storage area with a picture of each material and a number corresponding to the SDS for each
chemical. A perpetual chemical inventory list is maintained, and the chemicals are checked
daily. A review of the inventory list verified this practice. The perpetual inventory form identifies
the chemical number, description, amount used, amount remaining, date chemical is used, and
initial of staff. Observations of the storage area indicated it is clearly marked hazardous
chemicals and securely locked. A review of five unique chemical inventories were compared to
the actual items in the storage areas and verified the inventory was correctly documented.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 64 (Revised September 2022)
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedures prohibiting youth from handling any flammable,
poisonous, and/or toxic items or materials. Youth are not to clean, handle, or dispose of any
toxic chemicals, biohazardous bodily fluids, or human waste. Youth are strictly prohibited from
the maintenance area where toxic items and chemicals are stored. Three youth were
interviewed, and all three youth stated they did not handle any chemicals and/or cleaning
products. One youth reported the staff spray the chemicals and youth wipe the surfaces with a
towel. An observation of the youth sweeping the floor in the common area of the dormitory
verified no chemicals were used by the youth. A review of the program’s preventative
maintenance checklist verified maintenance schedules and repairs are being conducted, as
required.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program maintains a policy and procedures to ensure all flammable, toxic, caustic, and
poisonous items are disposed of appropriately. The facility administrator (FA) or designee and
maintenance staff are responsible for the control and accountability of all caustic, toxic,
poisonous, flammable, or hazardous, fluids, substances, or chemicals used in the program. All
unused hazardous materials are kept in the locked storage shed located outside the program
and are disposed of according to the Safety Data Sheet (SDS). An interview with the FA
indicated disposal of hazardous chemicals is accomplished within parameters of state, local,
and federal laws. The maintenance staff is responsible for the safe and lawful disposal of these
items and only maintenance or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and solid waste are responsible for disposing of
hazardous items and toxic materials. The FA stated there were no chemicals disposed of during
the annual compliance review period. Used kitchen grease and waste is stored in a large
container outside the kitchen area and is disposed of by a local vendor. All liquid waste from
work details is disposed down plumbing drains. The program’s policy states all chemical spills
are reported to master control immediately and the shift supervisor. An evacuation of the
affected area is conducted and a determination by the FA whether to contact outside assistance
to contain the spill. Staff and youth are not allowed to return to the affected area until it has been
deemed safe by a qualified professional. An interview with the FA indicated disposal of
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 64 (Revised September 2022)
hazardous items and toxic substances or chemicals is completed by taking them to the local
transfer station.
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a policy and procedures for youth to have visitation and communication
with family members in order to reestablish family and community relationships. Youth are
informed of visitation upon admission during the orientation process. The program encourages
visitation from the parents/guardians by forwarding a welcome letter upon the youth’s admission
notifying the days and time of visitation, who is allowed to visit, and the corresponding rules of
visitation. A list of authorized visitors and correspondence is maintained in the youth’s case
management records and updated, as needed. A review of five youth case management
records verified each record contained an approved correspondence, visitation, and telephone
log. Visitation is held on Wednesdays from 2:00 p.m. through 4:00 p.m. and on Saturdays and
Sundays from 1:00 p.m. through 3:00 p.m. Special visitations are also provided for
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 64 (Revised September 2022)
parents/guardians who are unable to participate in the regularly scheduled visitation days. A
review of the program logbooks and visitation sign-in logs since the last annual compliance
review verified visitation and special visitation are conducted. Youth are also provided one
fifteen-minute telephone call each week, writing material, and a self-addressed and stamped
envelope to talk with and send letters to approved family members. A review of the mail logs
since the last annual compliance review showed the youth were receiving and sending mail to
approved family members. Youth can have unimpeded access with the courts, attorneys, their
juvenile probation officer (JPO), and/ or the Department of Children and Families case worker.
Three youth were interviewed, and each indicated they are given the opportunity to
communicate with family members by mail, telephone, and/or visitation. None of the youth were
aware of an interpreter for youth who do not speak English. Three interviewed staff stated the
program uses bilingual staff and/or interpreters to provide translation services if needed. An
interview with the facility administrator indicated the program utilizes translation services, if
needed.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a daily activity schedule which reflects the youth receive at least one hour of
recreation each day and additional time allotted for leisure activities. The program’s contract
requires two recreation therapists. Both recreation therapists who provided services during the
annual compliance review period had the required credentials outlined in the program’s
contract. The program currently has one vacancy for a recreational therapist, which had been
vacant for one month at the time of the annual compliance review. The contract does not require
special provisions for the incorporation of recreation into the youth’s performance or treatment
plans. The recreation therapist created monthly activity calendars which reflect the recreation
and leisure opportunities available to youth each day. A review of the activities confirmed they
promote social and cognitive skill development, creativity, teamwork, healthy competition,
mental stimulation, and physical fitness. Logbooks were reviewed for the annual compliance
review period and recreation was documented each day for at least one hour, as required.
Recreation was observed during the annual compliance review week at its scheduled time and
staff were found to be taking precautionary measures to ensure the health and safety of the
youth. Three youth were interviewed, and two of the three youth reported they have the
opportunity to exercise, play outside, or down time to read a book, or play a board game. One
youth stated they did not. Two out of three youth reported they do not get one hour of physical
activities. One youth reported they did. All three mentioned when they do go outside, they play
basketball or do other large muscle movement. Three staff were interviewed and reported youth
receive recreation as required which includes basketball, football, cards, video games,
dodgeball, kickball, exercises, movies, and board games.
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 64 (Revised September 2022)
5.25 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.26 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 64 (Revised September 2022)

source: DJJ

program_name_raw: Deep Creek Youth Academy - MHSA