summary: QI Residential - FY23-24 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Cypress Creek Treatment Center
TrueCore Behavioral Solutions LLC
(Contract Provider)
2856 West Woodland Ridge Drive
Lecanto, Florida 33461
Review Date(s): January 16 – 19, 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:
Jennifer Tummino, Office of Accountability and Program Support, Lead Reviewer ([Standard 1])
Rob Aguis, Office of Education, Director of Postsecondary and Workforce Education (Standard
1)
Jeff Campbell, Office of Education, Education Coordinator (Standard 2)
Melissa Johnson, Office of Accountability and Program Support, Regional Supervisor (Standard
3)
Tamara Mahl-Adkins, Office of Accountability and Program Support, Regional Monitor
(Standard 4)
Gus Mazorra, Office of Accountability and Program Support, Regional Monitor (Standard 1 and
Standard 5)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Jeff Williams, Pasco Regional Juvenile Detention Center, Superintendent, (Standard 5)
Program Name: Cypress Creek Treatment Center MQI Program Code: 1055
Provider Name: TrueCore Behavioral Solutions LLC Contract Number: 10207
Location: Citrus County / Circuit 5 Number of Beds: 96
Review Date(s): Januray 16-19, 2024 Lead Reviewer Code: 201
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
4.17 Medication/Sharps Inventory and Storage Process
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 69 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Non-Applicable
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 69 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 69 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 69 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Limited
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 69 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Satisfactory
5.25 Controlled Observation Satisfactory
5.26 Controlled Observation Safety Checks and Release Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 69 (Revised September 2022)
Program Overview
Cypress Creek Treatment Center is a thirty-two bed program, for fifteen to twenty-one year old
males, located in Lecanto, Florida. The program is operated by TrueCore Behavioral Solutions
LLC, through a contract with the Department. The program provides mental health and
substance abuse services. In addition, the program fosters each youth by providing Aggression
Replacement Training, Skillstreaming the Adolescent, the Passport Program, the Bullying
Workbook for Teens, Social Perception Training, the Stress Reduction Workbook for Teens,
Problem Solving Training, Empathy and Social Competence Training, Living in Balance,
Resilience Builder Program for Children and Adolescents, and Impact of Crime. Additional
treatment services provided include family and individual counseling. Program administration is
comprised of a facility administrator (FA), assistant facility administrator of operations, assistant
facility administrator of support services, and a chief of security. Case management services are
provided by one director of case management, six case managers, one intake specialist, and
two transition services managers. Mental health staff at the program include one contracted
psychiatrist, one clinical director, one assistant clinical director, seven therapists, two
recreational therapists, and one file technician. Medical services are offered 6:30 a.m. to 7:00
p.m. daily and are provided by one designated health authority (DHA), one health services
administrator, and four registered nurses (RNs). Educational services are provided by the
programs educational staff. The layout of the program includes one large building which houses
all dormitories, kitchen, classrooms, administration, clinic, offices, controlled observation rooms,
maintenance, mental health, case management, and master control. The program has 121
operating security cameras providing coverage. At the time of the annual compliance review,
the program had twenty-six vacant positions including twenty-one youth care workers, one
assistant clinical director, two therapists, one part-time physical plant worker, and one human
resources generalist.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 69 (Revised September 2022)
Strengths and Innovative Approaches
Innovative Practices for Youth
• Positive Youth is a celebration of all youth who do not have any incident reports or
behavior reports for the month. Youth who achieve this goal receive a special meal.
• Birthday Club is for the youth who have a birthday each month. Youth celebrate their
birthday with cake and ice cream. Youth also receive a birthday card signed by the
management team.
• Youth who achieve their daily goals from Thursday through Monday are awarded with a
hamburger. Additionally, youth who achieve their daily goals from Monday through
Thursday are awarded with a sausage dog as an additional snack.
• Honors/Honors Gold Club is for youth who earn a specific level to get together and have
a meal.
• Independent Night is for youth on a specific level to have a meeting to discuss how to
earn the next level and receive a special snack.
• When a dorm earns “dorm of the month”, the youth assigned to the dorm receive a meal
and control over what to watch on television for the month.
Innovative Practices for Staff
• Employee of the Month is an award staff receive for positive performance and
attendance.
• Weekly themed activities are associated with football, states, heart awareness, Breast
Cancer Awareness, and holidays.
• Monthly Morale meeting to schedule more staff activities and staff are invited to join or
send their ideas.
• Staff Awards for performance, going above and beyond, mentoring youth, and rising
stars.
• Monthly Anniversary recognitions
• The program holds All Staff Meals, also yearly Thanksgiving and Christmas meals.
• Birthday Cards with gift cards mailed to staff on their birthday each month, all cards are
signed by the management team.
• Daily Snack bar for staff with snacks, cocoa, tea, coffee, and cereal.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 69 (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 addressing pre-employment background screenings.
An informal interview with the facility administrator confirmed the program had one new
volunteer who assisted or interacted with youth on an intermittent basis for less than ten hours a
month and did not need to be background screened. The program’s policy requires a staff, who
is background screened, to always be present within the line of sight of the volunteer who is not
background screened. An Annual Affidavit of Compliance with Level 2 Screening Standards was
completed and submitted to the Department’s Background Screening Unit on December 6,
2023, meeting the annual requirement. A review of the program’s staff, volunteer, and
contractor rosters found forty-four staff were applicable for an initial background screening
during the annual compliance review period. No volunteers were applicable for an initial
background screening during the annual compliance review period. Each of the forty-four
applicable staff had a completed and eligible background screening, as required, prior to contact
with youth and confidential youth records. Reviewed documentation validated a criminal history
report was reviewed for each staff. A pre-employment assessment tool was administered for
each direct care staff and a pre-employment assessment passing score was documented in
each reviewed direct care staff record. All forty-four staff were added to the program’s roster in
the Agency for Healthcare Administration’s Clearinghouse system, as required. A break in
service was indicated in the Staff Verification System (SVS) for nineteen staff and a new
background screening was completed for each of the nineteen staff. The remaining twenty-five
staff did not have a break in service.
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 addressing five-year background rescreening for
staff. The program had sixteen staff and two contracted staff applicable for a five-year
rescreening during the annual compliance review period. All eighteen applicable staff received a
five-year rescreening within the required time frame and a rescreening was submitted to the
Department’s Background Screening Unit (BSU) at least ten business days prior to the five-year
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 69 (Revised September 2022)
anniversary date, as required. There were no volunteers applicable for a five-year background
rescreening during the annual compliance review period.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
 The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
 All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
 Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
 The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
 A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to ensure program-related incidents, which place at
risk or have the potential to place at risk, the health, safety, or welfare of the public or of youth,
staff, visitors, the security of the facility, or the reputation of the provider are reported and
handled appropriately and in a timely fashion. The program has a zero-tolerance policy in
regard to any abuse. All staff shall immediately report any knowledge or suspicion regarding an
incident of abuse which occurred in the program by calling the Florida Child Abuse Hotline,
notifying the Central Communication Center (CCC), and the regional director. The program had
no incident reports of claims against staff for physical abuse or emotional abuse. The program
conducted the Trauma Response and Caring Environment (TRACE) self-assessment on
January 31, 2023. Staff adhere to a code of conduct, as acknowledged by the review and
signing of a code of conduct during their orientation which are contained in the staff personnel
records. Twenty-seven staff code of conduct forms were reviewed. Seven reviewed pre-service
training records and seven in-service training records reflected staff received training on child
abuse reporting. During the facility tour the Florida Abuse Hotline and CCC telephone numbers
were observed to be posted throughout the program. All seven interviewed youth reported they
feel safe in the program. All seven youth reported they have never been prevented from making
a call to the Florida Abuse Hotline. Two youth reported making calls to the Florida Abuse Hotline
and staff helped them. Six of seven youth reported either knowing the telephone number for the
Florida Abuse Hotline or knowing where it was posted; the remaining youth did not know the
telephone number was posted; however, the youth had just arrived at the program. Six of seven
youth reported staff are respectful when talking with youth and the remaining youth indicated
sometimes the staff are respectful. None of the seven youth reported hearing staff curse around
youth, nor have they ever exchanged emails, telephone numbers, or social medica contact
information with staff. Each of the seven interviewed staff were familiar with the program’s
abuse reporting procedures. All seven interviewed staff reported they have never observed a
coworker denying a youth the right to an abuse call and all seven reported they have not
witnessed their coworker’s using profanity, using threats, intimidation, or humiliation when
interacting with youth. Six of seven staff knew where to find the telephone number for the
Florida Abuse Hotline; however, the remaining staff indicated they did not know. The facility
administrator (FA) reported the program’s code of ethics directs staff to provide youth with
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 69 (Revised September 2022)
quality care, promotes excellent customer service, and states the abuse of youth will not be
tolerated. New staff are provided new hire training and discussions take place in all staff
meetings to ensure staff are knowledgeable in contacting the Florida Abuse Hotline and CCC.
The youth handbooks and youth information boards contain contact information as well. All calls
at the program are tracked in the master control logbook and are discussed in the daily
management meetings. The program incorporates trauma-responsive practices by utilizing the
champion team to develop a plan based upon surveys, Can We Discuss forms, community
meetings, and monthly educational handouts for staff and youth.
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.
The program had no incidents of physical, psychological, or emotional abuse during the annual
compliance review period; therefore, this indicator is rated non-applicable.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a policy and procedures addressing the process for contacting the
Department’s Central Communications Center (CCC). The program reported eight incidents to
the CCC during the annual compliance review period. A review of five CCC incidents during the
annual compliance review period revealed four of five incidents were reported to the CCC within
the required time frame and each incident was documented in the program’s logbook. The
remaining incident was called in by the program ten minutes late. There were no additional
internal incidents or grievances during the annual compliance review period which should have
been reported to the CCC and were not. An interview with the facility administrator (FA)
indicated when a youth requests an abuse call, the youth is taken to the telephone. Any
reportable incident must be reported to the CCC within two hours.
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 requiring a Protective Action Response Right
Interactions mode (PAR/RI) Incident Report to be completed and filed 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). The program had a total of ten PAR/RI incidents during the annual
compliance review period. A sample of five PAR/RI Reports were reviewed. All five reports were
completed by the end of the staff’s workday and included statements from all staff involved.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 69 (Revised September 2022)
None of the PAR incidents required the use of mechanical restraints; therefore, the Mechanical
Restraint Supervision Log was not required. None of the PAR incidents resulted in injuries to
youth or staff and there were no allegations of abuse; therefore, staff did not need to contact the
Department’s Central Communications Center (CCC) or the Florida Abuse Hotline. All the
PAR/RI Reports were reviewed by a supervisor, a PAR/RI instructor, and the facility
administrator (FA) within seventy-two hours of the incident. One of the PAR/RI incidents
required a medical review and the youth was seen by medical staff on-site. Copies of the
PAR/RI Reports were placed in the program’s centralized file within forty-eight hours of approval
by the FA. Monthly summaries of all PAR/RI incidents submitted to the Department’s regional
office by the fifteenth of each month are maintained by the program. The program last updated
the PAR/RI plan on January 6, 2023, and the plan was approved by the Department on January
12, 2023. The program had a total of thirty-one PAR/RI incidents during the previous annual
compliance review. The program experienced a decrease in PAR/RI incidents from the time of
the previous annual compliance review. The program’s PAR/RI rate during the previous quarter
was 2.55, which is above the statewide Residential PAR rate of 1.82. The FA was interviewed
and advised PAR/RI incidents are reviewed daily during the management meetings. Seven staff
were interviewed and four said they had used PAR/RI, while three said they had not. All seven
staff were able to describe the program’s process and procedures in which they could use
PAR/RI.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program has a policy and procedures outlining the training and certification requirements
for all new staff. Seven staff training records were reviewed for pre-service/certification
requirements. All seven staff completed all required pre-service trainings and essential skills
prior to contact with any youth. Six of seven staff completed trainings as required by other Rules
or manuals, with the single exception of one staff not completing training on the grievance
process. All trainings were documented in the Department’s Learning Management System
(SkillPro), as required.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a policy and procedures outlining the in-service training requirements for staff.
Seven staff training records were reviewed for in-service trainings including four direct care staff
and three supervisory staff. All four direct care staff completed all required in-service trainings.
Each of the three supervisory staff training records included all required in-service trainings and
exceeded the required eight hours of supervisor trainings in the areas of coaching, leadership,
and personal accountability. All seven staff completed trainings as required by other Rules or
manuals. All trainings were entered into the Department’s Learning Management System
(SkillPro). The program maintains an annual in-service training calendar which is updated as
changes occur. The program submitted a list of in-service training to the Department’s Office of
Talent, Leadership, and Culture and the training plan was signed on December 30, 2022.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 69 (Revised September 2022)
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 training requirements for the grievance
process, as well as the informal, formal, and appeal phase. Youth are encouraged to resolve
questions, disputes, and complaints through informal communication with program staff. Staff
are directed to use active listening skills, respectful conversation, and give youth the opportunity
for full expression of feelings regarding the conflict, with the ultimate goal of encouraging and
promoting open communication, and to assist the youth in the development of improved
problem solving skills. Informal complaints should be handled within twenty-four hours. The
program maintained grievance logs for each month of the annual compliance review period;
however, there were no formal grievances filed during the annual compliance review period. All
seven youth interviews indicated they knew where to find a grievance form and six of seven
youth knew what to do with the form upon completion. One of the youth indicated they do not
know the process due to not having to submit a grievance. All seven youth stated they could ask
for assistance in completing a grievance form. All seven staff interviews indicated the grievance
forms are placed throughout the program, two staff stated youth can request assistance in
completing the forms, five staff stated the supervisor reviews the grievances, and four staff
indicated the facility administrator (FA) reviews them as well. Six of seven staff were able to
describe the grievance review process, and the remaining staff was new and stated they did not
know about the grievance process. To ensure understanding for all staff, the program reviewed
the grievance process with staff during the all-staff meeting, during the week of the annual
compliance review. The FA interview indicated the program's informal grievance process is
resolved by using the Can We Discuss forms. Youth place the completed grievance in the box,
it is collected by staff, and then reviewed in the management meeting. The forms are logged
and resolved with the youth, and if not resolved, the FA will review the complaint and make a
final decision.
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 twelve facilitators who conducted groups since the last annual compliance review
indicated all had training in the groups they facilitated and were determined to be the right fit
regarding education and work experience to deliver the delinquency intervention services. Four
of the twelve staff who provided Impact of Crime (IOC) did not have degrees; however, they
each possessed over twenty years of work experience. The eight remaining staff had
appropriate education and work experience. All twelve staff were formally trained in the
corresponding curriculum. A review of the schedule indicated the minimum number of groups
were provided as indicated on the schedule. The program offered Skillstreaming the Adolescent
until January 1, 2024, which was replaced by Aggression Replacement Training (ART). The first
class was scheduled to begin on January 22, 2024. The program’s activity schedule was
reviewed and confirmed the program is providing structured, planned programming, or activities
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as least sixty percent of the hours youth are awake. The facility administrator (FA) interview
indicated Skillstreaming the Adolescent, ART, and IOC are utilized as evidenced-based and
promising practices to address the needs of youth. The designated mental health clinician
authority (DMHCA) interview indicated the licensed and non-licensed mental health
professionals provide group, individual, family, and supportive sessions. Recreation therapists
provide therapeutic activities.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures addressing how life and social skills training are
provided to youth. Impact of Crime (IOC) is provided twice a week by a trained case manager or
youth care worker. Living in Balance (LIB) consists of twelve core sessions addressing
emotional components and substance abuse situations, in addition to twenty-one supplemental
sessions, and is offered once a week. Skillstreaming the Adolescent utilizes homework
assignments for each youth to practice their new learned skills in between sessions. The group
is offered once a week by a trained therapist.
A review of group sign-in sheets indicated all groups were provided as required during the
annual compliance review period. In addition to the life skills intervention services, the program
works with the youth in career counseling, which includes résumé building, finances, budgeting,
and determining career choices. The program also has begun adding goals, which include
career counseling and the Holland assessment, which measure strengths and weaknesses with
regards to career paths. Seven interviewed youth stated they were all enrolled in groups, which
included substance abuse, mental health, anger management, and skillstreaming. The facility
administrator (FA) interview indicated youth are enrolled in IOC, which is available until January
16, 2024. The designated mental health clinician authority confirmed the program provides
Living in Balance (LIB), Pathways to Self-Discovery and Change, 100 Interactive Activities for
Mental Health and Substance Abuse Clients, Teen Relationships workbook, Bullying Workbook
for Teens, The Stress Reductions Workbook for Teens, Skillstreaming the Adolescent, Group
Treatment for Substance Abuse, Resilience Building Program, and Anger Management for
Mental Health and Substance Abuse Clients. Substance abuse curricula is provided weekly on
a rotation with other curriculum.
. The DMHCA also advised youth are able to practice skills through their daily use of the
positive performance system and how they navigate advancement through the level system.
Youth participate in daily meetings where they are provided an opportunity to appropriately
discuss their grievances and issues, demonstrate their leadership skills, and present for their
levels where they are encouraged to recognize and address their strengths and weaknesses or
areas in need of improvement. Many of the youth utilize conflict resolution as a means to
formally problem solve with peers to safely express their feelings and work together to solve
problems. Youth are provided opportunities to co-facilitate mental health and substance abuse
groups and they take turns in leading recreational activities. The youth advisory board is an
opportunity for youth to demonstrate their ability to advocate for themself and others.
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1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program provides the Impact of Crime (IOC) curriculum which addresses restorative justice
awareness for youth and helps them develop empathy for crime victims and survivors, while
increasing personal accountability for criminal actions and harm to others. The IOC curriculum is
facilitated by the case managers of the program. The program’s activity schedule addresses
group times. Both of these restorative justice groups are considered primary services as of
January 10, 2024. In addition to IOC, the program also affords youth opportunities to complete
community service hours on-site, send letters to members of the armed forces and appreciation
letters to mothers, mentoring opportunities through Big Brothers/Big Sisters, recognizing the
International Day of Peace, and participation in “Plant a Tree Day”. Seven youth were
interviewed and six advised they have completed IOC, while one is scheduled to begin IOC the
week following the annual compliance review. The youth advised some of the skills they have
learned in IOC are used daily, such as anger management and coping skills, remaining calm
and being positive, discussing, and writing essays on ways to help victims of crimes. The facility
administrator advised each youth who enters the program is required to participate in an IOC
group and they complete projects associated with restorative justice throughout the year, which
are presented to the community by the staff. The designated mental health clinician authority
(DMHCA) was interviewed and confirmed the youth participate in various restorative justice
projects throughout the year. The DMHCA also advised youth utilize skills learned in life and
social skills training when participating in these projects.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures which address and determine how youth alerts are
identified, documented, updated, and communicated to program staff. The program maintains a
continually updated internal alert system which is easily accessible to program staff and keeps
them alerted about youth who are security or safety risks, including escape risks, suicide or
other mental health risks, medical risks, sexual predator risks, and other assaultive or violent
behavior risks. Seven youth records were reviewed to address the program entering alerts in
the Department’s Juvenile Justice Information System (JJIS). One of the seven youth were
found non-applicable for alerts, which was confirmed in JJIS. The six applicable youth records
reflected alerts were entered into JJIS as required. All alerts were verified prior to being entered
into JJIS. Each of the six reviewed youth alerts were applicable for being documented within the
program’s logbook. A review of the logbooks confirmed the applicable alerts were documented
as required. A review of the program’s internal alerts found they were consistent with alerts
entered within JJIS. All alerts requiring removal or downgrading were found to have been done
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so by the appropriate staff member. The facility administrator (FA) confirmed the program
utilizes an internal alert system to include an alert form and an alert board which details youth
alerts. Case management, medical, and mental health are responsible for entering and closing
out alerts in JJIS. Alerts are reviewed during daily management meetings. Important medical
issues pertaining to the youth are relayed to the FA from the health service administrator (HSA).
Additionally, the HSA attends the daily management meetings to discuss medical concerns,
issues, and/or appointments. Nursing staff are present along with program staff, security, case
management, and mental health staff in the morning meeting held daily, where alerts are
discussed. The nurse interview confirmed licensed healthcare staff are responsible for updating
the medical alert system. Seven interviewed staff reported they are briefed on youth alerts
during briefings with shift supervisors, an alert binder in the break room, and the internal alert
board located in master control.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program separates each youth record into two separate records including an individual
case management record and an Individual Healthcare Record. All youth records are marked
Confidential. All records are maintained in either locked cabinets or locked rooms within the
responsible program area’s office. No records were observed to be accessible to youth. Office
area doors are also marked Confidential. A review of seven individual management records
found each record had a label which included the youth’s name, Department identification
number, date of birth, county of residence, and committing offense. Each individual
management record included legal information, demographic and chronological information,
correspondence, case management and treatment team activities, and miscellaneous.
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 joint community advisory board which is scheduled to meet on a quarterly
basis. A review of the community advisory board binder found meetings were held on June 15,
2023, September 14, 2023, and December 13, 2023, during the annual compliance review
period. Board meetings are held in person at the program. A review of the list of attendees, the
board roster, and letters from the program found the facility administrator (FA) has solicited
involvement from a law enforcement representative, a judiciary community representative, other
community partners, a business community representative, a school board or district
representative, a faith community representative, and a LGBTQIA+ community representative.
Reviewed documentation reflected a representative from each category was a member of the
advisory board or had been invited to join the advisory board. An interview was conducted with
the FA who confirmed meetings are held quarterly. The FA maintains the community advisory
board requirements. Community advisory board meetings are held quarterly and include review
of an agenda detailing program updates and community advisory board member updates.
Recruitment letters are mailed out annually to solicit new membership and ensure each position
on the board is properly represented. The interviewed board member stated they serve on the
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board, confirmed their attendance in the December and June 2023 meetings and will continue
attending the quarterly meetings, as frequently as possible.
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 for evaluating staff, performance standards, and the
frequency of evaluations. The program’s policy indicates evaluations are to be completed after a
ninety-day introductory period and annually by supervisory and management staff. A review of
three position descriptions was conducted and determined each staff member’s performance
standards were clearly identified. A review of seven performance evaluations confirmed annual
evaluations have taken place consistent with the program’s policy. Staff are evaluated at the
ninety-day mark in their first year and annually thereafter. The performance standards matched
job descriptions for each staff position reviewed. The program’s contract requires one facility
administrator (FA), one assistant facility administrator, five registered nurses, one designated
health authority, one designated mental health clinician authority, one licensed therapist, two
transitional case managers, and two recreational therapists. Key vacancies at the time of the
annual compliance review included one assistant clinical director and two therapists. An
interview was conducted with the FA who stated staff turnover has been a consistent issue.
Staff have cited their reasons for leaving as the demands and/or hours of the job as well as the
pay for direct care staff. The program has a staff morale committee which meets monthly and
plans activities for staff to participate in and has an employee suggestion box. The program
conducts hiring events to hire new staff and reduce turnover. The FA additionally indicated staff
evaluations are completed after the first ninety days and then yearly. Seven staff were
interviewed and five staff reported they felt communication was good amongst staff at the
program, one indicated very good, and one stated poor, adding communication could be better.
Additionally, four staff reported they receive a formal evaluation of their performance based on
performance standard annually, three newer staff indicated every ninety days, and one staff
stated every six months.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s contract with the Department of Juvenile Justice includes a Memorandum of
Negotiation (MON), Summary of Negotiated Points, and Secretary letter. There are four special
contract conditions not covered by the Monitoring and Quality Improvement indicators.
The first special contract condition requires either the president or the chief operating officer to
make a visit to the program at least once a quarter. A review of the facility visitor sign-in log
confirmed the numerous visits which were made during the annual compliance review period
including four in June 2023, one in July 2023, one in August 2023, one in October 2023, two in
November 2023, and two in December 2023, far exceeding the quarterly visit requirement.
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The second special contract condition requires eighty percent of eligible youth to be working
part-time or full-time within thirty days of exiting the program. The transition specialist shall track
employment of youth for the thirty days following their exit. There were five youth who left the
program in March 2024, and one youth was not applicable because they were arrested. A
review of closed records for the four youth released in March confirmed the transition specialists
made three contacts with youth after release. One youth was released less than a week before
the annual compliance review week, on March 29, 2024. No contacts have been made for the
recently released youth, yet.
The third special contract condition requires 100 percent of youth to complete, on average,
eighty percent of their community service hours prior to their release. During the annual
compliance review period there were no applicable youth released with court ordered
community service hours.
The final special contract condition requires an additional forty-five vocational slots to be made
available beyond those mentioned in the contract, covering computer programming in the future,
twenty driving certifications in commercial driver license (CDL) of forklifts, five food service
manager certifications, and twenty Microsoft Office certifications. The program offers agriculture
services, where the youth receive high school credits. Food handling and food management are
both offered, affording the youth certificates after completion. The program has a Home Builders
Institute (HBI) program on-site for youth to participate in, after vetted, and accepted, where
youth can receive a myriad of certificates. The vocational program offers basic computer literacy
programs such as Microsoft Word, PowerPoint, and Excel, where youth are able to receive a
certificate after completion. The program offers CDL courses, including opportunities in semi-
truck and forklift training, carpentry, electrical, brick masonry, landscape, and painting. During
the annual compliance review period, nineteen youth have received cardiopulmonary
resuscitation (CPR)/first-aid, two youth have completed Occupational Safety & Health
Administration (OSHA)-10, five youth have completed Florida Ready to Work, nineteen youth
are in the process of ServSafe, seventeen youth have received food service certifications, and
ten youth have finished the course and are scheduled to take the test for their ServSafe
certification. Additionally, the program has both CDL and Microsoft slots available; however,
there are no youth enrolled based on interest. Youth are informally asked at the beginning of
each semester to gauge interest.
The facility administrator (FA) interview indicated the contract negotiated items are provided.
Seven youth were interviewed and all seven confirmed they have either heard of or participated
in the services the program is required to provide. The FA indicated an additional forty-five
vocational slots will be made available beyond those mentioned in the contract including twenty
driving certifications CDL or forklift, five food service manager certifications, and twenty
Microsoft Office certifications.
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
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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’s contract requires them to provide career and technical education (CTE) services.
The program’s services include a Driving Certification, which shall aid in preparation for the
commercial driver license (CDL) or forklift certification. The program shall provide certifications
in ServSafe Food Service Manager, cardiopulmonary resuscitation (CPR)/first-aid, Florida
Ready to Work - Soft Skills, Occupational Safety and Health Administration (OSHA)-10, and
Microsoft Office. Nineteen youth have received CPR/first-aid, two have completed OSHA-10,
five have completed Florida Ready to Work, and nineteen are in the process of working on their
Food Service Handler certification. According to the program’s schedule, CTE services are
offered every Thursday between 2:30 p.m. and 3:30 p.m., and 4:30 p.m. to 5:30 p.m. CTE
instruction is provided by two transition service managers who possess bachelor’s degrees and
one CTE teacher with an associate’s degree who is certified through the school district. Seven
youth were interviewed and all were aware of the CTE services provided by the program. Two
youth were in Home Builders Institute (HBI) and one of those youth was also working on their
Food Handlers certification, two youth were waiting on the CDL, two youth were not receiving
services yet, and the remaining youth was not participating. The two youth in CTE services
indicated they participated three to five days a week. The five youth not in CTE Services
indicated they were waiting on a class to begin, two youth stated they did not know they could
sign up, and the remaining youth did not sign up because they are ready to get released from
the program. The facility administrator confirmed CTE services are being offered such as
CPR/first-aid, OSHA-10, and Florida Ready to Work.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a policy and procedures for reviewing and analyzing data trends to utilize in
decision-making practices. The provider uses several systems for the purposes of tracking data
and outcome measures. The provider has implemented an internal database and dashboard
system allowing for daily data entry by every program. This daily process and outcome
information are aggregated into weekly and monthly totals, displayed in interactive dashboards
specific to each program, and provided back to corporate as well as program management for
the purposes of tracking trends and informing risk management. The dashboards are updated
every Monday with the previous week's data. Additionally, the program compiles information
obtained from youth surveys and parent/guardian surveys completed upon exit from the
program. Information is shared with staff and administration during staff meetings, morning
meetings, shift briefings, and during advisory board meetings. A review of four youth exit
surveys, seven parent/guardian surveys, and the management meeting sign-in sheet for the two
most recent meetings, which took place in January 2024 and December 2023, confirmed the
information sharing with staff and administration. A review of the quarterly community advisory
board agendas, meeting minutes, and sign-in sheets for June 2023, September 2023, and
December 2023, confirmed the information sharing with providers and stakeholders. The
program also takes information received during supplemental and annual compliance reviews
and shares the outcome with staff.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures to ensure the parent/guardian of each youth is
notified by telephone within twenty-four hours of the youth’s admission and in writing within
forty-eight hours. The committing court, assigned juvenile probation officer (JPO), and post-
residential provider are notified in writing within five working days of admission. Seven youth
case management records were reviewed. All seven records contained documentation of
parent/guardian notifications by telephone within twenty-four hours and in writing within forty-
eight hours, as required. Six of seven youth records also contained documentation the court and
JPO were notified within five working days of admission. One youth was applicable for a post-
residential service and there was no documentation a notice was sent in the youth record.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to ensure each admitted youth receives an
orientation with all required elements within one day of admission. The program’s orientation
documentation was reviewed. The program utilizes a standardized orientation form with a
checklist including all required topics. The orientation form is initialed by the youth next to each
covered topic and signed by both the youth and staff conducting the orientation. Seven youth
case management records were reviewed. All seven records contained documentation of a
completed orientation within the required time frame and addressed all required elements. An
orientation was not observed during the annual compliance review week because the program
did not have any admissions. Seven youth were interviewed and all confirmed an orientation
was conducted within one day of admission. Each youth was able to explain and confirmed the
orientation process included program rules, procedures, schedules, and other required
elements.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures to ensure program staff obtain written consent from
all youth eighteen years of age or older before providing or discussing any of the youth’s
information with the parent/guardian. Three of seven youth case management records reviewed
were applicable; the remaining four records were for youth under the age of eighteen. All three
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applicable records contained documentation the program obtained written consent from the
youth prior to communicating any information related to the youth’s physical or mental health
screenings, assessments, or treatments to a parent/guardian.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a policy and procedures to ensure each youth is assessed for the proper
placement within the program’s classification system. The assessment is required at admission
and a youth can be reassessed and reclassified when needed to change the level of privileges
to include freedom of movement, work project participation, utilization of tools, and off-campus
activities. The classification system at the program utilizes a standardized form addressing all
the required elements needed to be reviewed, including the youth’s vulnerability of victimization,
any alerts or risks, historical behaviors, and the youth’s physical and mental statuses. Seven
youth case management records were reviewed and each youth’s classification form was found
to have all the required elements documented accurately based on known and reported
information. Each classification was conducted on the day of admission and all risk/alert
information corresponded to the Department’s Juvenile Justice Information System (JJIS) alert
list. The classifications were utilized for living area and room assignment. Two of seven youth
case management records contained documentation of reassessment and reclassification; the
remaining five records were not applicable. The two applicable youth reassessments and
reclassifications were conducted to place each youth in a different living area and room
assignment for safety and security reasons. The facility administrator (FA) was interviewed and
was able to explain the classification factors and procedures.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures to gather and report gang information regarding the
youth. Two of seven youth case management records contained gang documentation; the
remaining five records were not applicable. An additional record was selected to achieve a
minimum review of three records. All three applicable youth case management records
contained documentation the program notified local law enforcement prior to the program’s
seven-day notice for the annual compliance review. Two of three youth records contained
documentation of notification to the youth’s home county law enforcement agency; the
remaining record did not have supporting documentation of this required contact. All three
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records had the required alerts in the Department’s Juvenile Justice Information System (JJIS).
Each youth appeared on the internal alert binder and on the program’s alert board. The gang
status of each youth was shared with the program’s education department and the youth’s
juvenile probation officer. No notifications to post-residential providers were required.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures ensuring the implementation of gang prevention and
intervention strategies for all youth in the program. The policy and procedures address providing
youth the opportunity to create a plan to disaffiliate with a criminal street gang. The program
utilizes a specific gang prevention and intervention curriculum titled Achieve Realistic Impact to
Sustainable Enhancement (ARISE). Lessons are taught at the monthly community meeting for
the youth in the program. Documentation of the gang intervention and prevention lessons were
evidenced by meeting agendas, meeting minutes, and youth sign-in logs. Youth identified with
gang alerts or significant risk factors have additional gang intervention/prevention goals included
on their Individual Performance Plan (IPP). Two of seven youth case management records
contained evidence of gang affiliation; the remaining five records were not applicable, and an
additional record was selected to review. All three applicable youth case management records
contained documentation of identification or affiliation with a criminal gang. Each youth was
located on the sign-in sheets for the gang intervention/prevention lessons and each IPP
contained gang related intervention goals. The interview with the facility administrator (FA)
revealed youth who are identified as suspected gang members receive interventions on their
performance plans. The FA added, during the community meeting, the ARISE curriculum is
used to deter gang activity.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures to ensure each youth receives an initial Residential
Assessment for Youth (RAY) within thirty days of admission and a RAY Reassessment every
ninety days thereafter. The policy includes procedures for additional RAY Reassessments when
deemed necessary by the treatment and invention team. All RAYs are required to be maintained
in the Department’s Juvenile Justice Information System (JJIS) and in the youth’s case
management record. All seven youth case management records contained documentation an
initial RAY was completed within thirty days of admission and each initial RAY was maintained
in JJIS as required. Five of seven youth case management records reviewed were applicable
for at least one ninety-day RAY Reassessment; the remaining two youth had been in the
program less than ninety days. All five applicable records contained documentation of each
RAY Reassessment being completed in JJIS and were maintained in the youth records. Two
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youth records had all three required reassessments, one record had two required
reassessments, and two records had documentation of one required reassessment. None of the
five reviewed records contained documentation of other updates or reassessments completed
before a ninety-day RAY Reassessment was required.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
The program has a policy and procedures to ensure a Youth Needs Assessment Summary
(YNAS) for each youth is completed within thirty days of admission and the documentation shall
be maintained in the Department’s Juvenile Justice Information System (JJIS). All seven youth
case management records included documentation the YNAS was completed within thirty days
of admission and each YNAS was documented in JJIS.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a policy and procedures for ensuring an Individualized Performance Plan
(IPP) consisting of goals based on the youth’s initial Residential Assessment for Youth (RAY),
with all required elements is developed by the assigned intervention and treatment team for
each youth. The intervention and treatment team is required to consist of the treatment team
leader, youth, administrative staff, living unit staff, educational staff, and staff providing
treatment. Each IPP goal must contain a target date of completion and action
steps/responsibilities for the youth and staff to meet the goal. A copy of the IPP with a
transmittal letter must be submitted to the committing court, assigned juvenile probation officer
(JPO), and the parent/guardian within ten working days of completion. Six of seven youth case
management records reviewed had documentation each initial IPP was completed within thirty
days of admission, and after the completion of the RAY and Youth Needs Assessment
Summary (YNAS); the remaining youth has been in the program less than thirty days. All six
applicable records contained documentation required members of the intervention and
treatment team were present during the development of the IPP, which was evidenced by the
signature of each required member of the team on the original sign-in sheet attached to the IPP.
Each goal has specified responsibilities for the youth, applicable staff, and if necessary, the
parent/guardian. Five of six reviewed records had returned signature sheets from the
parent/guardian; the remaining record contained documentation the parent/guardian signature
was requested by mail two separate times, however, it was not received. Each IPP contained
the required elements to include individualized goals based upon the prioritized needs and risks
from the initial assessment, goals related to the identified top three criminogenic needs, specific
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delinquency interventions based on the RAY results, court-ordered sanctions, transition
activities for the last sixty days, youth and staff responsibilities, and target dates for the
completion of each goal. All six applicable reviewed records contained documentation a
transmittal letter and copy of the IPP were submitted to the committing court, JPO, and
parent/guardian. Seven youth were interviewed and each youth confirmed they participated in
the development of their IPP, have a copy of their IPP, and knew the specific goals contained in
their IPP.
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.
The program has a policy and procedures for performance plan revisions based on performance
reviews. Six of seven youth case management records reviewed were applicable; the remaining
youth had been in the program less than thirty days and had not had a performance plan
developed at the time of the annual compliance review. All six applicable records contained
documentation warranting a revision to the performance plan. Two reviewed records specified
Residential Assessment for Youth (RAY) Reassessment results, youth’s progress to complete
goals, and the youth’s lack of progress toward goals as the reason for revisions; three reviewed
records specified RAY Reassessment results and youth’s progress to complete goals as the
reason for revisions; and the remaining reviewed record specified the youth’s progress to
complete goals and the youth’s lack of progress toward goals as the reason for revisions.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a policy and procedures to ensure Performance Summaries are completed at
ninety-day intervals once the performance plan is approved and at the request of the committing
court, if necessary. A final Performance Summary is required prior to the youth’s release,
discharge, or transfer from the program. Five of seven reviewed youth case management
records contained documentation of the required Performance Summaries being completed
within the required time frames or specified event; the remaining two reviewed youth had not
been in the program for ninety days at the time of the annual compliance review. Three of five
applicable records included all three required ninety-day Performance Summaries; the
remaining two applicable records contained one required and completed Performance
Summary. Two of five applicable records contained the required Performance Summaries prior
to the youth’s release; the remaining three applicable records were not in the transition phase of
the program at the time of the annual compliance review. All completed Performance
Summaries in each of the five applicable records contained documentation of all the
requirement elements including the youth’s status on each goal, overall treatment progress,
academic standing, behavior, stage of change, interactions with peer and staff, significant
events, and, if applicable, justification for release, discharge, or transfer. All reviewed
performance transmittals contained documentation of the youth’s comments and signature.
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Each youth was provided a copy and the originals all appeared in each of the reviewed records.
Each reviewed Performance Summary was properly dated and signed by all required parties
including the treatment team leader, staff preparing the summary, facility administrator or
designee, and the youth. All five applicable records reviewed had documentation each summary
was sent within ten working days to the committing court, juvenile probation officer (JPO), and
the parent/guardian.
Three closed youth case management records were reviewed for release summaries. All three
reviewed records contained documentation the original summary, with release justification, were
sent to the JPO with the Pre-Release Notification (PRN) at least forty-five days prior to the
anticipated release date. A signed copy of the PRN was located in each closed record reviewed.
None of the three closed records contained a PRN with court objection. Each closed record
contained documentation of notification to the parent/guardian and the completion of a
Residential Assessment for Youth (RAY) exit assessment after the approved PRN was
received. None of the closed records required victim notification.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to ensure parent/guardian involvement in case
management services. All seven reviewed youth case management records contained
documentation of parent/guardian involvement, or attempts to solicit participation, in the
assessment process, development of the performance plan, progress reviews, advanced
notification of formal treatment team meetings with specified dates and times, and transition
planning. The program documentation confirmed when a parent/guardian is unable to attend in
person, telephone participation is offered and arranged or written input is accepted prior to the
meeting. Three treatment team meetings were observed during the annual compliance review
week. All required participants were present, on the telephone, or had submitted written input
prior to the meeting in two of the three observed meetings. The remaining observed meeting did
not include parent/guardian participation, however, attempts were made. All observed treatment
team meetings reviewed all required plans, goals, and topics, with the exception of safety plans.
The program reported safety plans are reviewed with the youth in a pre-meeting held prior to the
treatment team meeting and the safety plan is only discussed at the treatment team if revisions
have been or need to be made. The program facilitates parent/guardian involvement by hosting
family days and visitation hours or calls for families who cannot travel to the program. The
facility administrator (FA) interview confirmed the program’s procedures and practices to solicit
parent/guardian involvement throughout the length of stay. Seven youth were interviewed and
confirmed their parent’s/guardian’s participation and involvement in case management activities.
Six of seven youth reported their parents/guardians participate by telephone. The remaining
youth reported their parent/guardian is always unavailable when the program reaches out by
telephone because of work hours.
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2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
The program has a policy and procedures to ensure each youth’s Individual Performance Plan
(IPP) includes all other treatment or care plans developed for the program. Six of seven youth
case management records were applicable for review. The remaining youth has been in the
program less than thirty days. All six applicable records contained documentation on each IPP
of academic and mental health plans. None of the six applicable records required Department of
Children and Families (DCF) or Agency of Persons with Disabilities (APD) plans to be included.
2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
The program has a policy and procedures to ensure each youth is assigned an intervention and
treatment team with all required members at admission; and to ensure formal and informal
treatment team meetings are conducted. Six of seven youth case management records were
applicable for review. The remaining youth has been in the program less than thirty days. All six
applicable records contained documentation all required formal and informal treatment team
meetings were held at the required frequency and alternating bi-weekly. Each conducted
treatment team had documentation of attendance and written input of each required member.
Thirty-two of thirty-three reviewed formal treatment team meeting’s documentation included all
required signatures for all required members. One treatment team meeting did not have the
administrative staff signature on the treatment team form; however, the program was able to
provide additional documentation from the meeting to show the administrative staff was in
attendance as required. The treatment team documentation contained all required elements
including any member comments, a brief synopsis of the youth’s progress, performance plan
revisions and reassessments, if applicable, positive and negative observed behavior, if
behaviors resulted in physical intervention, the youth’s ability to demonstrate acquired skills,
treatment progress, and results from Residential Assessments for Youth (RAYs). All formal
treatment team documentation was maintained in the reviewed records. All thirty-five reviewed
informal treatment team meetings contained all required member signatures or input and all
required elements were observed in the documentation of each meeting held. All informal
treatment team meeting documentation was maintained in each youth case management
record. Five of six applicable records did not contain any documentation for, as they were not in
need of, a special treatment team meeting. The remaining record did contain all required
documentation for one special treatment team meeting conducted. Three treatment team
meetings were observed during the annual compliance review week and all three had the
required staff, to include education staff. Each observed treatment team meeting reviewed the
youth’s treatment plan and the anticipated release date. Seven youth interviews confirmed each
youth had staff review goals and progress with them, and each youth was provided an
opportunity during treatment team meeting to demonstrate acquired skills.
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2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a policy and procedures to ensure the intervention and treatment team plans
for the youth’s successful transition. The transition activities and goals, with target completion
dates, are reviewed at the transition meeting, and revisions are made if needed. The program
also ensures the youth’s attendance at the Community Re-Entry Team (CRT) meeting prior to
discharge. Three closed youth case management records were reviewed. Two of three records
were direct discharge youth. The remaining youth had transition services to comply with after
release. All three records contained documentation of a transition conference held at least sixty
days prior to the youth’s targeted release date. All required treatment team members were in
attendance to each transition meeting, to include the youth, team leader, program director or
designee, living unit representative, and treatment staff. The parent/guardian and juvenile
probation officer (JPO) were in attendance by telephone, and educational staff submitted written
input. The documentation of each transition conference confirmed the members reviewed the
transition goals, revise performance plans to include additional transition goals, as needed,
identified target completion dates, and included signatures of members in attendance. One of
the three closed records included documentation the plan was transmitted electronically to the
juvenile probation officer (JPO) evidenced by a review of the read receipt. Two of the closed
records did not include a copy of the read receipts. All three closed records included
documentation of the Community Re-Entry Team (CRT) meeting which was held prior to the
youth’s release with the youth and assigned case manager participation noted. An invitation to
the treatment team for the CRT meeting was documented in each record.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures to ensure a completed exit portfolio is created for
each released youth. Three closed youth case management records were reviewed, and each
record documented the exit portfolio was discussed and initiated at the transition conference.
Two of three closed records contained all required items, including a state-issued identification
card, a copy of the youth’s transition plan, calendars with all dates, times and locations of
upcoming community appointments, Social Security card, birth certificate, education and
vocational certifications earned, educational records/documents, school transcripts, a résumé,
and multiple completed sample employment applications. The remaining closed record did not
have the state-issued identification card, Social Security card or birth certificate as the
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parent/guardian did not respond to multiple requests to send the documents to the program.
Each closed record documented the exit portfolio was verified at the exit conference and the
original exit portfolio was provided to the youth, as evidenced by the youth’s signature at
release. Each exit portfolio was forwarded to the assigned juvenile probation officer (JPO). The
program does not have any additional contractual requirements for the exit portfolio.
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures to ensure an exit conference is conducted for each
youth release. Three closed youth case management records were reviewed and each record
contained documentation the exit conference was held after the program’s notification of
anticipated release to the assigned juvenile probation officer (JPO) and at least fourteen days
prior to release. All exit conference documentation contained the required elements including
the date of the conference, signatures of participants, and summary of transition goals. Each
closed record contained dates matching in the Department’s Juvenile Justice Information
System (JJIS) for admission and release. All transition activities established at the transition
conference were finalized in the documentation at the exit conference, which was attended by
the treatment team leader, youth, treatment staff, parent/guardian, and JPO. Written input from
educational staff was provided and documented in all three closed records. Two closed records
were applicable for and included written input from medical staff; the remaining closed record
did not require medical input. All three closed records had documentation to confirm the exit
conference was held separately from the transition conference and Community Re-Entry Team
meeting.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to cultivate youth input. The program’s formal
process to promote youth input is holding monthly resident council meetings. The meetings
were confirmed through the review of minutes and attendance logs for each meeting from May
2023 to January 2024, with the exception of June 2023, which did not have any documentation.
Each attendance log documented five to nine youth attendees and the staff who supervised the
meeting. Each set of meeting minutes documented the agenda items covered including
messages from management, daily, weekly, monthly scheduled activities, and canteen.
Community meetings are held monthly with each dormitory as evidenced by sign-in sheets,
meeting minutes, and copies of activities/information. The program solicits input from youth,
parents/guardians, and other stakeholders utilizing surveys. Parents/guardians are sent survey
requests at admission, throughout the youth’s length of stay, at exit through email, and in-
person during visitation. The surveys address general topics of clinical services, case
management, and medical services. Youth complete surveys throughout their length of stay, at
a minimum of quarterly, regarding general topics of admission/access, input, rights, treatment
plan, quality of care, quality of life cultural competency, accessibility, and other topics which may
need to be evaluated. The program also conducted a Trauma Responsive and Caring
Environment (TRACE) assessment during the annual compliance review period. The youth also
have an informal process available through “Request to Speak” forms. Seven youth interviews
confirmed youth surveys are utilized for a variety of topics. The facility administrator interview
also confirmed the program’s process for youth input through formal and informal methods, to
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include the Can We Talk form, grievances, treatment team, community meetings, resident
council meetings, and weekly management meetings.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures to provide career education based on age, which
appropriateness for the educational abilities and goals of each youth, and the length of stay of
the youth in the program. The program provides Type 3 career education development and
provides pre-apprentice certification and industry certification such as ServSafe certification,
Home Builders Institute, commercial driver license training, Microsoft Office, and agricultural
science. The course programming includes instruction in interpersonal skills, communication
skills, and decision-making skills. An interview with the lead educator indicated the program
administrates a career assessment using O*Net to identify and research potential career options
which is maintained in the youth record. An interview with the facility administrator indicated the
program provides career and technical education. Three closed youth case management
records and education records were reviewed. Two of three records contained a completed
employment application, a résumé, contact information for the Career Source Center, and
documentation essential to obtaining employment. The remaining record was lacking
documents essential to obtaining employment. Two of three records reviewed had a
Department of Highway Safety and Motor Vehicles state-issued identification card (ID) and the
remaining record did not include one. Each record included documentation indicating the
parent/guardian and juvenile probation officer were aware of the vocational plan for the youth,
along with evidence of each post-release discharge plan.
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 written policy and procedures to provide educational access. The program
provides education services through the provider TrueCore Behavioral Solutions LLC. The 253-
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 six fifty-five
minute classes from 7:45 a.m. through 2:10 p.m. with a thirty-five minute lunch break from 11:40
a.m. through 12:15 p.m., fulfilling the weekly requirement of twenty-five hours of instructional
time. The interview with the lead teacher indicated all the youth receive credit for each course
completed and the school schedule is adhered to. Seven interviewed youth reported there are
no interruptions during school. A review of seven randomly selected days in the logbook
indicated education classes started and ended on time or within a minute or two on six of seven
days. The school day still exceeded the required 300-minutes daily. On October 11, 2023, class
started fifteen minutes late. Observations of the program video on December 19, 2023, January
3, 2024, and January 11, 2024, indicated classes started and ended on time as scheduled.
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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 maintains 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. All three youth records included an individual Education Transition Plan developed
upon entry, including the youth’s post-release goals and other 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 an Electronic Educational Exit Plan
(EEEP) which identified the next educational placement information and input from the post-
release school district representative. Seven youth were interviewed, and six youth reported the
program was preparing them very well or well when it came to high school, high school
equivalency diploma provided (GED), vocational school, employment, and/or college. One youth
reported not being sure of their current school level. All seven youth confirmed they participated
in the development of their transition plan. The interview with the lead teacher indicated
information is shared with the multi-disciplinary treatment team members bi-weekly at treatment
team meetings, the transition plan includes educational, vocational, and special education
services, when needed, and education staff assist the youth in developing the transition plan
which is inclusive of youth needs from intake, through release, and beyond.
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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 maintains a policy and procedures requiring a designated mental health clinician
authority (DMHCA) to work as a full-time staff who is on-site at least forty hours each week. The
DMHCA is responsible for the coordination and implementation of mental health and substance
abuse services in the program. As part of the assigned responsibilities, the DMHCA shall
ensure consistent and appropriate mental health and substance abuse services, in addition to
being on-call twenty-four hours each day for emergency consultation. Throughout the annual
compliance review period the program has had four DMHCAs. The position was vacant three
times during the annual compliance review period. While the position was vacant, the corporate
regional mental health staff served as the DMHCA. The corporate regional mental health staff is
a licensed clinical social worker. The previous four clinicians who served as the DMHCA were
licensed mental health counselors. The review of all five licenses reflected they were free and
clear in the State of Florida and all five licenses have an expiration date of March 31, 2025. The
current DMHCA’s license was displayed within the program, as required. The reviewed license
confirmed it was valid with an expiration date of September 6, 2024. The interviewed DMHCA
verified they were on-site for sufficient time to ensure appropriate coordination and
implementation of mental health and substance abuse services. Documentation verified the
DMHCA was on-site for a minimum of forty hours each week. The program is licensed under
Chapter 397 through the Department of Children and Families to provide substance abuse
services to adolescents. The program’s chief clinical officer serves as the back-up DMHCA.
The back-up DMHCA is a licensed mental health counselor in the State of Florida. The reviewed
license verified it was free and clear with an expiration date of March 31, 2025. The acting
DMHCA was interviewed and confirmed their role in the coordination and implementation of
mental health and substance abuse services delivery. The acting DMHCA also ensures clinical
staff working under their supervision are performing services they are qualified to provide based
on their education, training, and experience. The acting DMHCA reported they are on-site for at
least forty hours Monday through Friday and on weekends as needed. The acting DMHCA is
also on call twenty-four hours a day seven days a week.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program’s
designated mental health clinician authority (DMHCA) serves as the program’s supervisor for all
on-site clinical staff. A review of the program’s staff listing and contractual requirements verified
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there is a position for an assistant clinical director who is licensed. The program had a licensed
mental health clinician serving as the assistant clinical director at the last annual compliance
review. The position became vacant right after the annual compliance review was completed
and was vacant for two months. The program hired another licensed mental health clinician who
served as the assistant clinical director for five months. The clinician then served in this role pro
re nata (PRN) for an additional two months. The assistant clinical director position became
vacant three days prior to this annual compliance review. A review of the licenses for the
previous two clinicians reflected they were free and clear in the State of Florida and both
licenses have an expiration date of March 31, 2025. The program is licensed under Chapter 397
by the Department of Children and Families to provide substance abuse services to
adolescents. The Chapter 397 license expires September 6, 2024. The program’s contract
requires one DMHCA, one assistant clinical director, two recreation therapists, and seven non-
licensed mental health clinicians. The program’s clinical staffing was in accordance with the
contract until the assistant clinical director position became vacant.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program’s
contract requires seven non-licensed mental health clinicians and two recreation therapists. The
acting designated mental health clinician authority (DMHCA) confirmed their responsibility for
ensuring non-licensed clinical staff are working under their supervision and performing services
they are qualified to, based on education, training, and experience. The program’s practice is to
complete group and/or individual clinical supervision for the non-licensed clinicians and the
recreation therapists. A review of clinical supervision logs since the last annual compliance
review was conducted. The clinical supervision was documented on the program’s form and
included all elements on the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log form with some
noted exceptions. On July 26, 2023, the clinical supervision log was a different form. There were
three dates when the clinical supervisor did not sign the supervision log. There were two
additional dates where the clinical group supervision sign-in sheets and logs were not signed.
Documentation verified each non-licensed clinical staff received clinical supervision for each
week they provided services. The program is licensed under Chapter 397 through the
Department of Children and Families (DCF) to provide substance abuse services to
adolescents. A review of the license reflected it was displayed in the lobby with the program’s
physical address listed. The reviewed license expires on September 6, 2024. There are seven
contracted non-licensed positions required. The program has had a high vacancy rate
throughout the annual compliance review period. The clinical regional director who is the acting
DMHCA indicated there was no way to track how long each position has been vacant since the
turn-over had been so high. At the time of the annual compliance review, five of the seven
therapist positions were filled. A person has been hired to fill the sixth position but there was no
established start date at the time of the annual compliance review. The program had one non-
licensed clinical staff vacancy during the annual compliance review week. A total of ten non-
licensed mental health and substance abuse clinical staff provided services to the youth
throughout the annual compliance review period. A review of the non-licensed staff’s education
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documentation reflected each held a master’s-level degree from an accredited university or
college in the field of counseling, social work, psychology, or a related human services field. Six
of the non-licensed staff were providing substance abuse services. Documentation supported all
six staff received weekly supervision and the program is licensed under Chapter 397. Three of
the non-licensed clinical staff completed Assessment of Suicide Risks (ASRs). Documentation
supported all three received training in the administration of the ASRs or Crisis Assessments
conducted on-site in the physical presence of the licensed mental health professional. All
trainings were clearly documented on the Department’s Non-Licensed Mental Health Clinical
Staff Person’s Training in Assessment of Suicide Risk form since the last annual compliance
review. There have been three staff who have filled the recreational therapist positions. During
the annual compliance review period the program had a major deficiency assigned for having a
recreation therapist position vacant. The deficiency closed a month later. The recreation
therapist credentials, schedule, and services were reviewed. Documentation supported
education and service requirements were in accordance with the contractual requirements.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program maintains a policy and procedures which establish the system for gathering
important treatment and emergent needs information prior to each youth’s entry into the general
population. A review of seven youth records confirmed each youth was administered a
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) on the day of
admission. The case manager completing the screening documented the review of available
information to include the commitment packet and other pertinent documents for existing mental
health or substance abuse problems, or history of human trafficking. Reviewed documentation
verified both case managers received MAYSI-2 training. Each MAYSI-2 was completed in full in
the Department’s Juvenile Justice Information System (JJIS). The program’s practice is to refer
all youth for additional assessment regardless of the screening results. Each MAYSI-2
documented the need for further assessment. Six of the seven referrals were reviewed and
signed by the facility administrator (FA). None of the screenings indicated the youth was in
crisis, requiring immediate attention, or required a staff override. None of the reviewed MAYSI-
2s indicated an assessment was needed due to the “suicide ideation” category. Each record
documented youth were referred for a comprehensive assessment and the referrals clearly
documented the reason for each referral. The program’s facility administrator (FA) is
responsible for the implementation of the standardized admission/intake mental health and
substance abuse screening process. The interviewed FA reported a MAYSI-2 and Assessment
of Suicide Risk are completed upon intake to identify risks.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a policy and procedures to establish an assessment and evaluation
process to guide the development of each youth’s individualized treatment plan. A review of
seven youth records reflected the program completed a combined mental health and substance
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abuse evaluation for six of the seven youth. One youth had not been in the program long
enough to have the evaluation completed. A new comprehensive evaluation was completed
within thirty days of admission for each of the six youth. Four of the six evaluations were
completed by a non-licensed clinical staff working under the direct supervision of the designated
mental health clinician authority (DMHCA). Documentation reflected the DMHCA reviewed and
signed each comprehensive evaluation within ten calendar days as required. One of the
evaluations was completed by the acting DMHCA and the other evaluation was completed by
the licensed clinical director from another True Core Behavioral Solutions, LLC program who
was providing assistance at this program. Each reviewed evaluation included identifying
information, the reason for evaluation, relevant background information, behavioral
observations, a Mental Status Examination, a summary of procedures administered, discussion
of findings, a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
diagnosis, and recommendations. Each comprehensive evaluation was inclusive of mental
health and substance abuse findings. A review of youth records confirmed consents for
substance abuse treatment services were obtained for each of the seven youth. Each
substance abuse portion of the reviewed evaluations documented the reason for assessment,
relevant background information, behavioral observations, methods of assessment, patterns of
alcohol and other drug use, impact of alcohol and other drugs on major life areas, risk factors of
continued alcohol and other drug use, a DSM-5 diagnosis, and recommendations. One of the
evaluations completed by a non-licensed clinician was completed prior to the program receiving
the Chapter 397 license. There was no documentation on the evaluation to support a licensed
clinician completed the substance abuse section of the evaluation. The program agreed with
this finding.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a policy and procedures to establish an individualized treatment
planning process to guide service delivery. A review of seven youth records reflected an initial
treatment plan was developed the day of or the day after the youth’s admission to the program.
Each reviewed initial plan was documented on the program’s form and included all elements of
the Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Each initial plan
was completed by a non-licensed clinical staff and signed by the designated mental health
clinician authority (DMHCA) the same day of completion. Additionally, each initial plan was
signed by all treatment team members who participated in the development of the plan. Each
plan was signed by the youth and documented juvenile probation officer (JPO) and
parent/guardian participation by telephone. Four of the seven initial treatment plans included the
need for a psychiatric evaluation. The program’s practice is to refer all youth for a new
psychiatric evaluation regardless of medication status. The program completed an individualized
treatment plan for each of the six applicable youth within thirty days of admission. One youth
had not been in the program long enough to have an individualized treatment plan completed.
Each individualized plan was documented on the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan form. Three of the six individualized plans were
completed by a non-licensed clinical staff and the signature of the licensed DMHCA was
documented on the plan the same date it was completed by the non-licensed staff. The other
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three individualized treatment plans were completed by a licensed clinician. Each of the six
plans were signed by all treatment team members who participated in the development of the
plan. Each individualized plan documented the participation of the assigned JPO and the
parent/guardian by telephone. Four youth were applicable for being on medication at the time of
the individualized plan development and each plan clearly listed the medication details and
monitoring frequency. The six reviewed records were applicable for a total of twenty-seven
treatment plan reviews occurring at thirty-day intervals. All treatment plan reviews were
documented on the Department’s Individualized Mental Health/Substance Abuse Treatment
Plan Review form. All reviews were completed at least every thirty days as required. Prescribed
services included individual and group therapy, family therapy, and psychiatric services for all
six youth. Observed goals and objectives were individualized for each youth. A review of the
program’s contract confirmed the program was providing groups as required. The program’s
required clinical groups according to the contract include Aggression Replacement Training,
The Passport Program, Living in Balance, and Skillstreaming the Adolescent which was
discontinued January 1, 2024. The program has available The Bullying Workbook for Teens,
Resilience Builder Program for Children and Adolescents, The Stress Reduction Workbook,
Problem Solving Training, Empathy and Social Competence Training, The Thinking, Feeling,
Behaving Curriculum, Group Treatment for Substance Abuse, and Social Perception Training. A
review of video for three randomly chosen groups verified the sign-in sheets coincided with the
video. A review of sign-in sheets confirmed the program was providing groups as outlined in the
daily schedule.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program maintains a policy and procedures regarding discharge and transition planning
requirements for mental health and substance abuse treatment services. Discharge and
transition planning is a continual and perpetual process which culminates into the development
of a final mental health and substance abuse treatment summary. A review of seven youth
records reflected each youth was assigned a treatment team on the day of arrival to the
program. Reviewed treatment plan documentation and the treatment team assignment form for
each reviewed record confirmed the treatment teams were comprised of the youth, program
administration, residential living unit, education, medical staff, mental health and substance
abuse staff, and parents/guardians, when applicable. A review of the seven youth records
reflected three were applicable for a substance abuse diagnosis and treatment. The program is
licensed through the Department of Children and Families (DCF) under Chapter 397 to provide
substance abuse services to adolescents. Each record contained an executed Authority for
Evaluation and Treatment (AET) form. Additionally, each youth record contained a signed Youth
Consent for Substance Abuse Treatment, and Youth Consent for Substance Abuse Treatment
Records form. All reviewed treatment notes were documented on the Department’s
Counseling/Therapy Progress Notes form except the youth’s date of birth. Reviewed progress
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notes and sign-in sheets confirmed treatment services included individual psychotherapy and
psychosocial skills training. A review of treatment plans in comparison with progress notes
confirmed each youth received services as stipulated on their treatment plan with one
exception. One youth missed an individual therapy session one month. The program indicated
they were unable to locate documentation to support the session was provided; however, the
program’s internal tracking system indicated the youth received an individual session during the
month in question. A review of three closed youth records for discharge plans was completed.
All discharge plans were completed on the Department’s Mental Health/Substance Abuse
Treatment Discharge Summary form. None of the closed records were applicable for the youth
being released while on suicide alert/precautions. Each of the three reviewed summaries
documented the services needed for daily maintenance of the positive improvement in
behavioral, emotional, and social skills made by the youth during treatment. Each reviewed
discharge summary documented the telephone participation of the assigned juvenile probation
officer (JPO) and parent/guardian. One youth’s discharge plan did not have the parent/guardian
signature; however, the exit conference documentation supports the discharge plan information
was addressed during the exit conference and the exit conference form was signed by the
parent/guardian. Documentation supported each of the three youth, parent/guardian, and JPO
were provided a copy of the discharge summary.
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 maintains a policy and procedures to establish a delivery protocol for Mental
Health Overlay Services (MHOS) programming. Mental health treatment is provided on-site
through the provision of MHOS. The program provides MHOS services through group therapy,
individual therapy, family therapy, and psychiatric services. The program’s required clinical
groups according to the contract include Aggression Replacement Training, The Passport
Program, Living in Balance, and Skillstreaming the Adolescent which was discontinued January
1, 2024. All seven interviewed youth indicated they receive family, individual, and group
counseling on a regular basis. The frequency of the services varied for each youth. All seven
interviewed staff indicated they and other direct care staff do not facilitate any mental health or
substance abuse groups. The designated mental health clinician authority (DMHCA) indicated
the youth at Cypress Creek Treatment Center participate in group therapy services four days a
week, individual sessions bi-weekly, family sessions monthly, career development individual
sessions monthly, and supportive therapy sessions as needed. Groups vary from process
groups to manualized curriculum, which include evidenced based services. Individual and
Family services are tailored to the presenting needs of the youth to include substance abuse
and mental health treatment services. Youth receive three mental health-based groups weekly
and one substance abuse education and/or prevention group. The facility administrator
indicated the program offers both MHOS and Substance Abuse Treatment Overlay Services
(SAOS). Caseload sizes were reviewed and reflected the average caseload for each program
therapist was sixteen youth. The reviewed schedule and youth progress notes confirmed the
program provides individual, group, or family therapy at least five days a week. These services
are included on each youth’s individualized treatment plan. Documentation also supported youth
with co-occurring substance abuse disorders receive substance services. The program has a
Chapter 397 license through the Department of Children and Families (DCF) to provide
substance abuse treatment services to adolescents. The license expires September 6, 2024. All
mental health clinicians working at the program were qualified to provide substance abuse
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treatment and education services. During the annual compliance review period the program had
a minor deficiency assigned for groups not being conducted the required length of time. The
deficiency was escalated to a major deficiency and was corrected and closed. The reviewed
sign-in sheets verified mental health groups consisted of ten or fewer participants and
substance abuse groups consisted of fifteen or fewer participants with the following exceptions.
There were ten instances in the months of August and September when the group size for
substance abuse groups was sixteen participants. The program has an agreement with a
psychiatrist for the completion of psychiatric evaluations and medication management needs.
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 maintains a policy and procedures for the provision of psychiatric services within
the program. The program’s contracted psychiatrist shall be responsible for psychiatric
evaluations, consultation, medication management, and medical supportive counseling. The
program maintains an agreement with a medical doctor for psychiatric services. The reviewed
license showed it was free and clear in the State of Florida with an expiration date of January
31, 2024. The psychiatrist has an education specialty in adolescent psychiatry. An interview with
the psychiatrist, a review of the policy and procedures, and a review of the agreement confirmed
the psychiatrist is on call twenty-four hours a day, seven days a week for emergency
consultation. Reviewed documentation confirmed the completion of psychiatric evaluations,
medication reviews, and treatment team participation. The program does not utilize a psychiatric
advanced practice registered nurse (APRN). The program did not utilize a back-up psychiatrist
since the last annual compliance review. The psychiatrist’s agreement and contract require bi-
weekly services, and a review of sign-in sheets and medication management documentation for
the past twelve months reflected the psychiatrist provided on-site services as required. The
program does not utilize telepsychiatry services. The interviewed psychiatrist confirmed their
responsibilities, regular communication with the team, time on-site, and treatment team
participation. The designated mental health clinician authority (DMHCA) confirmed the
psychiatrist conducts on-site visits bi-weekly. A review of seven youth records confirmed each
youth received a referral for a new psychiatric evaluation. The program’s practice is to complete
an evaluation regardless of psychotropic medication status. Four of the seven youth were
admitted into the program with psychotropic medication. All seven youth received a new
psychiatric evaluation within two weeks of program admission. Each evaluation included the
youth’s history, Mental Status Examination results, a Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-V) diagnosis which was consistent with the youth’s
treatment plan, and treatment recommendations. Each psychiatric evaluation for the four youth
admitted with psychotropic medications addressed the applicable prescribed medications,
explanation for the need for psychotropic medications, target symptoms, initial treatment goals,
potential side effects, risks and benefits to taking medication, and frequency of medication
management. Prescribed psychotropic medications included the name, dosage, quantity of
medication, dosage range, ordered dosage, frequency and route of administration, and
applicable reasons for change in medication or dosage in each of the four applicable records.
Each of the seven completed evaluations were completed on the Department’s Clinical
Psychotropic Progress Note (CPPN). Four youth were applicable for medications and page
three of the CPPN was completed as required. Each evaluation for youth prescribed
medications documented the youth’s adherence to the medication regime, height, weight, blood
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pressure, description of response to medication, most recent laboratory findings when
appropriate, whether there was telephone contact with the youth’s parent/guardian to discuss
medication, date, and signature of the psychiatrist. The psychiatrist ordered a sleep study for a
fifth youth. The five reviewed applicable records contained a total of nineteen medication
reviews completed every thirty days. Reviewed documentation supported all medication reviews
were documented on the Department’s CPPN form. Two of the youth were applicable for the
monitoring of tardive dyskinesia. Documentation supported the monitoring was completed on a
monthly basis. During an interview, the psychiatrist indicated they conduct initial psychiatric
evaluations, prescribe psychiatric medications, and monitor youth taking psychotropic
medications every thirty days. The psychiatrist is available by phone twenty four hours a day,
seven days a week for emergency consultation, and receives notification of youth admitted on
psychotropic medication for continuation of medication until seen by the psychiatrist. The
DMHCA indicated they meet with the psychiatrist bi-weekly for a psychiatric treatment team
meeting. During this time, youth are discussed, and mental health/substance abuse referrals are
reviewed. The psychiatrist provides psychiatric/psychotropic interventions, as needed, and
completes a psychiatric evaluation on youth admitted to the program within fourteen days of the
youth intake.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a policy and procedures regarding the implementation of a Suicide Prevention
Plan. The program maintains a Suicide Prevention Plan which was last signed and reviewed by
the designated mental health clinician authority (DMHCA) and the facility administrator (FA) on
November 8, 2023. A review of the plan supported it included identification, assessment, staff
training, suicide precautions, levels of supervision, referral, communication, notification,
documentation, immediate staff response, and a review process. The review process for suicide
attempts and mortality review included circumstances surrounding the event, procedures
relevant to the incident, relevant training received by involved staff, pertinent medical and
mental health services involving the victim, possible precipitating factors, and recommendations.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
The program maintains a Suicide Prevention Plan which outlines the methods used for
screening, supervising, and assessing youth exhibiting suicide risk. A review of seven youth
records reflected all youth received an Assessment of Suicide Risk (ASR) upon admission
based on historical information. One youth was placed on constant supervision as a result of the
ASR. The other six youth were placed on standard supervision. There were no other youth
applicable for suicide prevention services during the annual compliance review period. All ASRs
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were completed on the Department’s form by the designated mental health clinician authority
(DMHCA) or a trained non-licensed therapist. The youth was maintained on constant
supervision upon completion of the ASR. The ASR documented the parent/guardian and
assigned juvenile probation officer (JPO) were notified of the youth’s potential suicide risk.
Documentation supported the youth was provided supportive services and three Follow-Up
ASRs were completed prior to the removal of the youth from precautionary observation. Each
Follow-Up ASR was completed on the Department’s Follow-Up ASR form. Upon the completion
of the third Follow-Up ASR, suicide precautions could be discontinued and the youth was
stepped to close supervision. The discontinuation of suicide precautions was the result of a
documented conference with the facility administrator and mental health clinician in each
applicable record. The youth was maintained on close supervision until it was determined
appropriate to step the youth to standard supervision. A review of the Department’s Juvenile
Justice Information System (JJIS) reflected accurate alerts were initiated and updated as
required. A review of the program’s logbooks and assessments supported the administration
staff provided instructions regarding suicide precaution decisions. Logbooks also documented
the placement and removal of precautionary observation and close supervision. Documentation
supported the youth on suicide precautions was able to participate in activities with other
program youth in the specified safe housing areas. An interview with the facility administrator
and a review of the policy and procedures reflected the program does not utilize secure
observation. The program’s video recording system is capable of storing thirty-days of footage.
There were no youth on precautionary observation in the past thirty days; therefore, video
observation of suicide risk supervision was not possible. Seven staff were interviewed and four
staff indicated they would notify the mental health staff when a youth expresses suicidal
thoughts. Four staff indicated they would place the youth on sight and sound and document
supervision. Five staff indicated they would alert the supervisor.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a Suicide Prevention Plan which outlines levels of supervision and the
process for recording observations of youth on suicide precautions. A review of seven youth
records reflected one youth was placed on constant supervision as a result of the Assessment
of Suicide Risk (ASR) upon intake. There were no other youth applicable for suicide prevention
services during the annual compliance review period. The youth record contained
documentation where a Suicide Precaution Observation Log was maintained for the duration the
youth was on precautions. Youth behaviors were documented in real time and not exceeding
thirty-minute intervals for the youth. Each of the reviewed logs were reviewed and signed by the
shift supervisor and mental health staff. Additionally, each log documented safe housing
requirements.
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3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a Suicide Prevention Plan which requires all staff with direct day-to-day
contact with youth to participate in suicide training. A review of seven pre-service and seven in-
service training records documented program staff completed the required six hours of suicide
training. The program has a total of three suicide kits which are located in master control and
each sub-control area of the program. The suicide kits are co-located with the program’s first-aid
kits. The program is required to complete one mock suicide drill for each shift at least quarterly.
A review of suicide drill documentation for the past twelve months reflected the program
conducted a quarterly drill on each shift as required. Reviewed drills consistently included the
use of lifesaving measures to include the use of cardiopulmonary resuscitation (CPR). Staff who
were not present during a drill were given an opportunity to review the drills during the staff
meetings. The facility administrator (FA) indicated monthly drills are completed on all shifts and
reviewed in the all staff meeting monthly. Seven staff were interviewed and five staff indicated
the suicide response kit is maintained in master control. Four staff indicated the kits are located
in sub control. One staff indicated a kit is in the medical room. Three staff indicated the
supervisor has the kit. One staff indicated a kit is also maintained in the breakroom. Two staff
indicated a kit is maintained in the control observation room and one indicated there is a kit in
each van. Five of the seven staff indicated medical emergency and suicide drills are conducted
monthly. Two staff indicated drills are conducted at least every sixty days.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a policy and procedures to outline operating procedures for crisis
intervention. The program’s Crisis Intervention Plan addresses mental health crisis intervention
services and Crisis Assessments. The program’s Crisis Intervention Plan was last reviewed and
signed by the facility administrator (FA) and the designated mental health clinician authority
(DMHCA) on November 8, 2023. A review of the plan indicated it included the notification and
alert system, referrals, communication, supervision, documentation, and review. The plan states
it shall be the responsibility of all staff to ensure crisis plans are implemented immediately to
afford youth with a maximum amount of safety and security.
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.
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A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program’s Crisis Intervention Plan addresses mental health crisis intervention services and
Crisis Assessments. The program’s designated mental health clinician authority (DMHCA)
reported there were no youth requiring a Crisis Assessment since the last annual compliance
review. A review of the Department’s Central Communications Center (CCC) Prison Rape
Elimination Act (PREA) incidents did not identify any additional youth requiring a Crisis
Assessment since the last annual compliance review.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a policy and procedures outlining the mental health and substance
abuse procedures for youth who are believed to be an imminent danger to themselves or others
because of mental illness or substance abuse impairment. The program’s Emergency
Response Plan was last signed and dated by the facility administrator (FA) and designated
mental health clinician authority (DMHCA) on November 8, 2023. A review of the plan validated
it included immediate staff response, notifications, communication, supervision, authorization to
transport for emergency mental health and substance abuse services, transport for emergency
Baker Act, transport for emergency Marchman Act, 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 Act or Marchman Act procedures during the annual
compliance review period; therefore, this indicator is rated non-applicable.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a written policy and procedures to establish a planning process
designed to identify areas which affect the youth and incorporate trauma responsive practices.
A review of seven youth records confirmed each contained a safety plan. Each plan included
warning signs, youth baseline behaviors, crisis recognition, jointly developed coping strategies,
youth preferred intervention strategies, and a debriefing process. Each plan was completed
within fourteen days of admission and incorporated recommendations from clinical
assessments. Each plan was reviewed and updated at least every thirty days and after
significant behavioral or mental health events. Six of the seven reviewed records were
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applicable for safety plan reviews. One youth was not in the program long enough to require a
safety plan review at the time of the annual compliance review. All thirty-four safety plan reviews
were completed as required. All seven interviewed youth reported contributing to their safety
plan. Seven staff were interviewed and asked where the youth safety plans were located, one
staff indicated they did not know. Another staff indicated they did not know but guessed the
break room. One staff indicated they were in the dorm. Three staff indicated they were in the
break room. One staff indicated safety plans were located in master control, sub control,
medical, and case management. When asked the process for reviewing safety plans, one staff
said they did not know. Three staff said when they want to review them. One staff said at
treatment team which is every two weeks and one staff said they were not sure where the safety
plans were. When asked about the last time staff actually reviewed safety plans, one staff
indicated they had not reviewed safety plans. Three staff indicated they reviewed safety plans a
month ago. Two staff indicated they were not sure about the last time and one staff said a
couple of months ago. One staff indicated they did not know where the safety plans were
located. The staff interview results were provided to the facility administrator. The facility
administrator indicated safety plans are updated monthly or when a serious issue arises with the
youth.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a designated health authority (DHA) who is a licensed physician (MD). The
DHA holds an unrestricted license expiring January 31, 2025, meeting all requirements for
independent and unsupervised practice in Florida. The DHA’s specialty training is in internal
medicine and no disciplinary cases or public complaints were found on record. The DHA has a
back-up DHA, who is a MD, with an unrestricted license expiring January 31, 2025, meeting all
requirements for independent and unsupervised practice in Florida. The back-up DHA’s
specialty training is in family practice. A review of the DHA sign-in and out log since the last
annual compliance review indicated the DHA was on-site two times and the back-up DHA was
on-site for all other visits. The DHA/back-up DHA were on-site once a week for the contractually
required two hours, other than on three days. The DHA/designee was short the required two
hours by one hour and twenty-seven minutes, thirty-one minutes, and forty-seven minutes
respectively. The program does not utilize tele-health.
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) and one licensed practical nurse (LPN) who
provide on-site nursing coverage for at least 200 hours a week, as contractually required. All
five nurses are full-time exceeding the contractually required amount of four nurses working
forty hours a week each. One of the RN’s serve as the health services administrator (HSA). The
HSA or another RN provide direction to the LPN, including reviewing all medical cases daily with
the LPN, and being available for on-call consultation. All five nurses who provided services
during the annual compliance review period had clear and active licenses; two RN licenses
expire April 31, 2024, two RN licenses expire July 31, 2024, and the LPN license expires on
July 31, 2025. All five nurses had current cardiopulmonary resuscitation certifications.
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 designated health authority (DHA), the facility administrator, and the psychiatrist signed and
dated all respective treatment protocols on July 5, 2023. The nursing staff reviewed, signed, and
dated a cover page on which medical facility operating procedures (FOPs), treatment protocols,
and other procedures were listed. New policies or changes in policies made during the year
were reviewed, signed, and dated by each nurse on a signature page added with the specific
policy listed, date of revision, and signatures. The DHA completed an annual review of medical
FOPs and protocols on August 31, 2023, and authorized treatment protocols and standing
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orders. All newly employed healthcare personnel received a comprehensive clinical orientation
to the Department’s healthcare policies and procedures, given by a registered nurse.
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.
All seven reviewed Individual Healthcare Records (IHCRs) maintained a legible copy of a valid
Authority for Evaluation and Treatment (AET) with the word “copy” stamped on the form. Each
was signed by the parent/guardian and a Department representative. Three of the youth were
eighteen years old and each signed a release of information. None of the youth were in the care
of the Department of Children and Families. The nurse interview indicated the AET is part of the
admission packet in the Department’s Juvenile Justice Information System (JJIS) and if there is
no AET, the case manager will contact the juvenile probation officer (JPO) to obtain an AET.
Eighteen year old or older youth are not required to have an AET, as they will sign a release of
information on or near their eighteenth birthday.
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.
Two of the seven reviewed youth entered the program being eighteen years old; therefore, were
not applicable for parental/guardian notification and consent. Two of the remaining five youth
records included documentation of parental/guardian notification for over-the-counter (OTC)
medications beyond those covered by the Authority for Evaluation and Treatment (AET), and
parental/guardian consent was provided. Three of the five had a new medication ordered and
attempted contact with the parent/guardian was documented in the progress notes. All five
Individual Healthcare Records (IHCRs) had written notifications sent utilizing the Department’s
Parental Notification of Health-Related Care: General, Parental Notification of Health-Related
Care: Medications forms, or the Acknowledgement of Receipt of the Clinical Psychotropic
Progress Note (CPPN). Three of the five youth were taking psychotropic medications and one of
the three received a new psychotropic medication requiring a witness during the conversation,
which was documented. The one youth had a new psychotropic medication prescribed and
another discontinued and parent/guardian verbal consent was documented on the third page of
the CPPN. None of the youth were in the care of the Department of Children and Families
(DCF). In all five IHCRs, vaccinations were verified within thirty days of each youth’s admission.
None of the youth required vaccinations and none of the parents/guardians refused consent for
vaccinations. The program obtains immunization records through the Florida Shots website and
if an immunization is needed, the local county health department is notified. Immunization
records are reviewed by licensed medical staff immediately as they become available. The
nurse interview indicated parental/guardian notifications are made when new medications are
ordered, OTC medications are needed and not covered by AET, as well as for every encounter
with the designated health authority (DHA), psychiatrist, eye doctor, or off-site event.
Parental/guardian consents/notifications are sent within twenty-four hours of the youth's visit by
the DHA/psychiatrist, after medication orders, and/or on the date of admission. When a youth's
illness or injury requires emergency medical services or is life threatening the youth is sent to
the local hospital with ambulance or transport, and parental/guardian notification is made
verbally and in writing. The nurse interview stated the parent/guardian is contacted and consent
is obtained for prescription of new psychotropic medications, discontinuations, or psychotropic
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medication adjustments, and written notifications are completed. Vaccinations are provided on-
site. Parent/guardian exemption from immunizations are documented after the parent/guardian
has notified the program, completed the exemption form, and sent the form to the program.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
Seven youth medical records were reviewed for the healthcare admission screening and
rescreening. One of seven Individual Healthcare Records (IHCRs) contained a Facility Entry
Physical Health Screening Form (FEPHS) rescreening. The program provided an additional
youth medical record for review. The program had two examples of youth needing a rescreening
during the annual compliance review period. All eight IHCRs contained a FEPHS completed on
the date of admission by a licensed medical staff. In the two applicable IHCRs there was a
change in physical custody greater than twenty-four hours and each youth received a FEPHS
rescreening. The nurse interview indicated all new youth are seen on the day of admission by a
nurse. If the youth arrive after all nurses have left, a FEPHS and admission screening are
completed by a direct care staff and reviewed by a licensed medical staff within twenty-four
hours. A pre-notification email is sent to the nurses by the intake specialist before each youth
arrival. When a new youth arrives at the program the nurses are notified over the radio and the
youth is brought to the clinic to complete the intake process. When there is a change in physical
custody after the youth's admission, a new FEPHS is filled out, the youth is seen to ensure no
immediate medical attention is needed, and the youth is assessed to ensure placement in the
general population is appropriate.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for orientation
documentation. All seven HCRs documented, on an orientation sheet, each youth received a
general care admission orientation upon each youth’s admission. The program utilizes an
orientation checklist, which is in each IHCR. The admission orientation included information on
how to access to medical care, sick call, what constitutes an emergency and when to notify
staff, medication process to include side effect monitoring, the right to refuse care and how it is
documented, what to do in the case of a sexual assault or attempted sexual assault, the non-
disciplinary role of the healthcare providers, and standard universal precautions.
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.
A review of seven Individual Healthcare Records (IHCRs) indicated three youth had known or
suspected chronic conditions with evidence of a referral to the designated health authority
(DHA). None of the seven youth were identified as in-need of emergency care upon admission.
All seven IHCRs documented notification to the DHA within twelve hours of admission in each
youth’s Chronological Progress Notes (CPN). Four of the seven youth were taking psychotropic
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medication upon admission and the psychiatrist was notified. The nurse interview indicated if
youth are admitted with serious or chronic conditions and/or requiring emergency care, the DHA
is notified immediately by the nurses, which is documented in the youth's IHCR.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
A review of seven Individual Healthcare Records (IHCRs) indicated the Health-Related History
(HRH) form was completed within seven days of admission, prior to the Comprehensive
Physical Assessment (CPA), as evidenced by signatures and dates. The designated health
authority (DHA)/designee reviewed the HRH which was documented on the CPA. The nurse
interview indicated a new HRH is completed by a registered nurse on the day of admission. If
the HRH is updated, it will be completed within seven days of 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.
All seven Individual Healthcare Records (IHCRs) contained a new physical assessment
completed by the designated health authority (DHA)/designee on the Department’s
Comprehensive Physical Assessment (CPA) form within seven calendar days of each youth’s
admission. The Medical Grade and all required elements were documented on six of the seven
reviewed CPAs. One CPA was missing the age, height, weight, body mass index, pulse,
respiration, blood pressure, temperature, and visual acuity. These missing elements were noted
on the DHA progress note. All seven CPAs had all required sections marked with an “O” or an
“X”, as required. Any part of the exam refused by a youth was documented by the DHA with
“Youth Refused”, and each youth signed a refusal form which reflected the refused portion on
the CPA exam and matched the date of the exam. The Department’s Problem List was updated
in all seven IHCRs. At least one verified Tuberculosis Skin Test (TST) was documented on the
CPA and the Infectious and Communicable Disease (ICD) forms. The nurse interview indicated
the DHA completes a new CPA for all newly admitted youth within seven days of admission and
annually thereafter. All youth are screened for tuberculosis at admission and annually
thereafter.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures addressing sexually transmitted infection (STI) and
human immunodeficiency virus (HIV) screenings, evaluations, and testing. The program’s policy
and procedures also indicated HIV test results are only disclosed to the youth and the youth’s
legally authorized representative, healthcare providers during the course of consultation,
diagnosis, or treatment of the individual, the Department of Health for purposes of reporting and
control of spread of disease, health facility staff committees conducting program monitoring,
evaluation, and service reviews, medical personnel who have been subject to a significant
exposure, and healthcare facility personnel or agents for the healthcare provider who have a
need to know in the course of patient care activities or administrative operations. All seven
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Individual Healthcare Records (IHCRs) contained a screening and evaluation for STIs; none
required further evaluation or testing. One of the seven youth received a STI rescreening due to
being sexually active and out of the Department’s physical custody. All seven IHCRs had
evidence each youth was offered counseling and testing for HIV. None of the youth consented
to HIV testing. The program did not have any youth requiring or wanting HIV testing during the
annual compliance review period. The local health department provides HIV testing and the
designated health authority (DHA) provides HIV pre and post-test counseling services. All seven
youth interviews indicated they can ask for a HIV test. The nurse interview indicated all youth
are STI screened at admission through a questionnaire and the examination by the DHA, and
testing is ordered as needed. The STI screenings, evaluations, referrals, and test results are
documented on the Infectious Communicable Disease form, STI form, HIV forms, and if
completed, lab results are in the laboratory section of the IHCR. The nurse interview stated
youth are rescreened if they have been out of the program's physical custody for more than
thirty days, and/or symptoms are present through completion of a new STI screening, and
referral to the DHA is made. If the youth exhibits symptoms the DHA would be verbally notified
and testing would be completed as ordered. HIV test results are placed in a sealed envelope,
marked confidential, and maintained in the laboratory section of the youth’s IHCR. Youth are
asked about HIV testing at admission and told they can request HIV testing at any time by
speaking to a nurse or requesting a sick call. The nurse interview indicated the local health
department staff will come to the facility to provide HIV testing when needed.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures indicating only nurses conduct sick call and, if there is
no nurse on-site, the shift supervisor will review all sick call requests as soon as possible and
within two hours after the request is submitted. Five of seven Individual Healthcare Records
(IHCRs) were applicable for sick call. None of the five applicable youth presented with similar
sick call complaints three or more times within a two-week period. All five applicable youth
requested a sick call. Both the youth and the registered nurse completed the Sick Call Request
forms. All Sick Call Request forms were filed in each youth’s IHCR, in reverse chronological
order. None of the youth were in restricted housing. All Sick Call forms were documented in
accordance with Florida Administrative Code, and each sick call was documented on the Sick
Call Index matching the Sick Call Referral log with one exception. The program provides sick
call twice a day Monday through Friday and once a day Saturday and Sunday, exceeding the
contractual requirement of once a day seven days a week. Observations indicated the sick call
hours were posted in the clinic, as well as on each module accessible to all youth and staff. Sick
Call forms are available to all youth. A sick call was observed with the youth’s verbal consent.
The youth was escorted to the clinic by a youth care worker who remained outside of the
examination room and within visual observation of the youth, to afford privacy. No other youth
were present. The nurse identified themself, stated the reason for the sick call, and utilized the
examination table to conduct the sick call. All seven staff interviews indicated the nurse reviews
and conducts sick call. Six of seven youth interviews indicated they can see a nurse within one
day when requesting sick call; one youth stated it takes more than three days. The nurse
interview indicated if a youth is seen for the same illness three times in a fourteen-day period
the youth is referred to the designated health authority (DHA) and nursing protocols are
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followed. The DHA has approved the nursing protocols. The nurse interview stated the program
does not utilize restricted housing/confinement. The nurse stated human immunodeficiency
virus (HIV) testing can be requested at any time by the youth, and the local health department
will conduct the questionnaire and complete the testing. Sick call is typically completed by the
registered nurse (RN), by the DHA if on-site, and/or by the licensed practical nurse (LPN). The
RN will review the sick call conducted by the LPN within twenty-four hours. Sick call boxes are
on the dormitories along with the sick call forms. The sick call boxes are checked several times
throughout the day and at least once a shift if there is no nurse in the building. Youth are
normally seen within twenty-four hours. Sick calls are conducted in the clinic treatment room.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures addressing episodic and emergency care, which also
includes a process for ensuring contents of first-aid kits are maintained and stored in
accordance with guidelines to prevent expiration or deterioration and items are replenished as
needed. The program’s policy also talks about access and use of NARCAN®. Six of seven
Individual Healthcare Records (IHCRs) were applicable for on-site episodic or first-aid care. All
six youth received episodic or first-aid care by a licensed healthcare staff which was
documented in problem-oriented charting. The program has ten first-aid kits with one in the
kitchen, Home Builder’s Institute (HBI) building, education/vocation, controlled observation,
north sub control, south sub control, and master control, with three kits maintained in master
control for the transportation vehicles. Three first-aid kits were checked and all were fully
stocked with designated health authority (DHA) approved contents. A review of the first-aid kit
checks since the last annual compliance review indicated they were checked weekly as the
program’s process indicates, with the exceptions of two checks being missed. The program has
one automated external defibrillator (AED) located in master control. The AED procedures are
kept within the AED box. The AED was observed to be in working order during the annual
compliance review week. The batteries expire June 2024 and the pads November 4, 2024. The
pads were last changed on November 29, 2021. The staff were unsure of when the battery was
last changed; however, staff indicated it being around July 2023. A review of the AED checks
since the last annual compliance review indicated the nurses conducted weekly checks. A
review of medical drills for the last full year indicated direct care staff participated in at least one
drill, which included the use of cardiopulmonary resuscitation (CPR) annually. The reviewed
drills simulated 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. The staff who were unable to participate in a drill had the
opportunity to review each scenario. All staff with direct youth contact on a day-to-day basis had
the opportunity to participate in at least one emergency CPR drill annually. A review of the
emergency medical drills indicated they were conducted either announced or unannounced at
least quarterly on each shift. The nurses posted the emergency numbers accessible for staff
and inaccessible for youth in the nurse’s office/medication room. A review of seven pre-service
staff training records indicated all had been trained on the administration of the epinephrine
auto-injector by a registered nurse. All seven pre-service and seven in-service staff training
records indicated all fourteen staff had received training in episodic, first-aid, and emergency
care. The program has four doses of NARCAN®, two each in master control and in the
medication cart, accessible to all staff. The program has included NARCAN® training into the
training plan and all staff have been trained on its use. The nurses conduct a perpetual
inventory of NARCAN®. Four of seven staff interviews indicated they would call 9-1-1 if a youth
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has a medical emergency. Three stated would contact supervisor to call 9-1-1. All seven youth
interviews indicated they can see a dentist and a doctor if needed. The nurse interview indicated
the location of the first-aid kits and indicated on-site episodic care is documented on a nursing
note and on the episodic care log. If the non-healthcare staff provide first-aid/emergency care, it
is documented on the On-Site Health Care by Non-Health Care Staff form by the staff providing
the care. Youth who are sent off-site for emergency care are tracked in the off-site logbook. The
nurse stated the program has one AED in master control and the AED procedures are
maintained with the AED. The nurses conduct monthly AED checks which includes a review of
the battery and pads expiration dates. The nurse interview indicated drills are conducted
monthly on each shift, as well as sometimes during the all-staff meetings, and the emergency
numbers are posted throughout the facility, as well as in the nurse’s office.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for off-site care and off-site
referrals. One IHCR was applicable for off-site care. The program did not have any other
examples for youth receiving off-site care during the annual compliance review period. The one
applicable IHCR contained the Summary of Off-Site Care Consultation Report form and the
event was documented on the Episodic Care Log. The youth was eighteen years old and did not
require parental/guardian notification. The IHCR contained the discharge and other applicable
documents which had been reviewed and signed off by the designated health authority (DHA).
The youth did not require follow-up appointments, referrals, or testing. The nurse interview
indicated youth who are sent off-site for first-aid or emergency care needs are tracked through
the off-site log and an off-site schedule book. The DHA/designee is called once the youth
returns from off-site event to confirm all off-site orders. The off-site paperwork is placed in the
front of the IHCR for the DHA to sign when on-site.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for chronic conditions and
periodic evaluations. Three of the seven youth were identified on the Facility Entry Physical
Health Screening (FEPHS) form with a current chronic health condition. One of the three had a
condition which required taking prescribed medication on an on-going basis. All three were
undergoing treatment for physical health conditions, being classified with Medical Grade two to
four and placed on the chronic illness list. Two of the three received periodic evaluations at least
every ninety-days indicating no lapses in care. The remaining youth’s health condition was no
longer chronic; therefore, the youth was removed from the chronic illness list prior to the second
periodic evaluation. In all three applicable Individual Healthcare Records (IHCRs) the progress
notes documented each completed periodic evaluation. None of the youth were pregnant, taking
anti-tuberculosis medication, or received a periodic evaluation off-site. One of the youth
received periodic evaluations prior to renewing prescription medication. In all three IHCRs the
Department’s Problem List was updated as required. The facility administrator (FA) interview
indicated the health service administrator (HSA) informs the FA of any pertinent youth medical
information. This information is disseminated to staff based on a need-to-know basis. The HSA
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attends the daily management meeting to discuss medical concerns, issues, or appointments.
The designated health authority (DHA) interview indicated periodic evaluations for youth with
chronic conditions are completed every sixty days. The nurses maintain a chronic clinic log and
schedule applicable youth to be seen every sixty days or less. The nurse interview indicated
youth with chronic conditions are listed on a chronic clinic log and monitored every sixty days by
the DHA.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for medication
management. Four IHCRs were applicable and contained a Facility Entry Physical Health
Screening (FEPHS) form and progress note indicating each youth was admitted with
medication. In the four IHCRs, the medication was verified prior to each youth being admitted
into the program and the prescription verification was included in the Chronological Progress
Note, as well as the Prescription Medication Verification Checklist form. In six of seven IHCRs,
the designated health authority (DHA)/designee, and when applicable, the psychiatrist were
contacted to obtain the order to resume the specified medications prescribed prior to admission.
In six of seven IHCRs all medications had a current, valid order and were administered pursuant
to a current prescription. In the remaining one record, the youth did not receive one dose of a
prescribed over-the-counter (OTC) medication with no documented reason as to why. The
DHA/designee placed an order on the Practitioner Order form in all seven IHCRs for continued
current medications, discontinued, changed, or newly ordered medications. None of the youth
were in restricted housing, received parenteral medications, or had any non-healthcare staff
provide medications. Two of the seven youth received OTC medications not listed on the
Authority for Evaluation and Treatment (AET) form, which were administered according to
approved protocols. All seven IHCRs contained pre-printed pharmacy Medication Administration
Records (MARs) including all required information of the Department’s MAR, as well as clearly
indicating medication start and stop dates and staff initialing each administered medication
entry. All reviewed MARs indicated the nurses documented weekly side-effect monitoring and
the picture of each youth was maintained alongside the current MAR. Two of the youth signed
Refusal of Treatment forms indicating the refusal, which was clearly documented on each
applicable MAR. All seven IHCRs contained MARs with the required elements of youth name,
Department identification number (DJJID), date of birth, youth allergies, precautions, Medical
Grade, and medical alerts, other than two MARs for two youth. One MAR was missing the youth
name, DJJID, date of birth, youth allergies, Medical Grade, and medical alerts. The other
youth’s MAR was missing Medical Grade and medical alerts. Four of the seven youth were
prescribed psychotropic medication upon admission and the DHA and psychiatrist were notified.
All four youth received an initial diagnostic psychiatric interview within fourteen days of
admission and medication monitoring every thirty days as required. The program has no
standing orders, emergency treatment orders, or pro re nata (PRN) orders for psychotropic
medications. During the annual compliance review week ten medication administrations were
observed. Medication delivery was the sole responsibility of the nurse during the time of
administration. Verbal consent was obtained prior to observation from all ten youth. All ten youth
were escorted by a youth care worker (YCW), one by one, to the medical clinic. Each youth
approached the nurse individually who provided identification, and stated why the youth was
there. Each youth provided their name and medication being taken. The nurse prepared and
administered each of the medications, verifying allergy and alert status, the Six Rights of
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Medication Administration, and none of the medications were pre-poured. The nurse initialed
each MAR and the YCW ensured each youth swallowed the medication. Five of seven youth
interviews indicated the nurse provides medications. The five youth stated they walk up to the
nurse, provide their name, the dormitory, the medication name, take their medication, and get
their mouth swabbed. One youth reported they are supposed to cough and another said they
have to drink water after receiving medication. The remaining two stated they do not receive
medications. All seven staff interviews indicated the nurse provides medication and one also
mentioned the supervisor can provide medications. The nurse interview indicated only licensed
medical staff are allowed to verify medications at admission. The nurses review prior MARs,
orders, and all other important documentation, and the medications are documented on the
Health-Related History (HRH) and the FEPHS forms, and the DHA notification and admission
note. The nurse interview indicated the health service administrator (HSA) trains the non-
licensed healthcare staff to assist in medication administration with the list being kept in
medical, and the OTC medication book. The program has medication pass from 7:00 a.m. to
7:45 a.m. and 5:30 p.m. to 6:30 p.m. Monday through Friday, and 8:00 a.m. to 8:30 a.m. and
4:40 p.m. to 5:30 p.m. Saturdays, Sundays, and holidays. All medications are procured from a
local pharmacy, unless medication is brought in with the newly admitted youth, or in the event of
an emergency. The psychiatrist is on-site every fourteen days and provides psychiatric
evaluations and medication management.
4.17 Medication/Sharps Inventory and Storage Process Limited Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures addressing reporting criteria, a process regarding
inventory discrepancies, as well as the destruction and disposal or return of expired or
discontinued medications. A review of the medical equipment classified as sharps since the last
annual compliance review indicated they are secured and inventoried utilizing a routine
perpetual inventory with descending count as each sharp is utilized and disposed, as well as
weekly counts. An observation was conducted during the annual compliance review week and
indicated all medications were identified and secured, in a locked area designated for storage of
medications, with different types of medications kept separated and inaccessible to youth. An
observation of the medication cart revealed it was locked, cleaned, and organized with stock
items kept separate from youth specific medications, and controlled substances kept in a
separate locked box. The clinic had a separate refrigerator which is utilized for medications only.
A review of the stock over-the-counter (OTC) medications since the last annual compliance
review indicated of the five medication inventories reviewed, eleven weeks were missing. The
program had only one controlled substance on-site during the annual compliance review week.
The nurses maintained a perpetual inventory and stored the medication separately from other
medications. The controlled medication did not have a shift-to-shift inventory count documented
on the youth’s Individualized Controlled Medication Inventory Record, only a perpetual count. A
review of eighteen staff training records indicated the supervisory, non-healthcare staff were
trained in the delivery and oversight of medication self-administration by a registered nurse.
Counts of the only controlled medication on-site, three sharps, and three OTC medications
indicated the final count matched the inventory documentation. The nurse interview indicated all
medications are secured in the medication cart, including all controlled narcotics behind two
locks. Medications in a bubble pack are sent back to the pharmacy, and controlled narcotics are
disposed of in a pharmacy approved liquid when the consultant pharmacist is on-site once a
month.
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4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a policy and procedures addressing needle stick post-exposure evaluation.
The program has infection control procedures in place including prevention, containment,
treatment, and reporting requirements related to infectious diseases, in accordance with the
Occupational Safety and Health Administration (OSHA) federal regulations and the Centers for
Disease Control and Prevention (CDC) guidelines. The infection control procedures were
reviewed by the designated health authority (DHA) and the facility administrator (FA) on July 9,
2021, and the chief of compliance officer on July 1, 2021. The infection control procedures
include common, infectious diseases of childhood, self-limiting, episodic contagious illnesses,
viral or bacterial infectious diseases, tuberculosis, hepatitis A, B, C, human immunodeficiency
virus (HIV), and infectious diseases caused by blood-borne pathogens. The procedures contain
other outbreaks or epidemics caused by any other infectious agent, whether spread directly or
indirectly, outbreaks of pediculosis and/or scabies, Methicillin-Resistant Staphylococcus Aureus
and other emerging antibiotic-resistant micro-organisms, food-borne illnesses, bio-terrorist
agents, chemical exposures in the workplace, hepatitis B immunizations available for staff, and
staff access to protective equipment. The program did not have any instances in which the local
county health department, CDC, and/or the Department’s Central Communications Center had
to be notified of an infectious disease, quarantining, or hospitalization of at least ten percent of
the total population of youth or staff, or six individuals, whichever is less. The program’s human
resources department maintains a record containing all documents for youth and staff who have
experienced a facility/occupational exposure. The program’s exposure control plan is written in
accordance with OSHA standards and is available to all staff. The program maintains a copy in
master control, the staff break room, the medical clinic, and the FA’s office. The exposure
control plan was reviewed and signed annually by the administration of the program on July 25,
2023. The FA interview indicated the exposure control and infection control plan are reviewed
with staff yearly, and maintained in master control, the staff break room, medical and the FA
office within the policy and procedure book for staff access. The nurse interview indicated they
have access to the exposure control plan. They provide annual training on the exposure control
plan and infection control plan to the staff and they are reviewed bi-annually by the registered
nurse/health service administrator. Infection control training is provided to the youth upon
admission and annually thereafter. The nurse stated they utilize immunizations and HIV testing
through the county health department occasionally.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures which require staff to 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, and consistently
applying the programs behavior management system (BMS). Program staff must account for
the whereabouts of youth under their supervision at all times. The program adheres to a staff-to-
youth ratio of one-to-eight during daytime activities and one-to-twelve during hours of sleep.
Observations confirmed supervision ratios were being followed according to contractual
requirements. Additionally, observations of staff during the annual compliance review week
found staff were actively supervising and positively interacting with youth during school, physical
education, Home Builders Institute (HBI) instruction, medication administration, and during
breaks. The program has schedules of activities posted on each mod and observed youth were
engaged in activities and following the schedule. Three staff were informally interviewed and all
three staff were able to identify the number of youth assigned to them without stopping to count
them. All seven interviewed staff were able to provide steps to take if a youth count could not be
reconciled.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program has a policy and procedures addressing the collaborative behavior management
system (BMS) and protocols regarding feedback given to staff regarding their implementation of
the BMS during the annual performance evaluation for each staff. The written description of the
BMS was posted on each of the four active modules and in the youth handbook which included
the rules governing conduct and positive and negative consequences. The program’s BMS
allows for youth and staff to discuss behavior, impact on themselves and others, discussion of
alternate behaviors, and peaceful conflict resolution. The program reviews youth behavior cards
during morning management meetings and with youth during weekly treatment team. The
program employs their own teachers who are trained on the BMS. The facility trainers are
responsible for initial training of all staff on the BMS. Seven staff records were reviewed for
position descriptions and each reflected BMS training was completed. All seven youth records
contained an orientation handbook signed by the youth, which includes rules governing conduct
and positive and negative consequences. The program’s BMS was not changed or in the
process of being changed since the last annual compliance review. The program’s written BMS
includes maintaining order and security, promoting and protecting youth rights, positive and
negative consequences, constructive disciplinary actions, opportunities for positive
reinforcement, recognition of accomplishments and positive behaviors at a four-to-one ratio, and
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promoting socially acceptable means for youth to meet their needs. The program’s BMS does
not include increased 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. During an
observation of the facility administrator (FA) speaking with a youth, it was noted the staff
member was using the four-to-one ratio of positive affirmations and praise, which was
consistent with other observations. Consistent use of BMS was observed throughout week of
annual compliance review. The program offers daily and weekly canteen options, and food
incentives for perfect behavior on a day, week, and monthly basis. The program also has living
module incentives for no negative behavior over two week periods, which includes pizza parties
and movie nights. The program has birthday celebrations for the youth. Six of seven interviewed
staff were able to describe the program’s BMS. The remaining staff indicated they were not
trained on BMS; however, the facility provided documentation confirming the training on BMS
was completed by the staff. Five of seven staff accurately provided examples of rewards
provided as part of the BMS, such as canteen, special meals. The remaining two staff were
unable to provide examples of rewards. All seven staff confirmed things cannot be taken away
from youth as a consequence. Six of seven staff were aware of how youth are informed of the
consequences and when youth are able to explain their behavior. The remaining staff was not
aware. All seven staff explained feedback to staff regarding the BMS is provided by supervisors
during briefing or treatment team. Seven youth interviews were completed. Six of seven youth
were able to describe consequences, with only one youth indicating staff were fair in the
behaviors they will punish. One youth stated they did not know about the consequences used
because they have never received any consequences. Six of seven youth were able to name
rewards earned in the program, were able to describe the level system, and how to advance
through the levels; however, the remaining youth stated they did not think the program does
rewards and they really did not know the difference between levels. All seven youth agreed
youth are never allowed to punish other youth, as well as all staff use the rewards the same.
When youth were asked what they think about the BMS, four youth stated it was good and three
youth replied the BMS was fair at the program. The facility administrator (FA) interview reported
the program uses a positive incentive-based BMS, in which youth who do good are provided
rewards. If the youth have issues, then there are consequences. The FA also indicated rewards
and consequences are monitored through treatment teams and the daily review of behavior
reports. Staff implementation of the BMS is reviewed through the daily scorecard meeting and
behavior reports, as well as incident reports which are reviewed during management meetings.
Conflict resolution is conducted if there appears to be an issue. Retraining is conducted on the
process, when necessary and annually.
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 states the program does not use restricted housing, to include room
restriction; therefore, this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures which require staff to observe youth at least every ten
minutes, while the youth are in their sleeping quarters. Staff are required to conduct the
observations in a manner to ensure the safety and security of each youth. These checks shall
be documented in real time. The program has 121 cameras and all were operational at the time
of the annual compliance review. The program maintains thirty days of video recordings. A
sample of security tapes and corresponding logs was reviewed to verify ten-minute checks. The
sample included three samples of thirty-minute increments from each shift from each housing
mod. The review confirmed all checks were conducted at eight-minute intervals, which was
below the ten-minute requirement. All checks were documented in real time. A review of the ten-
minute check sheets confirmed staff who completed the checks initialed the check sheet. Video
review further confirmed checks were conducted as required and staff walked by the rooms,
pausing for a moment to observe the youth thoroughly enough to guarantee their safety. A
review was conducted of check sheets for the annual compliance review period which reflected
checks were conducted as required. Seven staff were interviewed, and all seven advised
checks are conducted every eight 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.
The program has a policy and procedures addressing census, counts, and tracking. The
program’s census and counts are documented in the master control logbook with three formal
counts completed each shift. The program’s policy states there are to be six formal counts
completed every twenty-four hours. Observations during the week of annual compliance review
found master control calling for and completing counts as required at various times throughout
the day. The program’s master control logbooks were reviewed, confirming counts were
completed three times a shift. A review of a full day for each month, since the last annual
compliance review, was conducted of the logbooks and each day contained documentation of
total daily census counts, head counts, youth movements, youth admissions, releases, and
youth temporarily away from the program. All seven interviewed staff reported counts are
conducted three times each shift. Six of seven interviewed staff were able to provide examples
of when emergency counts are done, while the remaining staff indicated one time a day. Four of
the seven interviewed staff were unable to provide the current census and three staff provided
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census numbers reflecting populations of both programs, none of which were accurate. This
information was passed along to the program.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures to address logbook entries. Observations during the
annual compliance review week confirmed the program uses a single bound logbook with
numbered pages for each month. A review of each logbook verified all entries were made in ink
with no erasures or white-out areas, no logbook entries were destroyed or removed, and all
errors were completed correctly using single line struck through with staff initials. The reviewed
logbook pages included entries with dates, time, brief description of event, and names of staff
making the entry. A review of the logbooks during the annual compliance review period
documented minimal interference of the educational instruction period. The master control
logbooks only documented class start times, as the youth classrooms are located on their
modules. Physical education was added to education instruction, in November, thus movements
to physical education and recreation were also documented. The program does not utilize living
unit logbooks. The program utilizes shift reports, which have the census of all living units,
incidents, youth out of facility, youth alerts, gang members, security alerts, staffing assignments,
sick calls, perimeter checks, and their findings. Shift reports are reviewed by the supervisor from
the previous shift and the on-coming shift during staff briefings at shift change. Shift reports
maintained during the annual compliance review period included signatures of staff and
supervisors confirming their review of the shift report. During the week of annual compliance
review, shift A briefing was attended, in which the program supervisor verbally briefed staff with
the shift report, along with the supervisor from the previous shift, staff were given their
assignments, and a review of the shift report was documented. Logbook entries contain all
required information. A review of master control logbooks and shift reports documented internal
incidents reported to the Department’s Central Communications Center (CCC) and/or Florida
Abuse Hotline.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures to address key control which includes key
assignment and usage, restrictions on usage, inventory and tracking of keys, secure storage of
keys not in use, procedures addressing missing or lost keys, and reporting and replacement of
damaged keys. The program keys are maintained in a padlocked clear view cabinet located in
master control, under camera view, and in an area which is secured and inaccessible to youth.
Staff personal keys are secured in master control within a locked cabinet. Master control issues
keys based on position. The key box is located in master control and is not easily accessible
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while locked. Each set of keys has an assigned number and corresponding key ring. A review of
the key inventory matched the actual key rings in use. Keys are always locked in a cabinet
when not in use. During the week of the annual compliance review observations of master
control issuing keys confirmed the key inventory matched with correct number of keys assigned
to the individual key set. Key sets in administration were in a locked box on the wall. Both key
storage boxes were secured. The facility administrator assigns the permanent and restricted
keys based on the position. An acknowledgment form for permanent keys is completed for each
permanent key assigned with signature, key number, and return date. Restricted keys are
stored in a separate locked box apart from non-restricted keys and only assigned staff can
access the restricted key box. The program has a broken key report which is given to the plant
manager who is the only staff authorized to replace keys. The program did not have any
incidents reported to the Department’s Central Communications Center (CCC), or Program
Monitoring and Management (PMM) deficiencies related to key control during the annual
compliance review period. An informal interview with the chief of security found they were able
to identify which keys were restricted and what positions are assigned restricted keys. The
program maintains a twenty-four hour key log, which the master control operator updates, listing
who keys are issued to, date, time of issue, who received the key, and the date and time the
keys were returned. Master control must initial each entry. Three random staff were informally
interviewed and staff were able to identify what key set they have and function of every key on
the key set. The key sets were also verified using master key inventory. Seven staff were
interviewed and two reported they did not know the key control process.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures in place to prevent contraband from entering the
facility. The policy includes items and materials considered as contraband, providing youth with
a list of items considered as contraband, informing program youth of the consequences if found
with contraband, searching the facility and grounds, and searching of youth, incoming mail, and
outgoing mail. The policy includes the consequences if any program staff is found in possession
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of contraband. The policy also includes contacting law enforcement if any item found is
considered illegal as defined in Florida Statutes or if there is any evidence of unlawful activities.
The program did not have an incident related to contraband during the annual compliance
review period. A review of the Department’s Central Communications Center (CCC) reports
showed there were no reports of contraband being confiscated. A review of the facility logbooks
and youth room search reports for the annual compliance review period showed the program
conducted searches as required. Contraband items or illegal contraband are documented on the
search log and disposed of as required. The interview with the facility administrator (FA) stated
all contraband is given to the shift supervisor and then to the chief of security. If necessary, the
CCC is contacted. If the contraband is illegal the police will remove the item. If the contraband is
CCC reportable, the contraband is kept until the end of the investigation, then removed and
disposed of by administration. Seven interviewed staff reported room searches are completed
once a shift.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures to address searches and full body visual searches to
ensure no contraband is introduced into the facility. During the week of the annual compliance
review, staff were observed searching youth prior to and after movement. Staff were observed
searching a youth returning from a detention transport. The program did not have any
admissions or releases during the annual compliance review week. Visitation did not take place
during the week of annual compliance review. During the week of the annual compliance review
there were not any off-campus activities scheduled. Youth searches were observed as youth
exited the Home Builders’ Institute instruction building. During observed searches youth were
treated with dignity and respect to minimize the youth’s stress and embarrassment. Observed
searches were conducted by same gender staff and with the appropriate number of staff. Youth
were given instructions and reasons for each search prior to the search, which was in line with
the program’s policy. Five of seven interviewed staff reported youth are searched whenever
youth leave the dorm and two staff stated youth are searched after line movements. Seven
interviewed youth indicated searches are conducted after every movement, as well as after
outdoor activities, meals, visitation, and if items are missing.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a policy and procedures to address vehicles and maintenance. The program
utilizes three vehicles for youth transport, one of which is waiting to be surplused. Reviewed
documentation validated the vehicles had received an annual safety inspection and all required
maintenance records were documented. During the week of the annual compliance review,
sixteen randomly selected personal vehicles and three facility vehicles were found secured.
Seven youth were interviewed; however, only two indicated they have been on transports and
reported they were secured with the seatbelt, handcuffs, and shackles. Four of seven
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interviewed staff reported using seatbelts, shackles, and handcuffs during transports and the
remaining three staff have not completed transports. Observations confirmed each of the facility
vehicles contained a seatbelt cutter, window punch, safety screen, fire extinguisher, the
appropriate number of seatbelts, and the youth doors cannot be opened from the inside. First-
aid kits are issued when vehicles are checked out. Each vehicle had an annual safety inspection
and maintenance records documented.
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 address transportation of youth and driver
eligibility. The review of the program’s policy indicated a program cellular telephone is issued for
all transports. The program’s policy also states a minimum of two staff to one youth are required
during a transport, and a staff of the same gender of the youth must be present during transport.
The program provides transportation for the youth. During the week of the review, two staff were
observed returning a youth from detention, one of the staff was the same gender as the youth,
and staff were also observed removing seatbelts prior to exiting the vehicle. All three facility
vehicles have safety screens installed. Reviewed documentation revealed the program
maintains an approved driver list and ensures each approved driver has a valid driver license.
Youth are not permitted to drive program or staff vehicles. An interview with the facility
administrator confirmed each facility vehicle has safety screens. Four of seven interviewed staff
were able to identify safety equipment in transport vehicles and the remaining three staff have
not participated in transport. All seven interviewed youth reported not seeing anyone place
contraband in vehicles and feeling safe during transports.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures outlining weekly safety and security audits and which
program staff conduct the weekly security audits and safety inspections. The policy and
procedures also include the development and implementation of corrective actions warranted as
a result of safety and security deficiencies found during any inspection, an internal system to
verify if the deficiencies are corrected, and existing systems are improved or new systems are
instituted as needed to maintain compliance. The program completes the weekly audits with
facility administrator, assistant facility administrator, chief of security, plant manager, and unit
manager. During the annual compliance review period weekly inspections were documented,
with only three weeks in July which did not include the chief of security. There were no safety
and security audit related deficiencies during the annual compliance review period. The
program’s preventive maintenance schedule was reviewed with the chief of security and repairs
were conducted as policy states. The interview with facility administrator (FA) revealed the FA
utilizes a weekly safety inspection sheet, work orders, daily perimeter checks, and discusses
items in the daily management meeting.
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5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures addressing the issuance, inventory, and control of
equipment and tools. The plant manager completes a monthly tool inventory which is signed off
by the facility administrator (FA). The program’s policy prohibits machetes, bowie knives, or
other long blade knives. The program has procedures for missing or lost tools and disposal of
dysfunctional tools. The program did not have missing, lost, or damaged tools during the annual
compliance review period. A review of the program’s tool inventory records confirmed tools were
inventoried when being issued were inventoried following return. Eleven tools were randomly
selected, all were secured, had easy identification, and accurately matched the inventory list.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures addressing the supervision requirements when youth
use tools including the ratio of one staff to five youth, issuing tools to youth and staff,
assessment to determine a youth’s risk to self and others, tool distribution, collection, and
search criteria during work projects. The program does not utilize disciplinary work projects. An
observation of Home Builder’s Institute (HBI’s) instruction class confirmed the ratio and
searches of youth followed policy. The program includes instruction of class B tools and the risk
assessments and training for seven youth were reviewed. All records included documentation a
risk assessment and training on appropriate tool usage was completed with each youth. Six of
seven interviewed staff reported youth are not to use tools and one staff responded tools are
used only in HBI. Five of seven youth interviews reported youth are not allowed to use tools and
the remaining two youth responded they only use tools in HBI.
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 to address outside contractors which include tools
shall never be left unattended, tools should be limited to only the required tools necessary to
perform tasks, no tool shall be given to youth at any time, and youth are restricted from work
areas. The physical plant manager or designee inspects all tools upon arrival and departure of
outside contractors, is responsible for providing approval if such tools are required, and missing
tool follow-up. The program has a vendor sign-in and out sheet where the plant manager and/or
designee and master control staff check in the vendors. A review of project invoices during the
annual compliance review period found two separate days where staff did not initial tools
checked in or out on the vendor sign-in sheet, the vendor sign-in sheet showed the vendor was
present for two days, however, the vendor invoice shows being present one day at program,
and two of the seven days reviewed did not include staff initials confirming the tool inventory
from contractor.
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5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a policy and procedures to address fire, safety, and evacuation drills. During
the annual compliance review period the program conducted fire drills monthly on every shift.
The drills included type of drill, date and time, participants, brief scenario, findings, and
recommendations. The fire evacuation routes and egress plans are posted throughout the
facility. The program has twenty-two fire extinguishers inspected annually. Seven staff were
interviewed and all said they participated in various types of drills during the past year, to
include fire, weather, disturbance, hostage, chemical spill, flooding, and escape. Seven youth
were interviewed and all said they have been instructed on what to do in case of a fire. In
addition, all seven youth said they participate in fire drills at least once a month. The facility
administrator (FA) was interviewed and advised fire drills, Continuity of Operations Plan (COOP)
drills, medical drills, and mental health drills are conducted monthly on each shift. Other
emergency drills are conducted quarterly on each shift.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program maintains a Continuity of Operations Plan (COOP) and it was last reviewed and
updated on February 9, 2023, by the facility administrator (FA) and submitted to the Department
for approval. Copies of the program’s COOP are in FA’s and assistant facility administrator’s
(AFA’s) offices, and the staff break room. The plan addresses alternative relocation sites
approved by the Department’s regional director and the COOP includes all the required and
relevant information for continuous operation during an emergency. Supplies and equipment
required for COOP are in the plant manager area and food items are stored in the kitchen.
Supplies observed were water, dry goods, canned goods, non-perishable items, and youth
related items which were stored on the mods. The program’s COOP includes delegation of
authority, new cooperative agreements, vendor contact list, emergency and staff contact
numbers, county cooperation checklist. The program’s COOP references fire, fire prevention
and evacuation, severe weather, disturbance or riot, bomb threats, hostage situations, chemical
spills, flooding, terrorist threats or acts, staff roles and responsibilities, equipment and supplies
needed, information about youth which may be needed, alternate housing arrangements,
provisions for continuity of care and custody, as well as provisions for public protection. The
program utilizes the Department’s Juvenile Justice Information System (JJIS) as well as hard
copies of youth records. In case of an emergency relocation, the program will transport medical,
program records, logbooks, education records, as well as juvenile demographics. Seven
reviewed youth records included a demographic card which reflected the youth’s full name,
Department identification number (DJJID), admission date, date of birth, gender, race, name,
address, and telephone numbers for parents/guardians. The demographic cards have additional
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information including the name, address, and phone number of the person with whom the youth
resides, relationship to the youth, person(s) to notify in case of an emergency and contact
information, juvenile probation officer’s (JPO) name, circuit/unit, and contact information, names
of committing judge, state attorney, and public defender (or attorney of record) with contact
information on each. It also includes the committing offense, judicial circuit where the offense
occurred, notation of whether or not the judge retains jurisdiction, victim notification contact
information, if notification is required, physical description of the youth to include height, weight,
eyes and hair color, any identifying marks, overall health status including chronic illnesses,
current medications and allergies, personal physician (if known), and a photograph of the youth.
An interview with the facility administrator (FA) confirmed the COOP is located in the staff break
room.
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 regarding the storage and inventory of flammable,
poisonous, and toxic items. The program stores all bulk flammable, poisonous, and toxic items
and materials in a secured area, which is in the maintenance shop. Items are inventoried and
maintained in this area. There is a mop room in the main hallway which contains a mixing
station for bathroom cleaner, disinfectant, glass/window cleaner, and floor cleaner. When these
items are depleted, a replacement bottle is removed from the bulk storage, the inventory is
adjusted, and the item is replaced. The mixing station is locked and only the maintenance
employee has an access key. Flammable, poisonous, and toxic materials are secured in the
bulk storage area, which is located in the maintenance shop. The youth do not have access to
the maintenance shop. Inventories are maintained for all flammable, poisonous, and toxic items.
Ten items were observed in the storage area and compared to the inventory. Nine of the ten
items matched the inventory and had the required Safety Data Sheets (SDSs). There was one
item which was not on the inventory and did not have a SDS. This was a donated item from a
local church and the program never added it to the inventory. The program immediately
removed the item from the facility and the maintenance staff took the item to be disposed. The
program maintains a list of positions authorized to handle flammable, poisonous, and toxic
materials which include the facility administrator, assistant facility administrators, chief of
security, maintenance staff, shift supervisors, and program support.
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).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 69 (Revised September 2022)
The program has a policy and procedures regarding youth handling and supervision of
flammable, poisonous, and toxic items. The program maintains strict control of flammable,
poisonous, and toxic items. The policy prohibits the use, handling, or clean-up of dangerous or
hazardous chemicals by youth, with the exception of youth in the Home Builders Institute (HBI)
program. These youth have access to paint, paint thinner, and wood stain under the direct
supervision of staff and only after being trained on how to handle these items. Youth were not
observed during the week of annual compliance review conducting cleaning activities. Seven
youth were interviewed and all said they do not handle any flammable, poisonous, or toxic
materials.
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 policy and procedures regarding the disposal of flammable, toxic, caustic,
and poisonous items. The program’s policy prohibits chemicals from being poured on the
ground or being disposed of in any method other than what is outlined by the Occupational
Safety and Health Administration (OSHA) guidelines. The program disposes of mop water in the
plumbing drains and kitchen liquid waste in the kitchen drain. The program’s plant manager is
the only individual authorized to handle flammable, poisonous, and toxic items. During an
informal interview, the plant manager stated the program has not needed to dispose of any
chemicals since the last annual compliance review. The program’s plant manager was
interviewed and advised the proper procedures for disposing chemicals is for the items to be
provided to the local bio-hazardous waste contractor; however, also advised the program has
not needed to dispose of any chemicals since the last annual compliance review. Although the
program's policy outlines the manner in which chemical spills are cleaned up, the program has
not had an incident which required this type of clean-up during the annual review compliance
period. The facility administrator was interviewed and advised if the program had a need to
dispose of any flammable, toxic, caustic, and poisonous items, they would utilize the local
landfill and secure a receipt for the disposal.
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;
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 69 (Revised September 2022)
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures addressing visitation and communication, youth
correspondence, and use of telephone by youth. The visitation schedule is posted in the lobby
and at the entrance of the facility. The program shall make every effort to assist youth in
maintaining and strengthening positive family and community ties in an environment which
unobtrusively monitors and controls the movement of visitors within the program. Each youth is
provided an opportunity on a regular basis to correspond with identified individuals specified on
their Approved Correspondence List and legal representatives. The program has visitation on
Saturday and Sunday from 1:00 p.m. to 4:00 p.m. Youth are allowed to make a minimum of one
telephone call weekly to approved family members. These calls are scheduled by the case
manager. The program provides postage for two letters a week for each youth within the
program and does not limit the number of letters a youth is able to mail each week. Youth may
use their own postage to mail more than the two letters paid by the program a week. A review of
the correspondence logs confirmed all incoming and outgoing mail is searched and recorded in
the correspondence logs. The facility administrator was interviewed and advised the program
also has translator services to assist in communication with youth and families. Seven youth
were interviewed and four said they could call their parent/guardian or send a letter, and three
youth said they could not. All youth said they were unaware of any translation services because
all of them spoke English. Seven staff were interviewed and two staff said they did not know
which translation services are available, and the remaining five staff said the program would
provide a translator. The facility administrator (FA) was interviewed and advised education
provides English as a second language services. The FA also said the program has translator
services to assist in communication with youth and families.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 69 (Revised September 2022)
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program provides a variety of recreation and leisure activities for the youth. The program
activity schedule contains at least one hour of supervised and structured indoor and outdoor
recreation and leisure activities, to include large muscle activity, for youth each day. A review of
the logbook confirmed recreation and leisure activities were conducted as scheduled. Physical
education was observed during week of annual compliance review and confirmed activities
which promote social and cognitive skill development, creativity, teamwork, healthy competition,
mental stimulation, and physical fitness. The program employs two recreational therapists and
there were no discrepancies with credentials. A review of seven youth records confirmed
recreational therapy was included in each youth’s individual performance and/or treatment plan.
Seven youth were interviewed, and all said they have at least one hour of outdoor recreation
daily. During this time, they are allowed to play flag football, basketball, soccer, kickball, and
weightlifting. Seven staff were interviewed and six said youth have at least one hour of outdoor
recreation daily, while the remaining staff said outdoor recreation was an hour and a half daily.
During this time, youth are allowed to play flag football, basketball, jump rope, and dodge ball. In
the event of bad weather, youth participate in indoor recreation, such as ping pong, billiards,
and indoor basketball.
5.24 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program has a policy and procedures for the search and inspection of the controlled
observation room. The rooms used for controlled observation had a metal door with a shatter-
resistant window, were at least thirty-five unencumbered square feet, had properly covered
vents and lighting, and no electrical outlets. There were no mattresses in the rooms, however,
mattresses in the program are fire retardant. Seven controlled observation reports were
reviewed, and found staff documented an inspection of the room and a search of the youth
before the youth was placed in the room, as required.
5.25 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program has a policy and procedures for controlled observation. The program had twenty
one documented controlled observations since last annual compliance review, and a sample
size of seven was reviewed. None of the reports reflected youth in a mental health crisis or at
risk of suicide. All seven contained documentation of supervisory or higher level staff authorizing
placement. Only two of the seven reports documented youth having active aggression, while
three reports documented violent behavior which, if continued, was likely to result in immediate
injury or harm to self or others or substantial property damage. Four of seven reports listed
youth as physically out of control, and less restrictive methods were ineffective or inappropriate.
In all seven reports, staff needed to quickly gain control and order for program safety and
security. In all seven reports, staff advised youth for the reason of placement in controlled
observation and expected behavior for removal. There were no injuries observed or reported
and staff of the same gender completed the health status checklist. Times of controlled
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 69 (Revised September 2022)
observation ranged from thirty minutes to five hours and thirty minutes, in which three reports
required and included facility administrator or designee approval to go over the two hour
window.
5.26 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program has a policy and procedures for controlled observation safety checks and
releases, including staff designations for controlled observation. A sample size of seven reports
was reviewed since last annual compliance review. Of the reports reviewed, all seven included
documentation of the staff making placement completing first page of controlled observation
report and submitting it to the supervisor. Staff conducted and documented safety checks at
least every fifteen minutes observing youth’s behavior on the controlled observation safety
check form. The program staff did not document if an internal alert was warranted nor an in
house alert was warranted when the youth was released. The Controlled Observation Report,
Health Status Checklist, and Controlled Observation Safety Checks forms were maintained in
an administrative file as well youth’s individual management record. Six reports documented
approval from facility administrator or designee for youth release from controlled observation
based on behavior, one report did not have this approval. All seven reports were reviewed and
approved by the facility administrator or designee within fourteen days after youth’s release from
controlled observation. Staff designations are included in the program’s policy and procedures.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 69 (Revised September 2022)

program_name_raw: Cypress Creek High Risk

rule: Indicator 4.17

rating: Limited Compliance