summary: QI Residential - FY23-24 - 1 finding

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Duval Academy
Wayne Halfway House
(Contract Provider )
7500 Ricker Road
Jacksonville, Florida 32244
Review Date(s): May 21-24, 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:
Kristine Harshaw, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Cio’nna Allen, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Jeff Campbell, Office of Education, Northeast Education Coordinator, (Standard 2)
Renette Crosby, Office of Accountability and Program Support, Regional Monitor (Interviews)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Carlametress Harrell, North Region Project Anchor, Regional Workforce Education Coordinator
(Standard 1)
Kayshala Patterson, Office of Accountability and Program Support, Regional Monitor (Standard
5)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Duval Academy MQI Program Code: 1280
Provider Name: Wayne Halfway House Contract Number: 10796
Location: Duval County / Circuit 4 Number of Beds: 28
Review Date(s): May 21-24, 2024 Lead Reviewer Code: 187
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
2.16 Exit Portfolio
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 70 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Non-Applicable
1.05 Incident Reporting (CCC) * Non-Applicable
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Non-Applicable
1.08 In-Service Training Non-Applicable
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Non-Applicable
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 70 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Limited
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 70 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 70 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 70 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
5.25 Controlled Observation Non-Applicable
5.26 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 70 (Revised September 2022)
Program Overview
The Duval Academy is a twenty-eight bed program, for fourteen to eighteen year old males,
located in Jacksonville, Florida. The program is operated by Wayne Halfway House, through a
contract with the Department. The program provides services including Mental Health Overlay
Services (MHOS) or Substance Abuse Treatment Overlay Services (SAOS). In addition, the
program fosters each youth by providing Cannabis Youth Treatment, Living In
Balance, Aggression Replacement Training, Impact of Crime, and Dialectical Behavior Therapy.
Additional treatment services provided include individual, group, family, and recreational
therapy. Program administration is comprised of a facility administrator, an assistant facility
administrator (AFA), a human resources/administrative assistant, a food service manager, and a
physical plant manager. Case management services are provided by two case managers
supervised by the program’s designated mental health clinician authority (DMHCA). Mental
health staff at the program include the DMHCA, two non-licensed therapists, a recreational
therapist, and a transition services manager. Medical services are offered daily from 7:00 a.m.
to 5:00 p.m., and are provided by a designated health authority (DHA), a health services
administrator (HSA), one full time registered nurse, and two part time registered nurses.
Educational services are provided by the Duval County School Board. The layout of the
program includes a main building which includes administration, staff offices, youth living areas,
a dining room, kitchen, a classroom, and large meeting area/pavilion. The program has thirty-six
operating security cameras providing coverage. At the time of the annual compliance review,
the program had no vacant positions.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 70 (Revised September 2022)
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 70 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures requiring all staff, volunteers, and contracted staff to
be background screened prior to contact with youth and youth records. The program did not
have any volunteers or interns who interacted with youth on an intermittent basis for less than
ten hours a month. An Annual Affidavit of Compliance with Level 2 Screening Standards was
completed and sent to the Department’s Background Screening Unit on January 30, 2024. The
teachers who are paid by the school board received their annual screening January 10, 2024.
The program hired twenty-six new staff during the annual compliance review period, and each
new staff received a background screening prior to hire. The program had five new volunteers
during the annual compliance review period, and all had a background screening completed
prior to contact with youth and confidential records. A criminal history report was reviewed for
each staff and volunteer, and all staff and volunteers were added to the Clearinghouse
employment roster. None of the staff or volunteers required an exemption prior to working with
youth. Documentation provided regarding what is utilized as a pre-employment assessment
found it was a provider-created form which does not provide a specific score. The provider has
recently obtained a program which gives a score which has been implemented within the last
couple of weeks. The provider made the change based on a discussion with the Department’s
Office of Residential Services, which was confirmed through email communications.
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 in place requiring all staff and volunteers to receive a
background rescreening every five years from their hire date. This is the first annual compliance
review for the provider at this program, so there were no staff applicable for a five-year
rescreening.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 70 (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 in place to promote an environment in which youth,
staff, and others feel safe, secure, and not threatened by any form of abuse or harassment.
According to the program’s policy, all staff are required to report any knowledge or suspicion
regarding an incident of abuse or sexual harassment which has occurred in the program
immediately and report any retaliation against youth or other staff who reported an incident, and
any staff neglect or violation of responsibilities which may have contributed to an incident or
retaliation. The telephone numbers for the Florida Abuse Hotline and the Department’s Central
Communications Center (CCC) are posted throughout the program. Staff adhere to a code of
conduct, which is agreed to, signed, and documented in each staff’s personnel record. A review
of five staff personnel records found each of the staff signed a code of conduct. The program
completed a Trauma Responsive and Caring Environment (TRACE) self-assessment on June
30, 2023. The program had two incidents of alleged staff abuse during the annual compliance
review period. It is unknown at this time if the incident was substantiated, due to Department-
wide system outages. None of the incidents included a potential human trafficking victim,
commercial sexual exploitation, or labor trafficking.
Five youth were interviewed. All five youth reported they feel safe at the program with two youth
stating it is a safe place, two youth reporting they feel safe because of the supervision, and one
youth reports it is a good environment and the staff treat the youth good. All five youth reported
staff are respectful when talking to youth, none have heard staff using profanity, and none have
exchanged emails, telephone numbers, or social media contact information with staff. Five staff
were interviewed. All five staff stated when a youth requests to call the Florida Abuse Hotline,
the supervisor is notified, and staff are allowed to make the call. Four staff reported the
supervisor makes the call, three staff report the youth is allowed to make the call, and two staff
stated they are to notify the administration. None of the staff knew the number to the Florida
Abuse Hotline, however, all five were able to explain where to find it. None of the staff report
they have observed a staff refusing a youth an abuse call. Three staff report never hearing a co-
worker using profanity when speaking to youth. Two staff report they have; however, the staff
was terminated.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 70 (Revised September 2022)
1.04 Management Response to Allegations (Critical) Non-Applicable
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
Due to Department-wide system outages, this indicator was unable to be reviewed.
1.05 Incident Reporting (CCC) (Critical) Non-Applicable
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.
Due to Department-wide system outages, this indicator was unable to be reviewed.
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program has a policy and procedures in place requiring a Protective Action Response/Right
Interactions model (PAR/RI) Report to be completed any time staff use a physical intervention
technique. There were seventeen PAR/RI incidents during the annual compliance review period.
Five PAR/RI Reports were reviewed, and each was completed by the end of the staff’s workday
and included statements from all staff involved. All five reports were reviewed by a supervisor
and PAR/RI instructor, as well as the facility administrator (FA) or designee within seventy-two
hours of the incident. A copy of all five reviewed PAR/RI Reports was placed in the program’s
centralized file within forty-eight hours of approval by the FA. None of the PAR/RI incidents were
applicable for completion of the Mechanical Restraint Supervision Log, Department’s Central
Communications Center (CCC) notification due to injury, Florida Abuse Hotline contact, or a
PAR/RI medical review. Monthly summaries of PAR/RI incidents were maintained by the
program and submitted to the Department by the fifteenth of each month. The program’s
PAR/RI plan was updated on July 1, 2023. The PAR/RI plan was approved by the Department
on December 22, 2023. The number of PAR/RI Reports from the previous quarter cannot be
compared to the number of PAR/RI Reports in the prior annual compliance review period due to
a new provider acquiring the program. The program’s PAR/RI rate at the time of the annual
compliance review was 4.28, which is above the statewide Residential PAR/RI rate of 1.76. The
facility administrator (FA) was interviewed and noted the FA is familiar with the program policy.
Five staff were interviewed. Three staff reported they have never used PAR/RI. The remaining
two staff reported using PAR/RI, and both were able to verbalize the program’s policy on
physical management of youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 70 (Revised September 2022)
1.07 Pre-Service/Certification Requirements (Critical) Non-Applicable
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
Due to Department-wide system outages, this indicator was unable to be reviewed.
1.08 In-Service Training Non-Applicable
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
This indicator was not applicable for being reviewed due to the contract being newly executed.
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 include the training requirements for the
grievance process. The program has a grievance process which includes an informal phase, a
formal phase, and an appeal phase. The informal phase includes encouraging the youth to
resolve questions, disputes, and complaints through informal communication with program staff
and use of a conference request form. Documentation correlated the program’s practice with
their process. The program had no grievances during the annual compliance review period. Five
youth were interviewed. All five youth were able to describe the grievance process and knew
where the forms were located. All five youth reported they are able to ask for help with filling out
a grievance if needed. Five staff were interviewed, and all were able to describe the program's
grievance process. The facility administrator (FA) was interviewed and is also familiar with the
program’s grievance policy and practice.
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 contractually required services, which were not primary services, revealed the
program is not providing any non-clinical or non-primary services at this time. The program
employs staff who are trained to facilitate Teen Relationships; however, the group is not being
conducted at this time. The staff assigned to facilitate this curriculum was reviewed for
education and experience which documentation confirmed the staff has the required years of
experience and education to facilitate the group. A review of the program’s posted activity
schedule confirmed the program was providing structured programing and activities at least
eighty percent of youth awake hours, as required in the program’s contract, and groups are
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 70 (Revised September 2022)
being provided as outlined on the program’s daily schedule. The facility administrator (FA)
interview reflected they are familiar with the program policy. The designated mental health
clinician authority (DMHCA) was interviewed and reported evidence-based treatment services
are utilized in the facilitation of individual, group, and family therapy. Evidence-based practices
are based on the need for interventions for substance abuse disorders and co-occurring mental
health disorders. Interventions approved by the Department are determined and utilized
contingent on the effectiveness and enhancement of the therapeutic process.
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 provides instruction focusing on developing life and social skill competencies in
youth. Youth are provided the opportunity to volunteer for community services projects inside
and outside of the program. The youth are provided health and wellness training from the
nursing staff regularly, participate in community service, work at the local food bank, and help
out in the independent living center for special needs adults. All of the youth are involved in the
local mentoring program, a leadership development program designed to encourage young men
to become functional leaders through empowerment and mentorship. Documentation, including
sign in sheets, agendas, photos, press releases, and certificates of participation were observed.
Five youth were interviewed and all five were able to verbalize the groups they participate in and
how they practice the skills they learn in group. The facility administrator was interviewed and
was familiar with the policy. The designated mental health clinician authority (DMHCA) was
interviewed and reported youth have the opportunity to practice skills learned in group during
daily facility activities and off campus outings.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program has a policy and procedures ensuring the program provides 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 provides Impact of Crime (IOC) for restorative justice, which is a primary service,
therefore, this group is not applicable for review. Youth are able to participate in restorative
justice projects provided in their community, including working at the local food bank, and
helping out in the independent living center for special needs adults. Two of five interviewed
youth reported participating in IOC, and three youth stated they are not in this group at this time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 70 (Revised September 2022)
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Non-Applicable
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
Due to Department-wide system outages, this indicator was unable to be reviewed.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains an Individual Healthcare Record and a separate individual management
record. The reviewed individual management records contained the youth’s name, Department
identification number, date of birth, county of residence, and committing offense. The individual
management records contained sections labeled legal information, demographics and
chronological information, correspondence, case management and treatment team activities,
and miscellaneous. All reviewed youth records were labeled confidential and secured in a
locked file cabinet.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a policy and procedures in place to ensure the program has a community
advisory board meeting at least every ninety to 120 days. Sign in sheets and agendas were
reviewed for the advisory board meetings, and documentation confirmed board meetings have
been held monthly. A review of the list of attendees, the board roster, and letters from the
program found the facility administrator (FA) solicited involvement from all required parties. The
FA actively solicits involvement of interested community partners including, but not limited to,
representatives from law enforcement, the judiciary, the school board or district, the business
community, faith community, victim, victim advocate, or other victim services community
representative, and a parent/guardian whose child was previously involved in the juvenile justice
system. All meetings are available to members virtually. Meetings are held monthly, and board
members are frequently involved in the program. Members of the advisory board were present
during the annual compliance review week for a presentation for the youth. The president of the
board along with several other members were interviewed and expressed they are very involved
and interested in the well-being of youth at the program. The interviewed FA was confirmed the
process for advisory board meetings and members.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 16 of 70 (Revised September 2022)
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures to ensure staff are evaluated, at least annually, based
on established performance standards. Five position descriptions were reviewed, and staff
performance standards were clearly identified in each. Performance evaluations were reviewed
for five staff, and each was completed as outlined in the program’s policy, and the performance
standards for each evaluation matched the job description for each staff. The program’s
contractual key positions were reviewed, and all were maintained by the program. A copy of the
evaluation is maintained in the staff’s personnel file. Five staff were interviewed. Two staff
reported communication between staff is very good, two staff reported communication is good,
and the remaining staff reported the communication between staff is poor. Two staff reported
getting yearly evaluations, two staff reported getting an evaluation every ninety days, and the
remaining staff reported they did not know, but they had just completed them for their staff.
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 has several contract requirements detailing services to be provided to youth while
in the program. The program is to provide three snacks per day, the ability to attend career and
technical education programs and work in the community, learning opportunities for youth who
have completed secondary education and wish to pursue post-secondary education, where
youth have the opportunity to earn an associate degree or to begin coursework towards a
bachelor’s degree, high school equivalency diploma test preparation and on-site testing, peer-
to-peer mentoring, a behavior modification process called the D-Board process, a youth
advisory board, religious services, the transitional services manager follows up with all youth
post commitment weekly for thirty days, the opportunity for youth to attend Narcotics
Anonymous (NA)/Alcoholics Anonymous (AA), ServSafe certification, Microsoft Office
certification, first-aid and cardiopulmonary resuscitation (CPR) certification, Heating, Ventilation
and Air Conditioning (HVAC), welding, or electrical applications programming, the Occupational
Safety and Health Administration (OSHA) certification, and access to self-paced online courses
such as business management or accounting. Documentation confirmed the program is
providing community activities, D-board process, youth advisory board, post release follow-ups,
and career certifications. The program established post-secondary resources, which one youth
was applicable for and took a tour and enrolled at the University of North Florida. The program
is also able to provide resources through the Tulsa Welding School and Acelius Academy. The
program is not completing the items dependent on the county school board, as the school is in
the process moving to Florida Virtual School for the upcoming fiscal year. The program
encountered a resistance to a partnership for Youth in Urban Agriculture program and stated will
find an alternative program. The program has provided NA/AA services, and the last
correspondence was in November, however, they did have a representative apply as a
volunteer. Five youth were interviewed and each confirmed snacks are being given as required
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and religious services are available. The interviewed facility administrator replied to refer to the
contract regarding negotiated items.
1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
The program has a policy and procedures which ensure career and technical education services
are implemented with the program. The provider is required to offer Florida Ready to Work Soft
Skills Credentials, Occupational Safety and Health Administration (OSHA)-10 certification, and
first-aid and cardiopulmonary resuscitation (CPR) certification. Case managers are to ensure
each youth has a career and technical education plan, the program will partner with local
colleges for learning opportunities for youth who have completed secondary education and wish
to pursue post-secondary education, and the program will build a relationship with a school
which offers technical and certification classes. The program will be seeking alternative options
to the county school board, as residential programs are moving to Florida Virtual School for their
schools.
At the time of the annual compliance review, forty-nine youth had participated in CPR/first-aid
training, nine youth received or are in progress of receiving OSHA-10 training, and one youth
has completed the training. No youth have completed or are in progress of completing Florida
Ready to Work training. Five youth are enrolled in ServSafe. No youth are enrolled in Microsoft;
the program is not in place currently as it was previously taught by Duval County School
instructors. Five youth were interviewed. Four of the five youth reported they have been trained
in cardiopulmonary resuscitation (CPR), three stated they have participated in ServSafe, two
reported participating in Heating, Ventilation, and Air Conditioning (HVAC) training, and one
youth reported speaking with a college. The interviewed facility administrator was able to report
the policy regarding vocational services in the program.
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 includes the review and analysis of data in decision-making practices and shares
the data among administrators and staff to proactively make policy, practice, and programming
changes designed to foster system and program improvement. The program tracks data trends
such as the Department’s Central Communications Center reportable incidents, physical
managements, abuse reports, and staff turnover through monthly reports and trackers. The
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program conducts regular internal leadership meetings in which these items are discussed and
reviewed. These leadership meetings occur, minimally, on a weekly basis. The program
conducts monthly staff meetings during which time critical issues and trends are reviewed and
discussed. Facility administrators participate in both weekly and monthly leadership meetings
across programs to review data trends. The program shares relevant trend information with
providers and stakeholders, such as the community advisory board, through regular advisory
board meetings. These practices were documented in meeting minutes for community, staff,
and board meetings.
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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.
Five youth case management records were reviewed for initial contacts to parents/guardians
and court notification. The program notified the parents/guardians by telephone within twenty-
four hours, and in writing within forty-eight hours of admission in all five records. The court,
juvenile probation officer, and post-residential services counselor (if applicable) were notified
within five working days of the youth’s admission in all five records.
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 provided each youth an orientation to begin on the day of admission in all five
reviewed records. The program’s orientation process included all the required elements. Five
youth were interviewed. All five youth confirmed orientation to the program began within twenty-
four hours and included the program rules, procedures, and schedules. No admissions were
scheduled during the annual compliance review week; therefore, an orientation could not be
observed.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
Five youth case management records were reviewed for written consent of youth eighteen
years of age or older. Three youth were applicable for being eighteen or older and written
consent was obtained from each youth before providing or discussing with the parent/guardian,
Agency for Persons with Disabilities (APD), and/or the Department of Children and Families
(DCF), if applicable, any information related to the youth’s physical or mental health screenings,
assessments, or treatments.
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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 utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. The program’s
classification forms were reviewed and included all the required elements including, but not
limited to physical characteristics, age and maturity, special needs, history of violence, gang
affiliation, criminal behavior, sexual aggression and vulnerability to victimization, youth’s
perception of vulnerability, history of human trafficking, and suicide, medical, escape, and
security risk. Five youth case management records were reviewed. Three of five youth had risk
factors for medical, escape, security, or other risk factors. The program reviewed the
Department’s Juvenile Justice Information System (JJIS) for any issues affecting classification.
All five youth were classified for the purposes of assigning them to a living area, sleeping room,
and youth group or staff advisor. Medical, mental health, substance abuse, security risk factors,
and/or special needs identified during or subsequent to the classification process were
immediately entered into the program’s internal alert system and JJIS in four of five records, as
required. One youth was in the custody of the Department of Children and Families (DCF),
however, DCF involvement was not correctly included in the youth’s classification form.
Reassessments were completed, if warranted, prior to considering an increase in the youth’s
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, and
participation in off-campus activities in all five records reviewed.
The program’s policy and procedures clearly outline the classification process and include a
classification system which promotes safety and security, as well as effective delivery of
treatment services, based on determination of each youth’s individual needs and risk factors,
which address, at a minimum, items outlined in Administrative Rule. The treatment team, as
outlined in policy, will reassess and reclassify a youth, if warranted and as necessary,
throughout the youth’s commitment 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. An interview with the facility administrator confirmed the program’s policy and
procedures for screening youth which includes group placement, sleeping arrangements, and
youth classification to determine each youth's individual needs and risk factors.
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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.
Five youth case management records were reviewed for gang identification. One youth was
applicable for gang identification, as such, the program provided two additional records for
review. One youth was identified as being suspected of gang activity while at the program. Two
youth were identified as being affiliated with gang activity prior to entering the program. For all
three youth, local law enforcement was notified of suspected gang activity, prior to the seven-
day notice for the program’s annual compliance review. Law enforcement in the youth’s home
county was notified of the youth’s gang affiliation in all three records. One youth was applicable
for requiring a gang alert be entered in the internal alert system and the Department’s Juvenile
Justice Information System (JJIS). The gang alert was entered into both systems, as required.
The other two youth already had alerts in JJIS prior to entering the program, but were entered
into the program’s internal alert system, as required. Information about the youth’s gang status
was shared with the education provider or local school district providing services at the
residential program, as required, for all three youth. One youth’s juvenile probation officer (JPO)
was applicable for being notified, and the program notified the JPO of the youth’s gang status,
as required.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
Five youth case management records were reviewed, and one of five youth were identified as a
gang member or affiliated gang member. Two additional records were requested for review. All
three youth participated in gang prevention and intervention strategies and their performance
plans included relevant goals and objectives related to gang intervention strategies for the youth
to complete prior to release from the program. The program uses the ARISE Gang Prevention
curriculum which consists of youth gang prevention strategies, including a life skills curriculum,
to help reduce the risk factors leading to gang membership. A review of sign-in sheets
confirmed groups were conducted, as required. Youth participate in ARISE and Impact of Crime
groups as part of gang prevention/awareness efforts. The program’s policy and procedures
address providing youth an opportunity, if they desire, to develop a plan to disaffiliate with a
criminal street gang. An interview with the program director confirmed the program’s policy
includes gang prevention and intervention strategies when youth are identified as being a
criminal street gang member, are affiliated with any criminal street gang, or are at high risk of
gang involvement. Identification of youth to participate in gang prevention or intervention
activities is based on information obtained through the program’s screening, assessment, and
classification processes, as well as gang-associated behaviors exhibited or the youth’s
expressed interest or intent while in the program.
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2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
Five youth case management records were reviewed for Residential Assessment for Youth
(RAY) assessments and reassessments. Two youth had their initial RAY completed within thirty
days of admission. One youth’s RAY was completed one day late, one was two days late, and
one was twenty-four days late. Two of five youth were applicable for RAY Reassessments. As
such, the program provided an additional record for review. One youth did not have a RAY
Reassessment completed as required. One youth had a RAY Reassessment completed seven
days late. One youth had two RAY reassessments completed every ninety-days after the
completion of the initial assessment, as required. For both youth who had a RAY Reassessment
completed, the program maintained all the reassessments in the youth’s official case record, as
required. Due to Department-wide system outages, the Department’s Juvenile Justice
Information System was unable to be reviewed at this time and affected the timeliness and
availability for the completion of the RAY and RAY Reassessments for some youth.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
Five youth case management records were reviewed for a Youth Needs Assessment Summary
(YNAS). One youth had a YNAS completed within the required thirty days of admission. One
YNAS was completed one day late, one was completed two days late, one was completed three
days late, and one was completed twenty-four days late. Due to Department-wide system
outages, the Department’s Juvenile Justice Information System was unable to be reviewed at
this time and affected the timeliness and availability of completion of the YNAS for some youth.
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2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
Five youth case management records were reviewed for Individualized Performance Plans
(IPPs). None of the five IPPs were developed within the required thirty days of the youth
admission. Two plans were one day late, two plans were three days late, and one plan was
twenty-four days late. All five IPPs were developed after the initial Youth Needs Assessment
Summary and Residential Assessment for Youth (RAY). All required intervention and treatment
team members were present during the development of the IPP and had the opportunity to sign
the plan in all five records reviewed. The program mailed the signature sheets to all five
parent/guardians for signature, however, none of the signature sheets were returned to the
program. All five youth IPPs included individualized goals based upon the prioritized needs
reflecting the risk and protective factors identified during the initial assessment process, top
three criminogenic needs, specific delinquency interventions based on RAY results, with
measurable outcomes which will decrease the youth’s criminogenic risk factors and promote
strengths, skills, and supports to reduce the likelihood of the youth reoffending, target court-
ordered sanctions which could be reasonably initiated/completed while in the program, youth
responsibilities to accomplish goals, program staff responsibilities to enable youth to complete
goals, and target dates for goal completion. Two youth IPPs included transition activities
targeted for the last sixty days of the youth’s anticipated stay. The three remaining records did
not include transition activities on the initial IPP but were later updated to include transition
activities. Within ten working days of completing the plan, a transmittal letter and copy of the
plan were sent to the committing court, juvenile probation officer, parent/guardian, and
Department of Children and Families counselor, if applicable. Five youth were interviewed. All
five youth confirmed they participated in the development of their performance plan and were
provided a copy. The youth stated their performance plan goals included anger, aggression, and
education.
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 revisions. Three
youth were applicable for plan revisions. All three youth received revisions based on Residential
Assessment for Youth Reassessments, newly acquired/revealed information, demonstrated
progress toward completing a goal, or demonstrated lack of progress toward completing a goal.
One youth was applicable for revisions of the performance plan to facilitate transition activities
during the last sixty days of the youth’s stay.
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2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
Five youth records were reviewed for Performance Summaries. Two of the records were
applicable for requiring Performance Summaries, as such, the program provided one additional
record to review. One of the summaries was completed ninety calendar days following the
signing of the performance plan. One summary was completed three days late and one was
completed twenty days late. One was applicable for being prepared prior to the youth’s release,
discharge, or transfer from the program, and was completed as required. All three summaries
included all the required elements of the Performance Summaries, including the justification for
the youth’s release in the one applicable record. Reviewed documentation regarding
performance transmittals reflected the youth was allowed to read and add comments prior to
signing, was provided a copy of the summary, and the original summary was filed in the youth’s
case management record in all three records. The Performance Summaries were signed and
dated by the treatment team leader, youth, and facility administrator in all three records. Copies
were sent within ten working days to the committing court, youth’s juvenile probation officer, and
parent/guardian in all three records reviewed.
Three closed youth records were reviewed. The original release summary or discharge
summary, if direct discharge, along with justification for release, were sent with the Pre-Release
Notification (PRN) to the juvenile probation officer (JPO) in two of three records. One release
summary was not able to be located for review. A signed copy of the PRN was retained in the
youth’s record in two closed records. One closed youth record did not include a PRN All three
records included a RAY exit assessment. One of the three reviewed records documented victim
notification letters were sent at least ten days prior to the youth’s release. The two remaining
records did not include a victim notification letter or waiver.
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 and facilitates involvement of each youth’s parent/guardian in the
case management process to include the assessment process, participation in the development
of the youth’s performance plan, progress review, formal treatment team meetings, and
transition planning. If unable to attend, the parent/guardian is given the opportunity to participate
by telephone/video conferencing or provide verbal/written input prior to the meeting. Two
treatment teams were observed during the annual compliance review week. Parents/guardians
participated through telephone and were given an opportunity to speak to the youth and
program staff during both treatment teams observed. In an effort to facilitate parent/guardian
involvement, the program mails a parent/guardian form which allows the parent/guardian to
provide information for the youth’s treatment process, allows virtual visitation for
parents/guardians who are unable to travel, and provides notification for upcoming treatment
team reviews. An interview with the facility administrator determined the case manager will
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make every effort to include parents/guardians to participate in the youth’s assessments,
performance plan development, progress reviews, and transition planning. Five youth were
interviewed and all five confirmed their parent/guardian was involved in their case management.
2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
Five youth records were reviewed for the incorporation of other plans into the youth’s
performance plan. All five youth had additional plans, including academic or treatment plans,
and the performance plans referenced or incorporated the applicable plans in all five records
reviewed. None of the youth were applicable for having a behavior support plan through the
Department of Children and Families or Agency for Persons with Disabilities.
2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
Five youth case management records were reviewed for treatment team members and
meetings. Formal treatment team reviews were held at least every thirty days in seventeen of
eighteen formal reviews for the five youth reviewed records. One youth had the first formal
treatment team review completed three days late. Reviewed documentation of treatment team
meetings included the youth’s name, date of the formal review, required attendees, comments
from treatment team members or others, a brief synopsis of the youth’s progress in the
program, performance plan revisions, progress on goals, positive and negative behaviors, and
behaviors resulting in physical interventions, when necessary. Documentation also included
youth being provided an opportunity to demonstrate skills acquired in the program, treatment
progress, and Residential Assessments of Youth (RAY) results. All formal treatment team
documentation was contained in the youth records for all five records reviewed. Informal
reviews were held bi-weekly each month for all five records. Informal treatment team meetings
included all the required documentation found in formal treatment team meetings, as required,
for four of five youth. One youth was missing the youth’s required RAY Reassessment. All
informal treatment team meeting documentation was contained in the youth’s record for all five
records reviewed. The youth’s juvenile probation officer, parent/guardian, and other pertinent
parties were invited and encouraged to attend treatment team meetings in all five records
reviewed.
Two treatment team meetings were observed during the annual compliance review week. All
required staff were present for both treatment teams and a review of the treatment plan was
completed to determine the youths’ anticipated release date. Both youths’ parents/guardians
were provided an opportunity to speak to the youth and treatment team attendees. Five youth
were interviewed and confirmed staff review youth performance to include progress on
performance plan goals, positive and negative behavior, and treatment progress. All five youth
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also confirmed they are given an opportunity during treatment team meetings to demonstrate
skills they have learned in the program.
2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
Three closed records were reviewed for transition planning and the Community Re-Entry Team
Meeting (CRT). For all three youth, the transition conference was held at least sixty days prior to
the youth’s targeted release date. The youth, treatment team leader, facility administrator,
juvenile probation officer, parent/guardian, education staff, and other pertinent team members
attended each of the three youths’ transition conferences, as required. During the transition
conference, the participants reviewed transition activities on the youth’s performance plan,
revised the performance plan, when necessary, identified additional transition activities, as
needed, identified target completion dates, and identified persons responsible for completion in
all three records reviewed. The treatment team leader obtained attendees’ dated signatures,
representing their acknowledgement of the transition goals and accountability for completion in
all three records reviewed. None of the records had an email receipt in the file acknowledging
the juvenile probation officer received a copy of the transition plan. All three youth had a CRT
meeting conducted prior to release, in which, the youth and case manager participated. There
was evidence of an invitation to participate in the CRT in two of three records.
2.16 Exit Portfolio Limited Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three closed youth case management records were reviewed for Exit Portfolios. The Exit
Portfolio was discussed and initiated for the youth during the transition conference in all three
records. All three records included a copy of the youth’s transition plan, educational and/or
vocational certificates earned in the program, educational records/documents, school
transcripts, résumé, and a completed sample employment application. All three youth were
missing copies of their state-issued identification card, Social Security card, and birth certificate,
and no evidence was found to show the program attempted to obtain the documents. Two of
three records were missing the youth’s Plan for Success, which included a calendar with all
dates, times and locations of upcoming community appointments. One youth record included
the youth’s Plan for Success, as required. Reviewed documentation did not indicate the Exit
Portfolio was completed and given to the youth upon release or forwarded to the youth’s
juvenile probation officer for any of the three youth records.
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2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Three closed youth records were reviewed for an exit conference. An exit conference was
conducted after the program notified the youth’s juvenile probation officer of the release, at least
fourteen days prior to release, in all three records. Two of three records had documentation
indicating the date of the conference, signatures, and a summary pending transition goals. One
youth’s record did not contain a copy of the exit conference, and the program was unable to
provide a copy; however, case notes confirmed the exit conference was held telephonically for
this youth covering all required transition topics and including all required participants. Due to
Department-wide system outages, the Department’s Juvenile Justice Information System was
unable to be reviewed for admission and release date correlations. The status of transition
activities established at the transition conference and plans for the youth’s release were
reviewed and finalized during the exit conference in two of three records. In the two records, the
exit conference included the intervention and treatment team members, parent/guardian,
education representative, juvenile probation officer, youth, and other pertinent parties. The exit
conference was held separately from the transition conference and Community Re-Entry Team
(CRT) meeting in two records. The remaining record did not have an exit conference summary
to review; however, cse notes for this youth documented a summary of the conference on the
day it was held.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a formal process to promote constructive input by youth which includes Town
Hall meetings, Speak-Out forms, and a youth advisory board. Reviewed documentation showed
town hall meetings were conducted where youth are able to provide input on a monthly basis.
Advisory board minutes, speak-out forms, and grievance forms were reviewed during the annual
compliance review week which showed the program’s efforts to solicit input from the youth and
were in compliance with the requirements determined in the program’s policy and procedures.
Five youth were interviewed, and the youth stated they talk to staff, use speak out forms, and
town hall meetings to provide input to the program staff. An interview with the facility
administrator (FA) determined the program solicits input from youth through multiple avenues of
communication allowing youth to give input and feedback on a daily, weekly, and monthly basis,
including the Request for Service form, the grievance and Request to Talk system, and monthly
Town Hall meetings. The FA also explained these avenues give the youth experience in
identifying systemic issues impacting their residential community and making recommendations
for resolutions to improve conditions and enhance the quality of life for staff and youth in the
program.
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 for career education based on age and
appropriateness for the educational abilities of the youth in the program. The program provides
Type 2 career education development. The interview with the lead teacher indicated the youth
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participate in career education by learning job skills, writing résumés, and utilizing the
authorized Department of Education Xello program to explore career pathways. An interview
with the facility administrator indicated the program provides career education programming
through the education department. The career education program is appropriate based on the
youth’s age, assessed educational abilities, and goals of the youth. Three closed case
management youth records were reviewed. All three records included a completed résumé;
however, were missing a valid state identification card and documentation essential to obtaining
employment. Documentation confirmed the youth's parent/guardian and juvenile probation
officer were aware of the vocational plan for the youth.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide educational access. The program provides
education services through the Duval County School District. The 250-day calendar is
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 three one-hundred-minute
class periods from 7:30 a.m. to 1:00 p.m., with a twenty-minute morning nourishment period,
meeting the required twenty-five hours of weekly instruction. Four of the five interviewed youth
reported there is little to no interruption to the school day. The remaining youth indicated it is
loud and they don’t have anything to do. The interview with the lead teacher indicated all the
youth receive credit for a course completed and reported the school schedule is adhered to. A
review of six randomly selected days in the logbook indicated education classes started and
ended on time. Observations of three days on the program video system indicated school
started and ended on time.
2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program has a policy and procedures requiring an Education Transition Plan to be
developed upon each youth’s admission. Three closed youth case management records were
reviewed, and each included an individual Education Transition Plan developed upon entry,
including the youth’s post-release goals, meeting the required elements. Each of the three
records contained an exit plan indicating the case manager, parent/guardian, and youth were all
aware of the plan. Included in each record was documentation identifying the next educational
placement information and input from the post-release school district representative. Four of the
five interviewed youth reported the program was preparing them very well when it came to high
school, high school equivalency diploma (GED), vocational school, employment, and/or college.
One youth reported it has been slow and they have nothing to do. Two of the five interviewed
youth reported they participated in the development of their transition plan and three youth did
not respond to the question.
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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 clinician authority (DMHCA) who is a licensed
mental health counselor. The DMHCA has a current and valid license in the State of Florida.
The DMHCA’s license expires March 21, 2025. The program did not utilize any other DMHCA
during the annual compliance review period. The DMHCA was on-site weekly to ensure the
appropriate coordination and implementation of mental health and substance abuse services
were taking place as required. A copy of the DMHCA position was provided and reviewed. The
DMHCA is responsible for the coordination and implementation of mental health and substance
abuse services at the program. The DMHCA reported their role includes administrative
oversight and management of substance abuse and mental health treatment services, weekly
hour supervision of non-licensed clinicians providing treatment services, record and document
Substance Abuse Treatment Overlay Services (SAOS) and Mental Health Overlay Services
(MHOS) records monthly, assign cases to case managers and primary therapists, ensure
evidence-based treatment services are facilitated according to the facility contract, and
participate in multi-disciplinary treatment team pre-classification, formal, and informal meetings.
The DMHCA reported providing clinical services of individual, family, and group therapy to a
small caseload and communication with clinical staff is maintained daily.
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 designated mental health clinician authority (DMHCA) was the only licensed staff at the
program during annual compliance review period.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) is the clinical supervisor at the
program. The DMHCA ensures the non-licensed staff working under their supervision are
performing services they are qualified to provide based on education, training, and experience.
Documentation revealed each non-licensed mental health clinical staff is working under the
direct supervision of a licensed mental health professional and 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 mental health services provided in the program during
the annual compliance review period. The supervisions were recorded on the Department’s
Licensed Mental Health Professionals and Licensed/Certified Substance Abuse Professionals
Direct Supervision Log. The program maintains a Chapter 397 license. The Chapter 397 license
expires October 16, 2024. The program’s contract requires a recreational therapist. The
recreational therapist’s credentials, schedule, and services provided to youth were reviewed and
all requirements were met. Staffing for licensed and non-licensed clinical staff were in
accordance with the current contract. There were no vacancies in clinical staff.
Three non-licensed staff records were reviewed for credentials. All three 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. All three of the non-licensed staff are qualified to
deliver substance abuse services. The service provider is licensed under Chapter 397 and the
non-licensed staff work directly under the supervision of a qualified professional. Due to
Department-wide system outages staff training could not be reviewed in the Department’s
Learning Management System (SkillPro).
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Five youth mental health records were reviewed for mental health and substance abuse
admission screening documentation. All five youth records included documentation a
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) was completed. The
records included documentation the screeners reviewed the available information to include the
commitment packet and available reports. All five MAYSI-2s were completed in full by the
assigned case manager at the program on the day of each youth’s admission. Due to
Department-wide system outages, training was unable to be reviewed in the Department’s
Management Learning System (SkillPro). The MAYSI-2 screenings were printed from the
Department’s Juvenile Justice Information System (JJIS) and were located in the youth mental
health records for review. All five MAYSI-2s indicated a need for further assessments and all
records included documentation a referral was completed for further evaluation to the
designated mental health clinician authority (DMHCA) and all required parties were notified. All
youth referrals documented the reasons for the referral being completed. None of the five
MAYSI-2s or collateral information indicated any youth was a potential suicide risk therefore an
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Assessment for Suicide Risk (ASR) was necessary; however, it is standard procedure all youth
are placed on precautionary observation at intake until an ASR is completed.
The program maintains a written policy and procedures for mental health and substance abuse
admission screenings. The policy and procedures include a standardized screening process
which includes a review of commitment packet information, report and records, administration of
the MAYSI-2 on 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 justice offenders identified by screenings as in need of further evaluation or immediate
attention. The policy and procedures also included staff training requirements 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 facility. The facility administrator interview was
completed by the state director who was able to relay the policy and procedures for the
program’s mental health and substance abuse admission screening process.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
Five youth mental health records were reviewed for mental health and substance abuse
assessments and evaluations. All five records included documentation the program completed a
combined mental health and substance abuse evaluation for each youth. All evaluations were
new and completed within thirty calendar days of admission. One evaluation was completed by
a non-licensed clinical staff which was reviewed and signed by a licensed mental health
professional within ten calendar days after the evaluation was conducted. The other four
evaluations were completed by the designated mental health clinician authority (DMHCA). Each
evaluation included the required elements of identifying information, reason for evaluation,
relevant background information, behavioral observations, Mental Status Examinations,
interview or procedures administered, discussion of findings, diagnostic impression, including
the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V), and
recommendations. All five youth records included documentation consent was obtained for
substance abuse services. All five youth records included documentation a substance abuse
evaluation was completed within thirty calendar days of admission. Each evaluation included the
required elements of reason for assessment, relevant background information, behavioral
observations, methods of assessment, patterns of alcohol and other drug abuse, impact of
alcohol and other drug abuse in major life areas, risk factors of continued alcohol and other drug
abuse, clinical impression to include the DSM-V diagnosis, and recommendations.
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3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
Five youth mental health records were reviewed for mental health and substance abuse
treatment. All five records included documentation the initial treatment plan was developed
within seven days of initiation of treatment. Each initial treatment plan was documented on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. All five initial
treatment plans were signed by the clinical staff completing the form, signed by the licensed
clinical supervisor within ten days of completion, and signed by all required members of the
treatment team who participated in the development of the plan. The plans did not have staff
titles and were difficult to determine which staff signed the forms; however, once explaining the
difficulty, the program verified the signatures of the staff and changed the form to include titles
of staff involved in treatment teams. One youth was eighteen years of age and did not have a
parent/guardian participate in treatment. Three youth records included documentation of the
initial treatment plan being mailed to the parents/guardians, and one youth record did not
include documentation of the initial treatment plan being mailed to the parent/guardian or the
assigned Department of Children and Families (DCF) worker. The one applicable initial
treatment plan included the psychiatric needs of the youth.
Five youth mental health records were reviewed for individualized treatment plans. Four of the
five individualized treatment plans were developed for the youth within thirty days of admission.
One plan was completed four days late. All five individualized treatment plans were developed
on the Department’s Individualized Mental Health/Substance Abuse Treatment Plan form. Each
individualized treatment plan was signed by the clinical staff completing the plan and reviewed
and signed by the licensed supervisor within ten days of completion. All five youth records
included documentation the individualized treatment plans were signed by all members of the
treatment team who participated in the development of the plan. One youth was eighteen years
old and did not have a parent/guardian involved in treatment, the other four records included
documentation the individualized treatment plans were mailed to parents/guardians. One youth
was applicable for psychiatric services. The youth’s individualized treatment plan included
psychiatric services. All five individualized treatment plan reviews were completed on the
Department’s Individualized Mental Health and Substance Abuse Treatment Plan Review form.
Each youth record included documentation treatment plan reviews were conducted every thirty
days as required.
None of the reviewed individualized treatment plans included documentation of the prescribed
services. All prescribed services were the same for each youth, along with the same dosages
for each service. These were also documented on each youth’s initial treatment plan. The
Department’s Office of Health Services was contacted who reported prescribed services are to
be on the individualized treatment plans. All of the individualized treatment plans included goals
and objectives for the youth. Video observations and sign-in sheets were reviewed for non-
primary mental health groups conducted at the program. A review of the sign-in sheets for the
groups revealed the facilitators are not documenting the end times of groups consistently. It is
unknown how long groups are being held. Three days of groups were observed on video which
confirmed all groups were being held for the appropriate amount of time.
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3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
Five youth mental health records were reviewed for treatment and discharge planning. All five
youth records included documentation the youth were assigned a treatment team upon arrival to
the program. This was evidenced by the initial and individualized treatment plans. The mental
health records do not include a separate form for treatment teams. The individualized treatment
plan reviews are the documentation for treatment teams. The treatment team members
documented in attendance of treatment plan updates included the youth, program
administration, residential living unit, education, medical staff, and mental health staff. Four of
the five youth had documentation of parents/guardians and the Department of Children and
Families being involved in the treatment plan reviews. One youth was eighteen and did not have
a parent/guardian involved in treatment. Five youth mental health records were reviewed for
mental health and substance abuse treatment services. All five youth records included
documentation on their initial treatment plans to be in need of individual therapy, group therapy,
and family therapy. The counseling is being provided by a licensed qualified professional or a
non-licensed clinical staff working directly under a licensed qualified professional, in accordance
with the youth’s initial individualized treatment plan. All five youth had a properly executed
Authority for Evaluation and Treatment (AET) form located in each youth’s medical record. All
five youth records included documentation each youth provided consent through a signed Youth
Consent for Substance Abuse Treatment as well as signed a Youth Consent for Release of
Substance Abuse Treatment Records forms. All five youth records included documentation
treatment notes were documented on progress notes form which contained all the elements as
the Department’s Counseling/Therapy Progress Notes form. The mental health and substance
abuse group therapy included individual psychotherapy and counseling and psychosocial skills
training.
All five reviewed records verified each youth received group and individual therapy as
prescribed on initial treatment plan. Three of the five youth received family counseling as
prescribed. One youth record contained one family therapy session out of five. The program
reported the youth refused to participate in family sessions. The youth turned eighteen while in
the program and no longer wanted parent/guardian involvement. The second youth did not have
any family therapy sessions documented in the progress notes. Documentation was requested
from the program. Progress notes were provided for review dated January 22, 2024, February
29, 2024, March 28, 2024, and April 30, 2024. All of the progress notes were titled as group
therapy sessions. One of the four progress notes included times. The progress note provided for
February 29, 2024, had a time of 1:27 p.m. to 2:35 p.m. however, the youth was documented to
be in a group session from 1:40 p.m. to 2:30 p.m. on the same date. The program reported
attempts to contact the family have been initiated and the family is inconsistent with
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communication, therefore, the youth has been receiving additional individual counseling
sessions.
Three closed youth records were provided to review for the Mental Health/Substance Abuse
Treatment Discharge Summary forms. All three closed records included documentation of the
youth’s discharge plan documented on the Department’s Mental Health/Substance Abuse
Treatment Discharge Summary form. None of the youth were released on suicide alert or
suicide precautions. The Mental Health/Substance Abuse Treatment Discharge Summary
documented the services needed for daily maintenance of the positive improvement in
behavioral, emotional, and social skills made the youth during treatment. All three youth records
included documentation the discharge plans were discussed with the youth. One of the three
plans included documentation the discharge summary was reviewed with the parent/guardian
as indicated by a parent/guardian signature and two records did not have documentation the
summary was reviewed with the parent/guardian. None of the closed records included
documentation the plans were discussed with the assigned juvenile probation officers (JPOs).
None of the records included documentation a copy of the Mental Health/Substance Abuse
Treatment Discharge Summaries being provided to the youth, parents/guardians, or assigned
JPOs. The program reported one youth flew out of state upon release. The designated mental
health clinician authority (DMHCA) flew with the youth and met with the parent/guardian. The
DMHCA reportedly provided a copy of the discharge summary to the parent/guardian, however,
there was no documentation of the parent/guardian or youth receiving a copy of the discharge
summary. The program stated for the second youth, the assigned JPO was in attendance by
telephone for the review of the discharge summary, however, there was no signature or
documentation of the JPO being present. The third youth record did not have documentation of
the parent/guardian signature or JPO signature. The record did not include documentation of
the discharge summary being provided to the youth, parent/guardian, or JPO. The program’s
response was the discharge summaries were mailed to the parents/guardians; however, no
documentation was provided for review.
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 specialized treatment through Substance Abuse Treatment Overlay
Services (SAOS) and Mental Health Overlay Services (MHOS). The program’s required clinical
groups according to the contract are Cannabis Youth Treatment (CYT), Living in Balance (LIB),
Aggression Replacement Training (ART), and Dialectical Behavior Therapy Skills (DBT). Five
youth were interviewed and reported participating in family and/or individual counseling. One
youth reported participating weekly, three youth reported participating once a month, and one
youth reported participating every two weeks. Five interviewed staff reported they do not
facilitate mental health or substance abuse groups. The designated mental health clinician
authority (DMHCA) reported the program provides CYT and LIB for SAOS and ART, DBT, and
Cognitive Behavior Therapy (CBT) for MHOS. All youth receive individual and family therapy.
The state director completed the facility administrator’s interview regarding specialized
treatment services at the program. The state director reported the program provides SAOS and
MHOS to youth admitted to the program based on the youth's needs. SAOS and MHOS
services are provided in accordance with Florida Administrative Code, the Residential
Specialized Services Manual, and any applicable agreement with the Department. The program
provides mental health treatment services through individual, group, or family therapy at least
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five days a week. Based upon the review of documentation, the program is not documenting
prescribed services as a part of the youth’s individualized treatment plans. None of the reviewed
individualized treatment plans included documentation of the prescribed services. All prescribed
services were the same for each youth, along with the same dosages for each services, and
were only documented on each youth’s initial treatment plan. The Department’s Office of Health
Services was contacted and reported to the review team the prescribed services are to be on
the individualized treatment plans. Reviewed documentation revealed the program is providing
individual and group therapy as prescribed. Family therapy is not being provided as prescribed
for all youth. The program is providing daily therapeutic activities by clinical staff. Youth with co-
occurring substance abuse disorders are receiving substance abuse services. Counselor
caseloads are thirteen youth. The program’s contract allows for counselor caseloads to not
exceed sixteen youth. Therapy groups have fourteen youth attending DBT. The program’s
contract states group counseling and therapy sessions shall not exceed ten youth with mental
health diagnoses. These groups would include ART and DBT. Clinical staff are providing
substance abuse groups. All staff are qualified to provide substance abuse education.
The program provides substance abuse treatment services. The program does provide
urinalysis drug testing for youth. Based upon the review of documentation, the program is not
documenting prescribed services as none of the reviewed individualized treatment plans
included documentation of the prescribed services, this is only provided on the initial treatment
plans. Substance abuse groups average thirteen to fourteen youth in each group as required.
The program is providing daily therapeutic activities. Youth with co-occurring mental health
disorders are receiving mental health treatment. The program is licensed under Chapter 397
and either the DMHCA or master’s-level therapists are on-site at least seven days a week to
provide services. A licensed psychiatrist provides psychiatric evaluations, medication
management, and participates in treatment planning.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
The program has a psychiatrist with a valid license which expires January 31, 2025. The
psychiatrist is available for emergency consultation twenty-four hours, seven days a week. The
interviewed psychiatrist reported they brief a representative of the treatment team regarding the
psychiatric status of each youth receiving psychiatric services who is scheduled for a treatment
team review. The psychiatrist’s evaluation and recommendations for the youth are incorporated
into the mental health clinical staff’s evaluations of the youth and youth’s individualized mental
health or substance abuse treatment plans. The program does not utilize a psychiatric
advanced practice registered nurse (APRN). The sign-in/out logs were reviewed and confirmed
the psychiatrist was on-site weekly, as required, during the annual compliance review period.
The psychiatrist actively participates in, manages, and supervises psychotropic medication
services in the program. The program does utilize a back-up psychiatrist when needed. The
back-up psychiatrist has a valid license which expires January 31, 2026. The back-up
psychiatrist has an equal education to the psychiatrist. The program does not utilize tele-
psychiatry. The psychiatrist was interviewed and reported they provide psychiatric evaluations
for every youth upon entry into the program, provide diagnosis and treatment plan
recommendations, provide medication management services as necessary, and provide staffing
and supervision for nursing and clinical staff as required. The psychiatrist is on-site weekly and
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performs psychiatric evaluations, medication management, nursing consultations and
supervision, and clinical staffings. The psychiatrist reported meeting with the designated mental
health clinician authority (DMHCA) on a weekly basis and as needed. The psychiatrist meets
with nursing staff after every youth is seen for weekly treatment. The psychiatrist is also
available for on-call services for any ongoing or urgent needs. The psychiatrist conducts face-to-
face or telephonic communication with representatives from the treatment team. The
psychiatrist reported concerns with the mental health or substance abuse services provided at
the program since the therapists have less certification in trauma focused
interventions/allowance in standard procedure in administering services than would be desired
for effective implementation of underlying conditions which have led to substance use lifestyles.
The psychiatrist stated this is not specific to this program; it is noted across programs. The
DMCHA reported meeting with the psychiatrist weekly on Wednesday mornings during clinic
hours. All youth who are admitted to the program receive an Initial Diagnostic Psychiatric
Interview. All five reviewed records contained an initial interview with all required elements of
history, a Mental Status Examination, the Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) diagnosis, and treatment recommendations. The initial diagnostic
interview was documented on the Department’s Clinical Psychotropic Progress Note (CPPN)
form, including page three, which was clearly identified as the Initial Diagnostic Psychiatric
Interview. Only one of the five reviewed youth entered the program on and were continuously
prescribed psychotropic medication. The program reported there were no other youth
prescribed psychotropic medication. The one applicable youth’s initial interview also contained
prescribed medications, explanation of the need for psychotropic medication, target symptoms,
initial treatment goals, potential side effects, risks and benefits of taking the medication, and
frequency of medication monitoring/management. A review of the applicable youth’s treatment
plan verified the plan was consistent with the DSM-5 diagnosis and included treatment
recommendations. The applicable youth record documented medication reviews by the
psychiatrist at least once every thirty days. The psychiatric evaluations were documented on the
CPPN which included the youth’s identifying data, diagnosis, target symptoms of each
medication, evaluation, description of effect of prescribed medication on target symptoms,
prescribed psychotropic medication, side effects, the youth’s adherence to the medication
regime, the youth’s height, weight, blood pressure, and most recent serum drug levels or
laboratory findings. The applicable CPPN indicated there was telephone contact with the youth’s
parent/guardian to discuss medication when necessary. The psychiatrist signed and dated each
of the reviewed CPPNs. Monthly monitoring of Tardive Dyskinesia was not applicable for the
reviewed youth.
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 maintains a written plan detailing suicide prevention procedures. The program’s
Suicide Prevention Plan was reviewed and included all required elements of identification and
assessment of youth at risk of suicide, staff training, suicide precautions, levels of supervision,
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referrals, communication, notification, documentation, immediate staff response, and a review
process for suicide attempts and mortality reviews. The suicide attempts and mortality review
process included the circumstances surrounding the event, facility procedures relevant to the
incident, all relevant training received by involved staff, pertinent medical and mental health
services involving the victim, possible precipitating factors, and recommendations. The Suicide
Prevention Plan was reviewed by the facility administrator, designated mental health clinician
authority (DMHCA), and psychiatrist. The facility administrator signed the plan on January 24,
2024, the DMHCA signed September 22, 2023, and the psychiatrist signed May 1, 2024.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
Five youth mental health records were reviewed for suicide prevention services. One youth was
applicable for suicide prevention services. One additional file was reviewed for suicide
prevention services. This youth record was provided for a review of Crisis Assessments;
however, as a result of the Crisis Assessments, the youth was placed on constant supervision.
No other youth were applicable for suicide prevention services during the annual compliance
review period. Both youth records had Assessments of Suicide Risk (ASRs) completed on the
Department’s ASR form. Both youth were placed on constant supervision. One of the two youth
records included documentation the parent/guardian was notified, the other youth reviewed was
eighteen years of age at the time of prevention services. There was documentation both youth
received supportive services from mental health staff. Both youth records included
documentation a Follow-Up ASR was completed prior to the youth being removed from
precautionary observation, which was documented on the Department’s Follow-Up ASR form.
Both youth were maintained on suicide precautions and constant supervision until a Follow-Up
ASR indicated suicide precautions could be discontinued. Both youth were subsequently
stepped down to close supervision prior to a transition to normal routine and standard
supervision. Close supervision was maintained until it was determined no longer necessary by
the designated mental health clinician authority (DMHCA), and both instances were
documented in the youth’s mental health record. Both reviewed records documented a
conference was held by the facility administrator and DMHCA to reduce the youth’s level of
supervision. Due to Department-wide system outages, the Department’s Juvenile Justice
Information System (JJIS) could not be reviewed for alerts.
A review of the facility logbooks revealed the supervisory staff did not provide instructions
related to the suicide risk assessment findings. For one of the two youth, one shift documented
the youth was on a mental health alert consistently; however, the other shift did not document
this information. For the other youth, no instructions related to the youth’s suicide risk were
documented in the logbooks. One of the two youth records included documentation on the
precautionary observation (PO) logs of designated safe housing activities. One youth did not
have this documentation on the reviewed PO logs. Both youth had an ASR completed within
twenty-four hours of their initial screening. One of these youth received a Crisis Assessment
and as the result was placed on PO. The reviewed ASRs were completed by an appropriately
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trained non-licensed staff and were reviewed by a licensed staff within twenty-four hours. Both
discontinuations of supervision were documented by a non-licensed staff and were reviewed
and signed by a licensed staff. One of the two youth had documentation of discontinuation of
close supervision in the facility logbook and the other documentation could not be located. Both
youth were transitioned to a lower level of supervision based on an ASR completed by a non-
licensed clinical staff who conferred with a licensed mental health professional as evidenced by
the date and time the clinician signed the ASRs. The one applicable youth in crisis had the ASR
completed immediately. The program does not utilize secure observation according to a
discussion with the state director. The program reported no youth were placed on PO during the
thirty days prior to the annual compliance review; therefore, video review could not be
conducted.
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.
Five youth mental health records were reviewed for Suicide Precaution Observation Logs
documentation. One of the five youth were applicable for review. One additional youth was
reviewed for logs. The youth was initially reviewed for Crisis Assessments; however, the youth
was placed on precautionary observation (PO) as a result of the Crisis Assessment. No other
youth were applicable for suicide prevention services during the annual compliance review
period. Logs maintained for the duration the youth were on suicide precaution were reviewed.
One of the two records included documentation the appropriate level of supervision and
observations of the youth’s behavior were documented in real time and not exceeding thirty-
minute intervals. One of the reviewed logs showed observations were completed as required
with the exception of a one hour gap. Both youth had documented warning signs and the clinical
staff were notified as evidenced by a signature of clinical staff who reviewed the logs. Both
youth records included documentation the logs were reviewed and signed by each shift
supervisor and mental health staff. One of two youth records included documentation the logs
had safe housing requirements documented, the other did not.
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.
Due to Department-wide system outages, staff training for suicide prevention in the
Department’s Learning Management System (SkillPro) could not be reviewed. The program
maintains four suicide response kits located in all living modules and master control. The suicide
response kits are co-located with first-aid kits. Mock suicide drills were reviewed for the
program. Mock suicide drills were held no less than quarterly. During the first quarter, B shift did
not have a documented mock suicide drill. All mock mental health drills were simulated in
response to a suicide attempt and/or incident of serious self-injury. None of the program youth
were used in the drill simulations. The program provided documentation showing semi-annual
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training on emergency response procedures which included mock training in emergency
response to a suicide attempt or incident of serious self-inflicted injury with the use of
cardiopulmonary resuscitation. Any staff who were not present during a quarterly drill had the
opportunity to review each drill scenario and procedures in an effort to understand the process
and receive the necessary training to respond to an incident of a suicide attempt or serious self-
inflicted injury in the program. The facility administrator (FA) interview was completed by the
state director. The state director relayed the program’s written policy and procedures for suicide
prevention training which details what the program is required to complete. Five interviewed
staff responded they would notify mental health staff, search the youth and room for sharp
objects, place the youth on constant sight and sound, and document the supervision when a
youth expresses suicidal thoughts.
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
substance abuse services plan. The plan included all required elements of notification and alert
systems, 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.
Five youth records were reviewed for Crisis Assessments. None of the five youth were
applicable for Crisis Assessments. Three additional youth were provided for review. All three
youth records included documentation a Crisis Assessment was completed timely based on the
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needs of the youth. All three Crisis Assessments included the reason for assessment, Mental
Status Examination and interview, determination of danger to self and others, initial clinical
impressions, supervision recommendations, treatment recommendations, and
recommendations for follow-up or further evaluation. None of the parents/guardians were
notified as all three youth were eighteen years of age or older. The designated mental health
clinician authority (DMHCA) conducted the Crisis Assessments for all three youth. Due to
Department-wide system outages, the Department’s Juvenile Justice Information System could
not be reviewed. Two of the three youth were determined to be a safety and security risk. One
of the two applicable youth remained on alert until a follow-up assessment was completed. The
other youth was placed on one-to-one supervision, however, was subsequently released without
any Follow-Up Crisis Assessments, Follow-Up Mental Status Examination, or Follow-Up
Assessment for Suicide Risk. Both youth’s supervision was documented on the Department’s
Suicide Precautions Observation Logs or Close Supervision-Visual Check Log and not the
Mental Health Alert-Observation Log as required. For one of the two applicable youth the shift
supervisor signed the log five out of sixteen shifts and did not sign for eleven shifts; the DMHCA
signed three of the eight logs and did not sign five logs. Documentation verified the youth was
on one-to-one supervision with the exception of a two-hour gap in the five day period. For the
other youth, the shift supervisor signed two of the three required shifts and the DMHCA signed
both logs. None of the youth were sent off-site. Both youth were part of an alleged Prison Rape
Elimination Act (PREA) event and a Crisis Assessment was completed for both youth. Both
youth received ongoing mental health treatment services.
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 maintains a written emergency mental health and substance abuse plan. The
emergency mental health and substance abuse services plan included immediate staff
response, notifications, communication, supervision, authorization to transport for emergency
mental health or substance abuse services, transport for emergency mental health evaluation
and treatment under Chapter 394, transport for emergency substance abuse assessment and
treatment under Chapter 397, documentation, training, and review.
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.
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3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Five youth mental health records were reviewed for ongoing safety planning. All five youth
records included documentation the safety plans included warning signs, youth’s baseline
behaviors, crisis recognition, jointly developed coping strategies, intervention strategies
preferred by the youth, and debriefing procedures. All five youth had an initial safety plan
completed within fourteen days of admission. All five youth records included documentation the
safety plans were prepared by the youth, parents/guardians, and program’s clinical staff. Two of
the five youth did not have parent/guardian involvement due to being eighteen years of age or
older. All five safety plans incorporated recommendations from previous or current clinical
assessments or screening instruments, and incorporated trauma responsive practices. Two of
the five safety plans were reviewed and updated, at least, every thirty days. Three youth records
were missing one safety plan review each, one youth received five out of six safety plan reviews
and two youth received four out five reviews. The youth safety plans were reviewed and
updated following any significant behavioral or mental health event identified by the youth’s
intervention and treatment team. Safety plans were reviewed by staff who have contact with the
youth and are maintained in master control at the program.
Five interviewed youth reported they are able to contribute to their safety plans. The interviewed
staff reported safety plans are located in master control, the break room, alert board, and case
management. Staff reported the processes for reviewing safety plans includes the designated
mental health clinician authority (DMHCA) telling staff to review the plans if a youth is acting out
or if staff notice any behaviors, staff share information with other staff on their shift, review them
on a daily basis, and when a change occurs with a youth. Two staff reported reviewing safety
plans the previous week, two reported reviewing them last month, and one staff reported
reviewing the plans on a monthly basis. The state director completed the facility administrator
interview. The state director relayed the program’s written policy and procedure for how often
safety plans are updated which states the plans shall be updated every thirty days or following
any significant behavioral or mental health event identified by the youth’s intervention and
treatment team.
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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 January 31, 2026. The DHA’s specialty training is in
family practice. The DHA has one disciplinary case but no public health complaints on record.
According to the Department of Health, the DHA had obligations imposed. According to the
contract, the DHA is required to be on-site weekly, for a minimum of two hours 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 licensed 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 did not provide services to the youth during the annual compliance review period. The
DHA reviewed facility procedures as documented by their dated signature. There was no
inclusion of telemedicine in the program’s contract. The DHA was interviewed, and confirmed
their responsibilities include completing Comprehensive Physical Assessments, periodic
evaluations, and any referrals required. The DHA follows up on off-site appointments and
conducts sick call if they occur while the DHA is on-site. The DHA performs any on-site services
needed by the program weekly for two hours and is available by telephone. All off-site findings
and information from outside medical providers are within the DHA medical binder for weekly
review and sign off. The DHA and other healthcare staff have informal communications to
review standards of care for the youth each quarter. All documentation from the meeting is in
the nursing office. The DHA also meets with the nurses weekly to discuss any clinic suggestions
or needs.
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 four registered nurses (RNs). 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. Three of the licenses were valid through April 2025,
and one was valid through April 2026. In addition, each of the 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 80 hours. The nursing staff are in compliance with
the contractual requirements.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related 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 FOPs on
January 27 and May 9, 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 May 15, 2024.
The nursing protocols were signed by the nursing staff on January 27, 2024. There were no new
policies or changes in policy made during the annual compliance review period. The annual
review of all FOPs and protocols was indicated by signatures by the respective individuals from
nursing on March 5, 2024, March 6, 2024, March 8, 2024, and March 27, 2024, signifying their
understanding of the FOPs and any new health-related Department policies. All newly hired
medical staff received 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.
A review of five youth Individual Healthcare Records (IHCRs) found three were applicable for
completion of an Authority of Evaluation and Treatment (AET) form. Each applicable youth had
a signed AET form filed in the IHCR with copy legibly stamped on it. One of the three applicable
youth was in the care of the Department of Children and Families and the IHCR contained a
valid court order authorizing treatment at the program. Each AET was valid, as required for as
long as the youth is in the program or until the youth’s eighteenth birthday. Two youth were
eighteen at admission and one youth turned eighteen after admission to the program. The two
applicable eighteen-year-old youth had a documented release of information dated on the day
of admission, as well as the youth who turned eighteen while in the program, dated on the
youth’s eighteenth birthday. An interview with the registered nurse (RN) confirmed the program
obtains a current AET from the Department’s Juvenile Justice Information System (JJIS). If the
AET is over one year old, the program will notify the juvenile probation officer (JPO) for a
current AET; however, the AET is valid for as long as the youth is under any type of supervision
by the Department. If the youth is in DCF custody the program must have a court order signed
by a judge for care and treatment of the youth. All youth sign a release of information form the
day of their eighteenth birthday. The youth may sign to discuss all health related information
with their parent/guardian, to release health related information only with written permission, or
not to share any information with the parent/guardian. The program maintains a medical tracker
telling staff when the youth in the program turn eighteen and to have them sign accordingly.
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4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is notified of any
changes in the youth’s condition and to document informed consent for youth healthcare. A
review of five youth Individual Healthcare Records (IHCRs) found three were applicable for
parental/guardian notifications for over-the-counter (OTC) medications beyond those covered by
the Authority for Evaluation and Treatment (AET), and consent was provided by the
parent/guardian. The remaining two youth were not applicable as no OTC medications beyond
the AET were required and both youth were over the age of eighteen. Two of three applicable
IHCRs included documentation of attempted contact to the parent/guardian in the progress
notes when a new medication was ordered. The remaining youth was not applicable for new
medications. All three applicable IHCRs contained written notifications documented on the
Department’s Parental Notification of Health Related Care: General or Parental Notification of
Health-Related Care: Medications forms. One youth was applicable for taking prescribed
psychotropic medications and parent/guardian verbal consent was documented on page three
of the Department’s Clinical Psychotropic Progress Note (CPPN) form. One youth was in the
care of the Department of Children and Families (DCF) and the court authorized all treatment
and procedures within a court order. In all five IHCRs, the youth vaccinations were verified
within thirty days of the youth’s admission. None of the youth were applicable for a religious
exemption from immunization.
An interview with the registered nurse (RN) confirmed parental/guardian notifications are made,
as required, when there are changes in the youth's health condition, when there is a new
medication or changes in existing medications, when a youth returns safely back to facility from
an appointment, and when there is recommended treatment by a medical provider. As soon as
the doctor’s order is received by a nurse, the parent/guardian is called which is witnessed
through the phone log form. This is required for any medications and treatments not listed on
the AET. This is part of orientation and training to all nurses. Verbal notification must be made to
the parent/guardian in emergency situations and is followed by written notification. Verbal
contact by the psychiatrist to the parent/guardian to explain the purpose and possible side
effects of the medication, or changes in psychotropic medications including new orders,
discontinued medication or increase or decrease in dosage require a parental/guardian consent
witnessed by the nurse or staff. When a youth is in need of vaccinations, they are sent to the
local health department’s immunization center. Vaccination records are obtained from the
Florida Shots website. All current immunization records are recorded in the database. When
youth enter the facility, part of the admission process is to go in the Florida Shots Database and
pull up the youth. The program then prints and looks for completion of immunization for the
youth’s age. The record is then placed in the youth medical file and flagged for the DHA to
review and sign. If a parent/guardian claims exemption and will not give consent for
vaccinations, the parent/guardian completes the religious exemption immunizations form, signs,
and submits it to the facility.
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4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures regarding youth healthcare admission screening and
rescreening each time the physical custody of the youth changes. Five youth Individual
Healthcare Records (IHCRs) were reviewed for a Facility Entry Physical Health Screening
(FEPHS) form. All five FEPHS forms were completed by the registered nurse (RN) on the date
of the youth’s admission. One of the youth was out of the physical custody of the Department for
greater than twenty-four hours and a FEPHS rescreening was completed on the date of the
youth’s return to the program. The interview with the RN confirmed the RNs complete the
FEHPS forms on the day of admission on all youth. If a youth is out of their custody, a new
FEPHS is completed upon return to the facility.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures ensuring all youth admitted to the program are
provided an orientation to healthcare services within twenty-four hours of admission. A review of
five youth Individual Healthcare Records (IHCRs) confirmed all youth were provided a general
care orientation upon admission to the program. Orientation included access to medical care,
sick call, what constitutes an “emergency,” medication process, right to refuse care, what to do
in the case of a sexual assault or attempted sexual assault, the role of non-disciplinary
healthcare providers, and Standard Universal Precautions. All topics were documented as
discussed with the youth as evidenced by their signature documented on the Health Education
form in the youth’s IHCR.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to notify the designated health authority (DHA) or
designee, by telephone or verbally, of each youth’s arrival at the program and provide
immediate notification when any youth admitted to the program requires emergency care. The
program’s practice is to notify the DHA of all youth admissions including youth with chronic
conditions, medical concerns, or any youth admitted on psychotropic medications. Five youth
Individual Healthcare Records (IHCRs) were reviewed, and three of the youth were admitted
with a known or suspected chronic condition which required a referral to the DHA. None of the
youth were identified as in need of an emergency response upon admission. All records
documented the DHA notification, completed within twelve hours of admission, in the youth’s
Chronological Progress Notes and the Chronic Conditions Log was updated after the
notification. One youth was applicable for taking psychotropic medication upon admission, and
the IHCR documented notification to the psychiatrist. According to an interview with the
registered nurse (RN), the DHA is notified of all new admissions and any chronic conditions on
the day of admission, as documented on the admission progress note.
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4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures ensuring the Department’s Health-Related History
(HRH) form is completed prior to the Comprehensive Physical Assessment (CPA) and
healthcare needs are identified. A review of five youth Individual Healthcare Records (IHCRs)
found each contained a HRH completed on the day of the admission. All five IHCRs indicated
the HRH form was completed prior to the CPA verified by the date and signatures. In each
reviewed IHCR, the designated health authority (DHA) reviewed the HRH form as evidenced by
a checkbox on the CPA and a focused note in the admission documentation. An interview with
the registered nurse (RN) confirmed a new HRH is completed on the day of admission for all
new youth by the nursing staff and a new CPA is completed by the DHA within seven days of
the youth’s admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of a
Comprehensive Physical Assessment (CPA). Though all youth had a current CPA on file, the
program completed a new CPA on all youth admitted into the facility. All new CPAs were
completed on the Department’s CPA form with in the seven day requirement. All reviewed CPAs
indicated the designated health authority (DHA) completed each. All reviewed CPAs contained
all required elements and the appropriate documented Medical Grade. Each CPA was marked
with an “X” or “O” accordingly. All five IHCRS indicated each youth refused a portion of the
examination. Four of five youth signed a refusal form completed on the date of the examination.
One youth signed the CPA. All five youth IHCRs documented the Department’s Problem List
was updated as required. All five youth had at least one verified tuberculosis skin test (TST)
within the last year documented in the IHCR. The TSTs were found documented on the CPAs
and Infectious and Communicable Disease (ICD) forms. An interview with nursing staff
confirmed a current CPA is completed within seven days of the youth admission. Medical Grade
one youth receive a new CPA every two years and for Medical Grade two through five, one is
completed annually from. The most recent TST is noted in the medical tracker, the front of the
medical chart, and on the CPA. A copy of the skin test is kept behind the ICD form. Screenings
are done yearly from the time of the last purified protein derivative or screening.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
Five youth Individual Healthcare Records (IHCRs) were reviewed for sexually transmitted
infection (STI) screening and human immunodeficiency virus (HIV) screening requirements.
Each record was applicable for screening. All five reviewed youth required further evaluation
and were referred to the designated health authority (DHA). Documentation in each record
confirmed the referral was documented on STI form. Four of five records indicated testing was
ordered. One youth was determined to not require testing. Two of the four records indicated
testing was performed. Two youth refused testing. For both applicable youth, testing screening
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results, clinical evaluations, and diagnoses were documented on the Infectious Communicable
Diseases (ICD) form. There was evidence in the applicable healthcare records to indicate each
youth was offered counseling, testing, and treatment, if indicated, for HIV. Both applicable youth
received HIV testing. Documentation confirmed each applicable youth provided consent for the
test and a copy is located within the IHCR. Results of HIV testing were filed confidentially in a
sealed envelope marked ‘Confidential’, consistent with Florida Administrative Rule. There was
also evidence on the sealed envelope indicating the DHA reviewed the results. Documentation
of pre and post-test counseling was observed in the youth’s healthcare record, as required.
Each youth’s confidentiality was protected by not indicating the youth’s HIV status on the
program’s internal alert system. The program maintains a policy reflecting HIV test results are
only disclosed to the youth, youth’s legally authorized representative, healthcare providers
during the course of consultation, diagnosis, or treatment, the Department of Health for
purposes of reporting and control of spread disease, health facility staff committees conducting
program monitoring, evaluation and service reviews, and/or healthcare facility personnel or
agents for healthcare providers who have a need to know in the course of patient care activities
or administrative operations. A local facility provides post-test and counseling services Five
interviewed youth reported they are allowed to ask for an HIV test. An interview with nursing
staff confirmed if the admission STI screening indicates an evaluation is required a referral to
the DHA is completed. The DHA determines the need for testing during the Comprehensive
Physical Assessment (CPA) or if the youth requests one during admission. STI results are filed
in the lab section of the chart and documentation is noted on the ICD form and STI screening,
which youth are to answer and sign. Retesting is ordered if symptoms are present. HIV testing
results are kept in a sealed and stamped envelope in the lab section of the chart signed by the
DHA. During admission, HIV is discussed in general, and youth complete a risk form and
answer test questions. If HIV testing is requested, it is notated on the form and the youth sign a
consent for the HIV testing.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
Five youth Individual Healthcare Records (IHCRs) were reviewed for the sick call process. None
of the reviewed youth presented with similar sick call complaints three or more times within a
two-week period. All five records indicated each youth completed a sick call request form as
well as the nursing staff. None of the sick calls were completed by a licensed practical nurse
(LPN). All applicable sick call request forms were filed in the IHCR in reverse chronological
order. There were no instances where youth were placed in restricted housing of any kind. All
sick calls were documented in accordance with the Florida Administrative Code. All sick calls
were documented on each youth’s sick call index and on the program’s sick call referral log. All
dates on the sick call index corresponded to the sick call forms located in each youth’s IHCR. A
review of the daily posted schedule and nursing interview confirmed sick call is conducted daily.
Sick call is conducted daily from 7:00 a.m. to 8:00 a.m. and from 2:00 p.m. to 4:00 p.m. Sick call
hours are posted on the medical area door. According to documentation, sick call is only
performed by a licensed nurse. The program has a procedure allowing shift supervisors to
review all sick call requests as soon as possible and within four hours after the request is made
when there is not a licensed nurse on-site. Sick call request forms are located in the large
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pavilion and both dormitories, available to all youth. An exam table and equipment are used to
perform sick calls.
An observation of a sick call was able to be conducted during the annual compliance review
week. The youth’s verbal consent was received prior to observation. The youth was escorted to
sick call by the assistant facility administrator. The medical provider identified themself and
stated the reason for the sick call The youth was seen in a private area with no other youth
present to hear or see the examination being conducted by a licensed medical staff. Medical
staff were able to maintain privacy during the exam as the escorting staff was outside the open
medical door office maintaining constant sight and sound supervision. Five interviewed staff
reported the nurse reviews sick call as well as responds to or conducts the sick call. An
interview with five youth was conducted. Four of five youth reported they are immediately seen
after a sick call request. One youth reported not ever having made a request for sick call. An
interview with nursing staff confirmed youth complete a sick call form and place it in the secured
sick call boxes, which are checked twice a day. Youth are informed of the sick call process at
admission and throughout their stay. Also, youth may tell a staff of any health concerns they
have and if emergent, can bypass the sick call process, and be seen right away. The registered
nurse (RN) on-site conducts sick call, no LPNs are used, and the DHA approves all protocols
and conducts sick call when on site. Sick call is conducted in the medical clinic during the
posted times. If youth present with similar complaints three or more times within a two-week
period, they are referred to the DHA.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
Five Individual Healthcare Records (IHCRs) were reviewed for episodic, first-aid, or emergency
care and three of the five IHCRs were applicable. Documentation revealed all applicable youth
required on-site first-aid or episodic care. Two of the three records indicated on-site care was
provided by a licensed healthcare staff and care was documented in subjective, objective,
assessment, and plan (SOAP) narrative. One of the three youth was provided episodic or first-
aid care by a non-healthcare staff and care was documented on the Department’s Report of On-
Site Health Care by Non-Health Care Staff form. The one applicable youth did receive a follow-
up evaluation from a licensed healthcare staff during the next on-site visit or sooner. The
program’s episodic and emergency care procedures were reviewed during the annual
compliance review week. The program has a total of nine first-aid kits. First-aid kits are located
in master control, sub-control A, sub-control B, maintenance, kitchen, and both classrooms. Two
first-aid kits are available for transportation, one for each van. First-aid kits are restocked by
healthcare professionals after use and inventoried monthly. Staff document use of kits and
submit to nursing. Inventories are monitored for expiration dates and expired items. First-aid kits
are re-sealed with breakaway tabs after each use and re-stocking. A review of three first-aid kits
was conducted during the annual compliance review week. Each first-aid kit was fully stocked
with designated health authority (DHA) approved contents, with a list of the contents which was
also attached to the kits. Nursing conducts weekly first-aid checks and documented checks
within a binder. Documentation confirmed first-aid kits are monitored as required. The program
utilizes one automated external defibrillator (AED), located in the pavilion. The AED procedures
are located along with the AED. The medical staff are designated to perform checks of the AED
batteries and pads to ensure they are operable. Annual compliance review team members were
able to observe an AED self-test during the annual compliance review. There were no issues
observed during the self-test. According to documentation, the expiration date of the AED
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battery is October 31, 2027, with the last date the AED battery was changed being March 3,
2022. Documentation confirmed the expiration date for the AED pads is August 7, 2024, and the
last date the AED pads were changed was March 31, 2022. According to reviewed drill
documents, direct care staff did participate in at least one annual drill which included the use of
cardiopulmonary resuscitation (CPR). Documentation supported the drills did simulate an
episodic care event which called for immediate first-aid and/or administration of CPR techniques
and the initiation of the emergency procedures to follow when a life-threatening emergency
does occur. A review of emergency medical drills indicated a drill was conducted on each shift
monthly, consisting of both announced and unannounced drills. Staff with direct contact on a
day-to-day basis had the opportunity to participate in at least one annual emergency man down
drill. Emergency numbers are in medical and master control, accessible to staff and not to
youth. Staff authorized to administer the epinephrine auto-injector were designated in writing
and appropriately trained. Due to Department-wide system outages, staff training records could
not be reviewed during the annual compliance review week.
An episodic care event was able to be observed during the annual compliance review week.
Nursing staff were able to maintain privacy as the escorting staff was located outside the
medical examination area in the hallway. The program does maintain a policy regarding the use
and access to Naloxone nasal spray. The program carries prescribed non-youth specific
naloxone nasal spray kits for emergency purposes of accidental overdose for use for all youth in
the program’s care. Naloxone is kept in the medication cart. The medication cart is locked and
the keys to the cart are placed in a lock box. The facility administrator (FA), assistant facility
administrator (AFA), and shift supervisors have access. Each designated staff has been
appropriately trained on when and how to administer Naloxone. Naloxone is inventoried daily
and documented. Five staff reported they are allowed to call 9-1-1 if a youth has a medical
emergency. An interview was conducted with five youth. Each youth reported they can see a
dentist or doctor if needed. An interview was conducted with nursing staff who knew the location
of the first-aid kits. Episodic care is provided by the RN and a SOAP note is placed in the
youth’s chart. If episodic care is conducted by a non-healthcare staff, the appropriate form is
completed and placed in the chart. A follow up episodic form or progress note is conducted by
the registered nurse within twenty-four hours. Off-site emergency care is tracked on a calendar,
the episodic log, and a monthly logbook. The AED is mounted in the pavilion on the wall along
with AED procedures. Nurses on-site perform weekly and as needed checks to ensure batteries
and pads are operable. Emergency medical drills are done monthly with CPR being included in
the drills at least quarterly, if not more. Emergency contact lists are posted in the medical
department, master control, and behind the alert board by the education director’s office.
Emergency medical drills are conducted monthly with code white announcements.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
Five youth Individual Healthcare Records (IHCRs) were reviewed for off-site care referrals. Four
of the five reviewed IHCRs were applicable for off-site care. In each applicable case, the
Summary of Off-Site Care Consultation Report form was utilized and filed in the IHCR. One
applicable record contained documentation of efforts to notify the youth’s parent/guardian. The
remaining three eligible records did not require parental/guardian notification efforts due to
youth being eighteen years of age. Three applicable records contained filed discharge
documentation, with one record not being applicable for being discharged. Documentation in the
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three applicable records confirmed the designated health authority (DHA) reviewed, signed, and
initialed all off-site care findings, instructions, and information. An interview with nursing staff
was conducted. Nursing staff confirmed a calendar, episodic log, and regional notification logs
are used to track youth who receive off-site emergency care. Nursing further confirmed when
hospital orders are received, the registered nurse (RN) calls the DHA for a telephone order to
continue the orders. Orders are faxed to the pharmacy and transcribed to the Medication
Administration Record (MAR) and parent/guardian is notified if needed. To confirm how the
DHA is reviewing and initialing off-site care findings, nursing reported a calendar is used. When
off-site information is received the RN notifies the DHA and places the summary in the DHA’s
book for review and signature during their next visit. The youth is also added to the list for their
next visit. Follow-up testing, referrals, and appointments are tracked in the appointment log and
calendar.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of chronic
condition periodic evaluations. Two of the five IHCRs were eligible for chronic condition. An
additional record was requested for review. The three applicable records indicated each youth
was admitted to the program with a chronic condition and was taking prescribed medications on
an ongoing basis. None of the youth had a communicable disease. Two of the three records
indicated youth were undergoing treatment for physical health condition. According to
documentation, all three records indicated each youth was classified as a Medical Grade
between two and four. All three records indicated youth were placed on a chronic illness list and
received periodic evaluations at least every ninety-days. Documentation further revealed all
three IHCRs contained progress notes which were reviewed for each completed periodic
evaluation, which were also conducted prior to the renewal of an expired prescription
medication, if applicable. There was no indication any of the youth were administered anti-
tuberculosis medications. Two of the three youth required an off-site evaluation which was
documented on the summary of Off-Site Care form, filed in the chronological progress notes
section of the IHCR. Documentation indicated the designated health authority (DHA) did follow
up with each youth after receiving off-site care and signed off on the documents. There were no
instances of lapses in care or periodic evaluations. The Department’s Problem List was updated
in accordance with Florida Administrative Code for all applicable youth. An interview with the
facility administrator (FA) confirmed the FA’s understanding of procedures in place for
healthcare staff’s review of important medical issues and how they meet with healthcare staff
daily. An interview with the DHA was conducted. The DHA confirmed periodic evaluations are
completed every ninety days and nursing staff maintains a hardcopy of the chronic illness list in
a binder as well as in the medical tracker. An interview with nursing staff was conducted.
Nursing staff confirmed youth with chronic conditions are placed on the medical tracker which is
reviewed monthly and updated accordingly. The chronic list is added to the DHA’s weekly visit
list when appropriate.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
Five youth Individual Healthcare Records (IHCRs) for medication management requirements.
According to documentation, two of the five youth were eligible and admitted to the program
with medications. Three of five were not admitted to the program with medications. Of the
eligible youth, all medications had been verified prior to being admitted to the program. The
prescription verification was included in the chronological progress notes, the Electronic Medical
Record (EMR), or the Prescription Medication Verification Checklist form. The designated health
authority (DHA) or designee and psychiatrist were notified to obtain orders to resume specified
medications prior to admission. Documentation in all five IHCRs revealed all medications had a
current, valid order, were administered pursuant to a current prescription, and the DHA placed
an order on the Practitioner Order form. None of five had evidence of being in restricted housing
during the annual compliance review period. Three of the five reviewed IHCRs were applicable
for receiving over-the-counter (OTC) medications not listed on the Authority for Evaluation and
Treatment (AET) form, which were administered for each applicable record according to the
Practitioner Order form as required. The program utilizes a form similar to the Department’s
Medication Administration Record (MAR) with all the required elements. There was evidence in
two of five records indicating trained non-healthcare staff assisted in the delivery of medications
during a period when licensed staff were not on-site. Both applicable MARs were initialed by the
staff and the youth as well. Three of five records were not eligible and there was no evidence
trained non-healthcare staff delivered medications. There were no instances of undocumented
explanations for lapses or errors in medication administration. There was evidence in each
IHCR reflecting nursing staff documented weekly side effect monitoring on each MAR. There
were no instances of medication refusals. None of the five reviewed records indicated the youth
required parenteral medication. One applicable youth was admitted to the program with
prescribed psychotropic medications. All records contained documentation each youth received
an Initial Diagnostic Psychiatric Interview within fourteen days of admission. The one eligible
youth prescribed psychotropic medications received medication monitoring every thirty days. No
other youth were prescribed psychotropic medications. The program has no standing orders,
pro-re-nata (PRN) orders, or emergency treatment orders for psychotropic medications.
Medication administration was able to be observed during the annual compliance review week.
The administering medical staff’s sole responsibility was to conduct medication pass and not
conduct other activities or supervise youth. The youth’s verbal consent was obtained prior to
administration observation. The youth was observed being escorted by master control staff
individually. The medical provider appropriately identified themself and reported to youth the
specific reason for their presence. Medications were prepared and administered by the same
nurse and were not pre-poured and placed in another container prior to administration. The
youth’s allergy and alert status were verified by nursing staff. The MAR was initialed by both the
youth and staff. Nursing staff did observe the youth to ensure medications were swallowed.
Administered OTC medications were appropriately documented by nursing staff. The Six Rights
of Medication Administration were verified during observation. An interview with five youth was
conducted. One of the five youth stated the nurse gives medications. Four youth stated they do
not take medications. An interview with five staff was conducted. Each staff reported the nurse
dispenses medications. An interview with nursing staff was conducted. Nursing staff reported all
youth medication is verified upon admission using the Department’s Prescription Medication
Verification Checklist. The medication is verified prior to arrival and recorded on the
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Department’s Medication, Receipt, Transfer, and Disposition form. The form and medications
are double checked by the receiving nurse upon the youth’s arrival. All medications must
contain an intact pharmacy label with the youth's name on it. The DHA must be notified when a
youth arrives with medication and an order must be obtained to continue the ordered
medication. Nursing staff confirmed the program utilizes a pre-printed pharmacy MAR which
contains all components of Department’s MAR. The nursing interview also confirmed non-
healthcare staff provide medications. There is a training curriculum, and the RN provides the
training. The approved list of non-healthcare staff is in the medication passbook located in the
nursing office and on the front of the MAR. Medication pass times are 8:00 a.m., 1:00 p.m., 5:00
p.m., and as needed seven days a week. The program does have a modified class II permit.
Medications are mainly procured through a vendor, and occasionally are procured through the
local pharmacy if state order is needed. The psychiatrist is on-site for two or more hours a week
to provide therapy and prescription management as well as discuss pertinent issues with the
clinical director and therapists as needed. The psychiatrist also provides administrative support
with facility operating procedures.
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 maintains a policy and procedures addressing medical equipment classified as
sharps. Sharps were secured and inventoried utilizing a routine perpetual inventory. All
medications were identified and secured in the locked area designated for storage of
medications. The medication cart was clean, organized, and stocked with items separate from
youth-specific medications. The program was not in possession of any controlled substances
during this annual compliance review. When controlled medications are on-site, they are stored
behind three locks, a lock box inside the locked medication cart, and the keys are kept in a lock
box mounted on the wall. All medications were stored in a separate, secured location not
accessible to youth. The program does not have any medications requiring refrigeration. In the
event they are in possession of any, there is a refrigerator located in the clinic equipped with a
thermometer and temperature log. Expired medications are destroyed weekly by way of
dissolvent. Perpetual and weekly inventories of all sharps and stock over-the-counter (OTC)
medications were conducted as required. Nursing staff were able to articulate the process of
shift-to-shift inventory of controlled substances. The program maintains a list consisting of seven
non-healthcare staff who have been trained in the delivery and oversight of medication self-
administration. Staff training was delivered by a registered nurse (RN) or higher. Three OTC
medications were observed and counted. The final count listed on the inventory sheet matched
the actual count observed. Three sharps were observed and counted in which the final count
listed on the inventory sheet matched the actual inventory. The program has procedures in
place for reporting inventory discrepancies. Any staff who opens the medication cart is
responsible for signing the key log. Nursing checks with staff who have signed the log and will
rectify any discrepancy and correct the log if applicable. An interview with nursing staff was
conducted who reported a prescription drug buster is the process used to dispose of
medication, which occurs weekly or as needed. A disposal binder and disposal container are
utilized as well. Medication disposals are tracked using the binder. Each medication disposal is
witnessed. All medications are stored behind a double lock system in the clinic. The OTC
medication stock inventory is locked in the clinic, behind a locked door, and the medication cart
has a lock box key in the clinic to access the cart. The OTC medications on the med cart are
counted daily. The stock OTC medications in the closet are counted weekly, and as they are
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removed. The pharmacy consultant is on-site for monthly inspections to monitor medication
carts, medication disposals, and storage of medications. A copy of the license is maintained on-
site.
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 maintains a policy and procedures for infection and exposure control. The
program’s procedures include prevention, containment, treatment, and reporting requirements
related to infectious diseases according to federal regulations and the Centers for Disease
Control and Prevention (CDC) guidelines. The program’s policy and procedures were signed by
the designated health authority (DHA) on May 9, 2024, and by the facility administrator (FA) on
January 27, 2024. The program’s infection control procedures include all required elements
such as common infectious diseases from childhood, self-limiting, episodic contagious illnesses,
viral or bacterial infectious diseases, tuberculosis, Hepatitis A, B, and C, human
immunodeficiency virus (HIV), infections caused by blood borne pathogens, other outbreaks
caused by infectious agents, outbreaks of lice or scabies, Methicillin-Resistant Staphylococcus
Aureus (MRSA), food born illnesses, bio-terrorist agents, and chemical exposures. Hepatitis B
vaccinations are available for staff and staff have access to protective equipment. There were
no instances in which the local county health department, CDC, and/or the Department’s
Central Communications Center had to be notified of any infectious diseases. The FA has
established a sperate file of documents for youth and staff who have experienced a
facility/occupational exposure. The program’s Exposure Control Plan is written in accordance
with Occupational Safety and Health Administration (OSHA) standards and is available to staff.
The plan was reviewed and signed by the FA on January 27, 2024. The program maintains a
policy and procedures for needle stick post-exposure evaluation. There were no cases of
reportable infectious diseases nor were there any instances requiring hospitalization or
quarantining. An interview the FA was conducted. The FA displayed an understanding of the
program’s policy relating to the exposure control plan. An interview with nursing staff was
conducted. Nursing staff reported a copy of the Exposure Control Plan is in the nursing office
and in the lobby for all staff to read. On duty nurses conduct staff training on the Exposure
Control Plan and infection control procedures. Nursing staff also provide infection control
training to youth upon admission and throughout the year.
4.19 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a written policy and procedures requiring all program staff to promote
safety and security by maintaining active supervision of youth to include interacting positively
with youth, engaging youth in a full schedule of constructive activities, closely observing
behavior of youth, and consistently applying the program’s behavior management system
(BMS). The program’s contract requires staff-to-youth ratios to be one-to-eight during awake
hours and one-to-twelve during sleep hours. The ratio for off-site activities, transportation, and
visitation is one staff to five youth. The program staff are required to account for the
whereabouts of youth under their supervision and ensure staff-to-youth ratios are in compliance
with contract requirements. A program tour verified the daily youth activity schedule was posted
throughout the program and is designed to keep youth engaged in a full schedule of activities.
Observations of staff supervision for four days during the annual compliance review week
included classroom activities, line movement, school breaks, youth head counts, mental health
groups, vocational activities, youth searches, and outdoor/indoor recreation activities. In
addition, youth were observed attending an assembly to honor veterans and using tools while
cleaning the unit/dormitory. The observations ensured staff-to-youth ratios were maintained, as
required. A tour of the program verified the program and living units were clean, well
maintained, and graffiti free. A perimeter check was conducted, and fencing appeared to be in
good repair. Staff and youth were appropriately attired. During outdoor activities and/or
movement, observations verified staff were strategically positioned to ensure proper supervision
of youth and to ensure there were no physical obstructions in their view of the youth.
Observations of interactions between program staff and youth reflected the interactions were
positive and consistent with the program’s BMS. An informal interview with three staff verified
each staff knew the number of youth they were supervising. Video observations of youth were
conducted during sleep hours. The observations verified youth to staff ratios were in
compliance, staff were awake and alert, and staff conducted ten-minute checks as required.
Five interviewed staff explained if there is a discrepancy in the youth count, all movement stops
until an accurate count is completed and the youth is found.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program maintains a written policy and procedures addressing the implementation and
training of the program’s behavioral management system (BMS), which included all required
parties in the development, implementation, and on-going maintenance of the system. The
policy includes a protocol where staff are provided feedback of the implementation of the BMS.
There is an agreement between the program and the county school system related to the BMS.
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Documentation reflected both the program and education staff were trained in the BMS. Five
reviewed position descriptions confirmed each job’s function includes implementation of the
program’s BMS. A review of the policy, youth handbook, and BMS documentation demonstrated
a system which outlines youth behavioral expectations, rewards and consequences, and a level
system which has a gradation component. The process also includes explaining to youth the
reasons for any sanctioning, gives the youth the opportunity to explain their behavior,
opportunities for staff and youth to discuss the impact of behavior on others, reasonable
reparations of harm caused to others, discussions of alternative behaviors, promotes positive
dialogue and peaceful conflict resolution, and minimizes separation of youth from the general
population. The BMS included all required elements and does not include consequences which
increase length of stay, denial of a youth’s basic rights or services, promotion of group
discipline, punishment of youth by other youth, or disciplinary confinement. All youth are
oriented to the system through the handbook during their admission. Five reviewed youth case
management records confirmed youth orientation included a review of the program’s BMS, and
four of the five contained an acknowledgement form signed by the youth, one was missing
youth initials. Provided documentation detailed youth are monitored daily throughout each
activity and assigned points based on adherence to the expectations. Staff provide justification
for low scores and/or positive feedback on the back of the card. Incentives are designed with
youth and applied to the BMS based a gradient system. Consequences are also on a gradient
system and based on severity. Rewards are offered at a minimum of four positive to one
negative consequence and demonstrate youth can earn extra privileges, recreational activities,
movies, additional time in the game room, and can buy items from the program’s point store.
Observations found the BMS is posted throughout the program in each living unit and provided
in the youth handbook. Staff and youth interactions were observed for adherence to the BMS, to
include negative consequences and positive rewards, where consequences were in direct
relation to the seriousness of the inappropriate behavior. Five staff were interviewed, and each
staff indicated they received training in the BMS and was able to articulate an understanding of
the system. The staff collectively reported youth are rewarded with canteen, off-campus outings,
and movie night with popcorn and nachos. Staff also reported youth are informed of the
consequences and are they able to explain their behavior immediately with staff during the
problem behavior reporting process and during treatment teams. Staff stated they receive
feedback from supervisors through coaching notes, verbally through one-on-one meetings, and
daily debriefings. Five interviewed youth were able to articulate the rewards and consequences
of the BMS, as well as how to move from level to level. Each youth indicated staff are
consistent, using rewards the same, with two youth stating the system is fair and three stating
the system is good. All interviewed youth confirmed they are never allowed to discipline other
youth. The facility administrator’s (FA’s) interview indicated an understanding of the program’s
BMS.
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5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program’s policy, procedures, and practice confirm the program does not use room
restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program maintains a policy and procedures to ensure ten-minute checks are conducted
when the youth are asleep or in their rooms. The program has a total of thirty-six cameras which
were all operating at the time of the annual compliance review. The program’s video recording
has a thirty-day storage capacity. 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.
Checks are documented on the program’s Ten-Minute Check Logs with the time of each check
noted in real time along with the initials of the staff conducting each check. A review of eight
separate video footage samples, which include two shifts and two dormitories of ten-minute
checks and Ten-Minute Check Logs documented by staff reflected one discrepancy. On May
10, 2024, for shift A/dormitory A, one ten-minute check was completed four minutes late. An
interview with the facility administrator (FA) and observations confirmed all the cameras were
functional during the week of the annual compliance review. Five staff were interviewed, and all
indicated room checks are completed when the youth are sleeping in their rooms and
throughout the sleep period every ten minutes.
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.
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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’s policy is to conduct formal head counts each hour and after outdoor activities. In
addition, the policy indicates counts are conducted during power outages, escapes, program
disturbances, or any other disruptions which may occur. A review of 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, and at regular
intervals. Six randomly selected dates and times in the program’s logbook were reviewed for
census counts during the annual compliance review period. Documentation validated head
counts and movements were conducted at the beginning of each shift, after outdoor activities,
and during actual and/or simulated drills. There were no emergency situations, such as program
disturbances, on the dates reviewed. In addition, the program logbooks included documentation
of new admissions, releases, daily census counts, youth movements, 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. Five interviewed staff
verified formal counts are conducted every hour. Each staff stated emergency counts are
conducted anytime a code is called, if there is a discrepancy in the count, and during drills. All
five of the interviewed staff knew the youth census during the annual compliance review week.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a written policy and procedures requiring a chronological record of routine
events, incidents, activities, and emergency situations in a logbook in accordance with Florida
Administrative Code. A review of the program logbooks confirmed the program’s logbooks were
bound with pre-printed numbered pages; however, the logbook for November 12 through 26,
2023, had some loose pages. Observations and a review of logbooks during the annual
compliance review period found logbook entries were documented in ink with no erasures or
white-out errors. Errors were typically 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 names of the staff
and youth involved, a brief description of the event, and the name and signature of the staff
making the entry. The logbook, as well as activity schedule, showed there was minimal
interference of educational instruction, reflected youth arrive on depart school on time, and
indicated recreation was conducted as scheduled. The program utilizes shift reports to
summarize the events, incidents, and activities documented in the program’s logbook and to
brief all incoming staff, who initial their review in the logbook. A review of the logbooks and shift
reports demonstrated staff documented the required events, incidents, and activities. The
logbook included documentation of incidents, counts, perimeter checks, youth transports,
emergency situations, admissions, releases, and calls to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC).
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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, secure storage,
missing or lost, and damaged program keys. Keys are bound on a tamper resistant ring which
includes a brass-colored tag with the number of keys and a key/tracking number. Program keys
are maintained in master control in a wall cabinet with the corresponding key number which can
be locked if necessary. Master control is secured, and youth do not have access. 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 and the master control staff knew which area each
key was assigned to. Active keys are assigned to direct care staff while restricted keys are
designated for medical staff, kitchen staff, case managers, and therapists. An interview with
master control staff as well as observations indicated the program’s practice is when direct care
staff arrive to the program, personal keys are placed inside of the box located outside of master
control. Medical staff, kitchen staff, case managers, and therapists receive their respective
restricted keys from master control after their personal keys are placed in the box. Both the
master control operator and staff receiving a program key initial the key log before and again at
the end of the shift when the keys are returned. A review of the key logs and logbooks during
the annual compliance review period verified this practice. In addition, the program has a list of
staff who are assigned permanent keys. The key is not easily accessible while locked.
Permanent keys are issued, and staff sign an acknowledgment form indicating a 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. Any damaged key is reported
to the shift supervisor and maintenance request form is completed, which is then given to the
maintenance manager along with the broken key to be replaced. A random check of three staff
verified the number of keys on the key ring matched inventory and each staff knew the key’s
function. A review of the Department’s Central Communications Center (CCC) reports during
the annual compliance review period indicated there were no incidents related to key control.
Five staff were interviewed and were able to explain the program’s key control process. All staff
reported youth do not have access to keys.
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
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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’s youth handbook and policy include a
list of contraband items, outlined in the Florida Administrative Code, and informs youth of the
consequences if found with contraband. Each youth is provided with a written copy of the youth
handbook upon admission into the program and all are oriented to the program rules including
the list of items considered to be contraband. The list of contraband items include sharps,
escape paraphernalia, tobacco products, lighters or matches, electronic or vaporless cigarettes,
unauthorized food or clothing, any intoxicating beverages, any controlled substance, any
prescription or non-prescription drug, any firearm or weapon, any explosive substance, non-
program issued keys, unauthorized currency, non-program issued cellular telephones and/or
equipment or electronic devices capable of taking pictures or video recordings, as well as smart
watches. In addition, the program’s policy includes contraband search procedures of the
physical plant, searching the program grounds, youth searches, and searches of incoming and
outgoing mail. The program’s policy specifies the way any unauthorized or contraband item is to
be disposed, to include return to the sender, mailed to the youth’s home, returned to the youth
upon release, or, in the case of illegal contraband, turned over to law enforcement.
Unannounced room searches and common area searches are conducted daily on each shift at
irregular and unpredictable times. During the program tour, several randomly selected rooms
were checked, and no contraband was found. A review of the master control logbook, visitation
forms, and incident reports validated the program’s practice of monitoring areas of the program,
grounds, and youth rooms for contraband. The program’s policy requires case managers to
inspect all outgoing and incoming correspondence in the presence of the youth for unauthorized
items, contraband, or information which may breach the security of the program. The program’s
policy and procedures, with orientation training provided to all new staff, stipulate staff, including
supervisors and administrators, found in possession of contraband will be subject to disciplinary
action up to and including dismissal. Eight staff have been hired since the last quarterly review
and documentation verified each staff signed an attestation form. The visitor log contains an
attestation statement. The program documents the confiscation and disposal of contraband. All
instances involving confiscation of illegal contraband require the program to turn the item over to
local law enforcement authorities and file a criminal report. A review of the Department’s Central
Communications Center (CCC) reports since the execution of the contract indicated there were
no instances of contraband found at the program which needed to be turned over to law
enforcement. A review of logbooks, incident reports, and search reports confirmed the
frequency and quality of searches and the results. In an interview with the facility administrator
(FA), it was indicated any discovery of contraband and/or illegal contraband is immediately
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reported to the CCC. Law enforcement is then contacted, at which time all contraband items are
turned over to the responding police agency. Five staff were interviewed, and each stated room
checks are conducted daily on each shift at irregular and unpredictable times.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures to ensure searches and full body visual searches are
conducted according to Florida Administrative Code at the time of admission, after off-campus
activities, and visitation. Parent(s)/guardian(s) 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 before all movement, during a new admission, during readmission, after returning
from visitation, when returning from off-campus activities and/or appointments, when suspected
of having contraband, or when a youth is determined to be a security risk. The program
conducts searches as a method to prevent the introduction of contraband and unauthorized
items into the program. Policy indicates searches of youth are conducted after off-site
transports, after visitation, before moving youth from an outside area into the building, and prior
to moving youth from the building to an outside area. There were observations of searches
made during line movements, returning from an off-campus appointment, and before moving
from the building to an outside area during the annual compliance review week. Youth search
and full body visual search forms were reviewed and confirmed the program conducts full body
visual searches at the time of admission and other off-site appointments. Searches were
documented in the program’s logbook. Observations made throughout the annual compliance
review week validated youth are provided instructions regarding the search, searches were
conducted by staff of the same gender as the youth, were conducted in a manner as to not
degrade the youth and were based on the Protective Action Response (PAR)/Right Interactions
(RI) training manual. Five staff were interviewed, and each staff was knowledgeable of the
program’s policy regarding the search procedures. Five youth were interviewed and reported
youth searches occur when returning from off campus, after outdoor activities, after visitation,
and after meals. Two youth indicated searches also occur when items are missing and after
work detail.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a policy and procedures requiring the program vehicles to be properly
maintained, contain safety and emergency equipment, and be operated in a safe manner. 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 seatbelts, a seatbelt cutter, a
window punch, a fire extinguisher, and an approved first-aid kit. At the time of the annual
compliance review, the program had two operational vans used to transport youth. Both
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transportation vans were equipped with fire extinguishers, approved first-aid kits, seatbelt cutter,
window punch, and the appropriate number of seatbelts. Doors for the youth passenger area
cannot be opened from the inside. The safety screen is not applicable as the program is non-
secure. Both vans passed inspections during the annual compliance review period. The
program maintains a log which had documentation of completed weekly vehicle inspections.
The results of the vehicle inspections are documented and stored in the program’s vehicle
maintenance log/binder. A review of the weekly inspections showed all were completed, as
required. A random check of eight personal vehicles and the program’s transportation vehicles
was conducted during the annual compliance review week. The staff vehicles and one of the
transportation vehicles were found to be locked. The back door of one transportation vehicle
was found to be unlocked at the time of the random check. There was a transportation available
for observation during the annual compliance review week and no issues were noted. Five
interviewed youth indicated during vehicle transports youth are secured within the vehicle with a
seatbelt. Five staff were also interviewed and three staff indicated youth are secured within the
vehicle with shackles and handcuffs, one staff indicated youth are secured within the vehicle
with shackles and seatbelts, and one staff also indicated two staff must accompany the youth on
a transport and the youth are secured within the vehicle with a seatbelt.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures to ensure the safety and security of youth and the
community during transportation of youth, and to ensure the appropriate staff-to-youth ratio is
maintained while youth are transported off program grounds. The program has an approved
transport list which is updated monthly to ensure staff driver’s licenses are valid. The approved
driver list is in the administrative area by the facility administrator’s (FA’s) office. Reviewed
documentation verified all approved drivers had a valid driver’s license. The program is not
applicable for providing secure transportation for secure high-risk and secure maximum-risk
youth, or non-secure youth determined to be at greater risk. Youth are not permitted to drive
program or staff vehicles. An observation was conducted of the vehicles, and they were found to
be in working order. Observations of a transport, during the week of the annual compliance
review, confirmed the staff-to-youth ratio was within the contract requirements, both staff and
youth wore seatbelts, and at least one staff was the same gender as the youth. An interview
with the FA confirmed the program’s transportation process. Five staff were interviewed, and
each was able to articulate the correct ratio to be maintained during transports. Five youth were
interviewed, and all stated they felt safe while being transported and have not seen staff place
contraband in a transport vehicle. Five staff were interviewed, and each indicated the safety
equipment in the transport vehicles includes a fire extinguisher, first-aid kit, window punch, and
seatbelt cutter. All staff reported transport vehicles are searched for contraband prior to and
after each use, and they are not allowed to use personal vehicles to transport youth. Four staff
indicated the emergency response process consists of notifying the program, the program
director, and calling emergency services. One staff indicated to obtain a headcount and a clear
description of the event. One staff indicated to call the Department’s Central Communications
Center (CCC).
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5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures requiring the maintenance of a safe and secure
physical plant, grounds, and perimeter. The program has designated the facility administrator
(FA) and/or designee as the person responsible for conducting the weekly safety and security
audits. The weekly safety and security audits include the inspection of the program’s camera’s,
radios/communication devices, keys, locks and doors, vehicles, and living areas to include
youth rooms and bathrooms. A review of the programs Preventative Maintenance Checklist and
Safety Inspection Logs during the annual compliance review period confirmed the physical plant
worker conducts weekly safety/security inspections. Findings are documented on the Weekly
Safety Inspection Report and provided to the safety and security specialist for review. All
deficiencies are tracked, and efforts are made to correct any deficiencies noted. During the
annual compliance review period, there were no inspections missing or any discrepancies. The
forms documented safety and maintenance repairs needed and the date and time the repairs
were completed, or due to be completed. All inspection forms were reviewed and signed by the
physical plant worker. The program had ongoing efforts for any repairs. An interview with the
physical plant worker stated all work orders are submitted for each issue identified and are
tracked for resolution. An interview with the FA confirmed safety and security audits are
conducted on a weekly basis. Additionally, the FA stated all deficiencies are documented, a time
frame is given to have the items corrected, and deficiencies identified are discussed during
morning meetings.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures to address the proper identification, control, and
management of tools to ensure youth do not use tools or equipment as weapons or security
breaches. The reviewed policy addresses the issuance, inventory, and control of equipment and
tools. The policy prohibits specific tools including machetes, bowie knives, and long blade
knives. The program has a policy and procedures for missing/lost tools and for tools requiring
disposal. The program has identified the physical plant worker as the program’s tool control
manager. The policy classifies tools into two categories, Class A tools and Class B tools. Class
A tools are hazardous with sharp edges or points with a high potential to be used as a weapon
to inflict serious bodily harm such as knives, hammers, screw drivers, and electric drills. Class B
tools do not have sharp edges or points such as brooms, mops, and scrub brushes. A review of
inventory logs and the tool storage room verified tools are securely stored when not in use,
easily marked for identification, and are inventoried prior to and following work activities.
Observations found the maintenance office to be organized, neat, and clean. All tools were
observed to be maintained in a secured location. All Class A tools were stored on the
maintenance office walls with a photo of the tool and a number to identify the tool was stored in
the proper place. All Class A tools were in good repair and accounted for. All Class A tools are
inventoried daily by the physical plant worker except on days when the maintenance office is not
accessed. Class B tools are inventoried daily by program staff. The facility administrator (FA)
reviews the inventories monthly. A review of the inventory sheets validated this practice. The
program has a sign-in and sign-out log for Class A and Class B tools. All tools were properly
identified and inventoried during the annual compliance review period. A review of twenty tools
and corresponding inventories validated inventories were accurate. A review of five pre-service
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training records indicated all staff were trained on the safe use of tools. During an informal
interview, the program’s physical plant worker was aware of the proper procedures to follow if
tools are missing or damaged. Further indicating, if a tool is missing while youth are in the area,
staff will notify administration, the program will stop all youth movement, and the program will be
searched until the tool is found. Additionally, the physical plant worker stated there were no
tools which were damaged or out of use at the time of the annual compliance review. A review
of the Department’s Central Communications Center (CCC) reports verified there were no
instances of missing/lost tools during the annual compliance review period.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures to ensure youth use tools safely and are supervised
appropriately to prevent injuries to themselves, other youth, and staff. The program’s policy and
procedures included supervision requirements, issuance and collection of tools to youth and
staff, established ratios during activities involving tools and disciplinary work projects, and
searches. Class B tools which include mops, brooms, toilet brushes, and scrub brushes are
inventoried daily by staff to ensure each is accounted for. A review of the Class B Tool Inventory
Log sheets confirmed the program’s practice. A risk assessment of each youth’s risk to self and
others is required to determine their eligibility to use Class B tools. Use of Class B tools and
participation in work projects is based upon each youth’s level within the program’s behavior
management system (BMS). Five youth case management records were reviewed, and all
indicated youth have been trained on the proper usage of tools. A signed acknowledgement
form is filed in each youth’s case management record. An interview with program staff indicated
risk assessments are completed monthly and risk reassessments are completed if youth are
required to go off-site for an off-site scheduled activity, such as a home visit or for community
service. During the annual compliance review week, video footage was observed which involved
youth and the use of tools. One youth was observed sweeping the common area of the dorm
with a broom while being monitored by one staff; one youth was observed using a mop and mop
bucket to mop the common area of the dorm while being monitored by two staff. Based on the
observations, the staff to youth ratios when youth were using tools was accurate. Five youth
interviews confirmed youth are allowed to use a mop and broom. Five staff were interviewed,
and each confirmed youth are allowed to use a mop and broom.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures establishing guidelines for outside contractors who
come on-site to complete repairs. When a contractor or vendor enters the program, they sign
the Outside Contractor On-Site Work Project Log which lists unauthorized items. The physical
plant worker or designee inspects all tools upon the arrival of outside contractors and is
responsible for providing approval if such tools are required. The program’s guidelines for
external workers include checking of tools upon arrival and departure, searching of all vendors
prior to entering the program, tool restriction while in the program, missing tool follow-up, and
restriction of youth from the work area. The outside contractor completes the program’s Outside
Contractor form upon entrance to the program, where they list what tools are needed to
complete the work order. Maintenance will review the form and sign once the tools are
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inventoried and approved. Upon exiting the program, the Outside Contractor form is reviewed,
all tools are verified, then the form is signed. Any tools required to be used within the program
are inventoried and recorded on the contractor’s agreement form before and after the repair is
completed. Reviewed documentation for three project invoices showed the vendors signed
contractor agreements, an inventory of tools was completed when they arrived and left, and the
inventory was documented. Documentation for the outside contractor forms verified the forms
were completed and all requirements were met. A review of the work project logs during the
annual compliance review period verified the contractors signed the log confirming notification of
what items are considered unauthorized. If any unauthorized items are needed by the contractor
while in the program, approval is obtained by the facility administrator (FA) or designee.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a policy and procedures to ensure fire safety and evacuation drills are
conducted, and youth and staff are prepared for immediate implementation or mobilization in the
event of an emergency or disaster. A review of the program’s Continuity of Operations Plan
(COOP) revealed the program conducts monthly fire drills on each shift. COOP drills are
conducted semi-annually on each shift. A tour of the program, during the annual compliance
review week, found fire evacuation routes and egress plans were posted throughout the
program. The program has eight fire extinguishers and reviewed documentation reflected all
were inspected annually. A review of drill documentation for the annual compliance review
period indicated the program conducted one monthly fire drill, as required, on each shift. A
COOP drill was conducted semi-annually on each shift. The program conducted semi-annual
COOP drills which included emergency drills, disturbances, escapes, medical situations, and
severe weather. Reviewed documentation for all drills contained the type of drill, date and time,
participants, brief scenario, findings, and recommendations. Five interviewed youth reported
they have been instructed on what to do in case of a fire and drills are conducted once each
month. Five interviewed staff said they have participated in at least one COOP drill which
included either a weather, major disturbance, chemical spill, escape, and fire drills. An interview
with the facility administrator (FA) confirmed the program conducts monthly fire drills on all
shifts. COOP drills are conducted semi-annually.
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 has a written policy and procedures requiring the development of a Continuity of
Operations Plan (COOP) which is updated as necessary and maintained for the continuity of
essential functions of the provider in the event an emergency prevents occupancy of the primary
program location, in compliance with state law and the Department’s policy. The COOP
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addresses phases of a disaster plan as well as emergency management including
preparedness, response, and recovery. The COOP addressed emergencies including fire
prevention and evacuation, severe weather, major disturbances, bomb threats, hostage
situations, chemical spills, flooding, terrorist threats or acts, staff roles and responsibilities, any
equipment and supplies needed, information about youth which may be needed, alternative
housing arrangements, provisions for continuity of care and custody of youth, and provisions for
public protection. The COOP details alternative housing plans in case the program is required to
vacate due to an emergency or disaster. A review of the COOP validated the plan was
submitted and approved by the Department on April 29, 2024, and provides for basic care and
custody of youth in the event of an emergency or disaster. The interviewed facility administrator
(FA) indicated the staff have access to the program’s COOP and it is in the FA and master
control offices. The program has the necessary supplies readily available in case of an
emergency evacuation maintained within the storage room. The food supplies are in the kitchen.
The program maintains an administrative hard copy for each youth in case of an emergency.
The program’s hard copy records are easily accessible and mobile in the event of an
emergency resulting in the program relocating quickly or in the event needed information cannot
be accessed electronically for all youth in the program. A review of five youth case management
records confirmed each contained the youth’s name, a photograph, Department identification
number, admission date, date of birth, gender and race, overall health status, address, and
parent/guardian contact information which included name, address, telephone number of the
person with whom the youth resides and their relationship to the youth, and person(s) to notify
in case of an emergency. In addition, the records contained the youth’s assigned juvenile
probation officer (JPO), committing judge, state attorney, public defender. Victim notification
contact information and personal physician (if known) were not applicable.
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 addressing storage and inventory, to ensure all youth
and staff are safe from the effects of the unauthorized use of flammable, poisonous, toxic, and
caustic materials. The program’s physical plant worker maintains a monitoring system to ensure
compliance with flammable, poisonous, and toxic items. The chemical inventory is completed
daily and documented in the Chemical Inventory Sheet. A tour of the program and observations
found the program stored the flammable materials in a flame-resistant locked cabinet located
outside of the program. A review of the flammable, poisonous, and toxic items list verified the
items were securely stored. Toxic cleaning items and materials are located within a secure
cabinet outside of the program which was inaccessible to youth. A review of five unique
cleaning items verified four out of the five chemical inventories were accurate; however, eight
bottles of toilet bowl cleaner were not listed in the inventory. The physical plant worker stated
the toilet bowl cleaner is not used at the program and the product was removed from the
program. A review of five unique flammable chemicals were reviewed and found four of the five
were listed in the inventory; however, one adhesive remover was not listed in the inventory. The
physical plant worker added the chemical into the inventory during the annual compliance
review week. Copies of each Safety Data Sheet (SDS) are maintained in the locked cabinets
with the chemicals with the exception of the toilet bowl cleaner and the adhesive remover. The
program has an approved list of staff authorized to handle flammable, poisonous, and toxic
items which include maintenance staff, the facility administrator (FA), the assistant facility
administrator (AFA), safety and security officers, shift supervisors, and food service staff.
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5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures prohibiting youth from handling any flammable,
poisonous, and/or toxic items or materials. Program youth are strictly prohibited to use, handle,
or clean dangerous or hazardous chemicals, respond to chemical spills or clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste.
Observations confirmed all chemicals were maintained behind at least one locked door/cabinet
and youth do not have access to areas where items are being stored. Youth do not have access
to these items and are supervised by staff during daily cleaning. During the annual compliance
review week, youth were observed by video on two separate instances cleaning and did not use
chemicals. Five interviewed youth reported not using any chemicals and/or cleaning products.
The physical plant worker indicated staff handle cleaning products and youth are only able to
wipe with a cleaning cloth.
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 has a written policy and procedures for the disposal of flammable, toxic, caustic,
and poisonous items. The policy prohibits chemicals from being poured on the ground or being
disposed of by any method other than what is outlined by the biohazard guidelines. The policy
also states upon becoming aware of a chemical spill, staff notify master control of the location.
The shift supervisor shuts down all of the air handlers and ventilation systems and closes all
windows and doors. If needed, assistance from outside of the program is contacted. The
program reported liquid waste, including dirty mop water and unused beverages, is disposed of
in the specialized plumbing drains. All kitchen waste, with the exception of grease, was
disposed in the kitchen drains. The kitchen staff placed grease in a separate container for
disposal. The program’s physical plant worker, facility administrator (FA), safety and security
officer, shift supervisors, food service, and assistant facility administrator (AFA) are the only
staff authorized to handle flammable, poisonous, and toxic items. Reviewed documents
confirmed the program’s disposal procedures of chemicals were created in accordance with
Occupational Safety and Health Administration (OSHA) standards. The program maintains a
Safety Data Sheet (SDS) Log to track the disposal of such items. An interview with the physical
plant worker indicated the program has not needed to dispose of any chemicals during the
annual compliance review period. The program’s physical plant worker was interviewed on the
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Office of Accountability and Program Support Page 67 of 70 (Revised September 2022)
proper procedures of disposing chemicals and stated all items for disposal are returned to the
vendors or hazardous waste center. An interview with the FA validated this practice.
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.
This 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 has a policy and procedures to allow youth to have visitation and communication
with family members while in the program. The program assists youth and families in
maintaining connections in a visitation environment which provides monitoring, control of
movement, and security practices to ensure visitor, youth, staff, and program safety. The
program’s policy provides each youth opportunities to promote communication and engagement
which fosters family reunification and community connections. The program also maintains a list
of approved visitors; however, attorneys, representatives of the court, juvenile probation officers
(JPO), other agency representatives, and clergy are authorized to visit at any time. Searches of
visitors will be conducted upon entry and all youth shall be searched following visitation
sessions. The program’s visitation policy indicated consideration for requests of alternative
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Office of Accountability and Program Support Page 68 of 70 (Revised September 2022)
visitation arrangements with parents/guardians, if needed. Youth are informed about visitation
upon their admission to the program during the orientation process. The visitation and
communication procedures are covered in the youth handbook, parent/guardian handbook, and
addressed on the orientation checklist. The visitation procedures are posted in the lobby.
Visitation is held two days a week on Saturdays and Sundays from 1:10 p.m. to 2:10 p.m. Youth
are given opportunities to communicate with their family in person, by telephone, and by mail.
Youth are provided with writing materials and stamped self-addressed envelopes to send letters
to approved family members. The program maintains a Correspondence Log for each youth
which documents incoming and outgoing mail, which is inspected by staff. The Correspondence
Logs are maintained in each youth’s case management record. Youth are permitted weekly
telephone calls. Each youth’s use of the telephone is documented in each youth’s case
management chronological documentation. A review of the logbooks, visitation sign-in logs, and
outgoing and incoming mail logs verified the program allows visitation and mail only for
approved immediate family members. The JPO must approve the immediate family members. A
review of the telephone chronological notes verified youth have consistent telephone
communication with family members. It is the program’s practice for the assigned case manager
to follow-up with the JPO regarding human trafficking victims to determine whether the
parent/guardian should be permitted to communicate with the youth; however, there were no
youth applicable with a history of human trafficking during the annual compliance review period.
Five youth were interviewed, and each confirmed they can call and/or send letters to their
parent(s)/guardian(s). Two interviewed youth indicated a translator can be utilized if a youth’s
primary language is not English, one youth indicated program staff can be utilized, one youth
indicated the Language Line can be used, and one youth did not know what services the
program utilizes for youth who do not speak English. In an interview with the facility
administrator (FA), it was stated the program utilizes the Language Line for youth if English is
not their primary language. Five staff were interviewed, and all indicated the program utilizes the
Language Line for youth when English is not their primary language.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a written policy and procedures to ensure each youth has a variety of
recreation and leisure activities. A review of the staff roster confirmed the program has a
recreation therapist, who met all requirements for the position. The program’s recreation
calendar designates an activity for the youth to participate in during outdoor recreation each
day, as well as a calendar of alternative activities if recreation is indoors. The program’s activity
schedule is posted throughout the living units and common areas of the program. All activities
promote social and cognitive skill development, creativity, teamwork, healthy competition,
mental stimulation, and physical fitness. Youth are provided with at least one hour of large
muscle activity daily. Reviewed documentation of the logbook and daily activity schedule
confirmed the program has a range of supervised and structured indoor and outdoor recreation
and leisure activities for the youth, for at least one hour daily. Observations made throughout
the annual compliance review week validated youth are provided with at least one hour of
indoor or outdoor recreation and leisure time. Five interviewed staff indicated the program
provides youth with at least one hour each day of recreational activities. Staff indicated the
outdoor activities consist of basketball, football, soccer, volleyball, and kickball, and the indoor
activities consist of board games, indoor games, and other card games. Five youth were
interviewed, and each youth indicated the program allows youth the opportunity to exercise,
play outside, or play inside depending on the weather. Each youth indicated they are allowed to
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Office of Accountability and Program Support Page 69 of 70 (Revised September 2022)
participate in basketball, football, or soccer while outside, and when inside, they participate in
board games and/or can watch television.
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.26 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 70 (Revised September 2022)

report_type: QI Residential

program_name_raw: Duval Academy

rule: Indicator 2.16

excerpt: Exit Portfolio

rating: Limited Compliance