state: FL

facility_name: Daytona Juvenile Residential Facility

summary: QI Residential - FY25-26 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Daytona Juvenile Residential Facility
Rite of Passage, Inc.
(Contract Provider)
1386 Indian Lake Road
Daytona Beach, Florida 32124
Review Date(s): October 21-24, 2025
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Kristine Harshaw, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Jeff Campbell, Office of Education, Northeast Education Coordinator, (Standard 2)
Jamie Franz, Office of Postsecondary and Workforce Education, Deputy Director (Standard 2)
Forrest Hallam, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Michele Maynard, Office of Accountability and Program Support, Regional Monitor (Interviews)
Miguel Roca, Wayne Halfway House, Regional Training Manager (Standard 5)
Rebecca Smith, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Devon Whitten, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Daytona Juvenile Residential Facility MQI Program Code: 1226
Provider Name: Rite of Passage, Inc. Contract Number: 10693
Location: Volusia County / Circuit 7 Number of Beds: 33
Review Date(s): October 21-24, 2025 Lead Reviewer Code: 187
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), 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
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 61 (Revised August 2025)
2.18 E
T h e fo llo w in g lim ite d a
Lim ited R atings
ducation A ccess (R esidential P rovider) *
n d /o r fa ile d in d ic a to rs re q u ire im m e d ia te c o rre c tiv e a c tio n
Failed R atings
.
Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 61 (Revised August 2025)
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t a n d M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 3
In c id e n t R e p o rtin g (C C C ) * 1 .0 4
R ig h t In te ra c tio n s (R I) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 5
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 6
In -S e rv ic e T ra in in g 1 .0 7
G rie v a n c e P ro c e s s 1 .0 8
D e lin q u e n c y In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .0 9
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 0
R e s to ra tiv e J u s tic e A w a re n e s s fo r Y o u th 1 .1 1
In te rn a l A le rts S y s te m a n d A le rts (J J IS ) * 1 .1 2
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 3
A d v is o ry B o a rd 1 .1 4
S ta ff P e rfo rm a n c e 1 .1 5
S p e c ia l C o n tra c t C o n d itio n s 1 .1 6
D a ta T re n d A n a ly s is 1 .1 7
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 61 (Revised August 2025)
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n 2 .0 1
Y o u th O rie n ta tio n 2 .0 2
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r 2 .0 3
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s 2 .0 4
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t 2 .0 5
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s 2 .0 6
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y ) A s s e s s m e n ts a n d R e a s s e s s m e n ts 2 .0 7
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S ) 2 .0 8
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls , a n d T ra n s m itta l * 2 .0 9
P e rfo rm a n c e P la n R e v is io n s a n d In c o rp o ra tio n o f O th e r P la n s 2 .1 0
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls 2 .1 1
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s 2 .1 2
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s ) 2 .1 3
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T ) 2 .1 4
E x it P o rtfo lio 2 .1 5
E x it C o n fe re n c e 2 .1 6
Y o u th In p u t 2 .1 7
E d u c a tio n A c c e s s (R e s id e n tia l P ro v id e r) * 2 .1 8
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s (R e s id e n tia l C o n tra c t P ro v id e 2 .1 9
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 61 (Revised August 2025)
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity o r C lin ic a l C o o rd in a to r 3 .0 1
L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff * 3 .0 2
N o n -L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff 3 .0 3
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A d m is s io n S c re e n in g 3 .0 4
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A s s e s s m e n t/E v a lu a tio n 3 .0 5
M e n ta l H e a lth a n d S u b s ta n c e A b u s e T re a tm e n t * 3 .0 6
T re a tm e n t a n d D is c h a rg e P la n n in g * 3 .0 7
S p e c ia liz e d T re a tm e n t S e rv ic e s * 3 .0 8
S u ic id e P re v e n tio n P la n * 3 .0 9
S u ic id e P re v e n tio n S e rv ic e s * 3 .1 0
S e c u re O b s e rv a tio n * 3 .1 1
S u ic id e P re c a u tio n O b s e rv a tio n L o g s * 3 .1 2
S u ic id e P re v e n tio n T ra in in g * 3 .1 3
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s * 3 .1 4
C ris is A s s e s s m e n ts * 3 .1 5
E m e rg e n c y M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e rv ic e s * 3 .1 6
B a k e r a n d M a rc h m a n A c ts * 3 .1 7
S a fe ty P la n n in g P ro c e s s fo r Y o u th 3 .1 8
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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N o n -A p p lic a b
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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 Psychiatric Services * Satisfactory
4.18 Medication/Sharps Inventory and Storage Process Satisfactory
4.19 Infection Control/Exposure Control Satisfactory
4.20 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 61 (Revised August 2025)
Standard 5: Safety and Security
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 61 (Revised August 2025)
5555555555555555555555555 .0 1
C .0 2
.0 3
.0 4
.0 5
.0 6
.0 7
.0 8
.0 9
.1 0
.1 1
.1 2
.1 3
.1 4
.1 5
.1 6
.1 7
.1 8
.1 9
.2 0
.2 1
.2 2
.2 3
.2 4
.2 5
* T h e D e
p ro g ra m o
in d ic a to
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
Y o u th S u p e rv is io n *
o m p re h e n s iv e a n d C o n s is te n t Im p le m e n ta tio n o f th e B e h a v io r M g t S y s te m a n d S ta ff T ra in in g
U s e o f R o o m R e s tric tio n
T e n M in u te C h e c k s *
C e n s u s , C o u n ts , a n d T ra c k in g
L o g b o o k E n trie s a n d S h ift R e p o rt R e v ie w
K e y C o n tro l *
C o n tra b a n d P ro c e d u re
S e a rc h e s a n d F u ll B o d y V is u a l S e a rc h e s
V e h ic le s a n d M a in te n a n c e
T ra n s p o rta tio n o f Y o u th
W e e k ly S a fe ty a n d S e c u rity A u d it
T o o l In v e n to ry a n d M a n a g e m e n t
Y o u th T o o l H a n d lin g a n d S u p e rv is io n
O u ts id e C o n tra c to rs
F ire , S a fe ty , a n d E v a c u a tio n D rills
D is a s te r a n d C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P )
S to ra g e , In v e n to ry , a n d D is p o s a l o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
Y o u th H a n d lin g a n d S u p e rv is io n o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
E le m e n ts o f th e W a te r S a fe ty P la n , S ta ff T ra in in g , a n d S w im T e s t *
V is ita tio n a n d C o m m u n ic a tio n
R e c re a tio n a n d L e is u re
S e a rc h a n d In s p e c tio n o f C o n tro lle d O b s e rv a tio n R o o m
C o n tro lle d O b s e rv a tio n
C o n tro lle d O b s e rv a tio n S a fe ty C h e c k s a n d R e le a s e P ro c e d u re s
p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra
re s id e n tia l, p ro b a tio n ).
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
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S a tis fa c to ry
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S a tis fa c to ry
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S a tis fa c to ry
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N o n -A p p lic a b le
N o n -A p p lic a b le
N o n -A p p lic a b le
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
m a re a (d e te n tio n ,
Program Overview
The Daytona Juvenile Residential Facility is a thirty-three bed program, for thirteen to eighteen
year old males, located in Daytona Beach, Florida. The program is operated by Rite of Passage,
Inc., through a contract with the Department. The program provides the following services:
juvenile sexual offender treatment services through Pathways: A Guided Workbook for Youth
Beginning Treatment, Roadmap to Recovery, or Footprints: Steps to a Healthy Life. In addition,
the program fosters each youth by providing Anger Management for Substance Abuse and
Mental Health Clients, Conflict Resolution from the Inside Out, Transforming Anger to Personal
Power, Social Skills Lessons and Activities for grades seven through twelve, Stress
Management for Adolescents, 100 Interactive Activities for Mental Health/Substance Abuse
Recovery, Creative Therapy, and The Council for Boys and Young Men. Additional treatment
services provided includes family and individual therapy, group therapy, and recreation therapy.
Program administration is comprised of a program director (PD) and a human resources
coordinator. Case management services are provided by a transitional service manager and a
case manager. Mental health staff at the program includes a contracted psychiatrist, a clinical
director who serves as the designated mental health clinician authority (DMHCA), three master-
level therapists, and a recreation therapist. Medical services are offered seven days a week,
from 7:00 a.m. to 5:00 p.m., and are provided by a health services administrator (HSA) who is a
registered nurse (RN), one full-time RN, one part-time RN, and one contracted medical doctor
who serves as the designated health authority. Educational services are provided by the Florida
Scholars Academy. The layout of the program includes two primary buildings including an
administrative and education portable, and a brick building which houses the youth dormitory,
medical office, cafeteria, multi-purpose room, and staff offices. The program has fifty-eight
operating security cameras providing coverage. At the time of the annual compliance review,
the program had six vacant positions including one registered nurse and five coach counselor
positions.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 61 (Revised August 2025)
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 in place regarding initial background screenings,
including volunteers, mentors, and interns who work with youth less than ten hours a month
requiring sight and sound supervision. A review of the program’s staff, volunteers and contractor
roster reflected six program staff were applicable for an initial background screening during the
annual compliance review period. Each staff received a completed and eligible background
screening in the Clearinghouse system prior to their date of hire, and each had a criminal history
report reviewed for each. None of the staff were applicable for an exemption and none of the
new staff had a break in service. Each staff was added to the program’s roster in the
Clearinghouse system and a pre-employment assessment tool was administered for the three
applicable direct-care staff. All three of the new staff received a passing score on the pre-
employment assessment. A review of the program’s volunteer roster and sign-in logs verified
the program did not have any volunteers, mentors, or employed interns requiring a background
screening during the annual compliance review period. An Affidavit of Compliance with Level 2
Screening Standards was submitted to the Department on January 8, 2025. The Annual
Affidavit of Compliance with Level 2 Screening Standards for education staff was completed and
submitted to the Department’s Background Screening Unit, on January 28, 2025, meeting the
annual requirement. A signed contraband attestation form was completed for all six staff.
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. A review of the staff, volunteer, mentor, and intern roster found the program had twelve
staff applicable for a background rescreening during the annual compliance review period. All
twelve staff were found to have a completed and eligible background rescreening in the Agency
for Healthcare Administration (AHCA) Clearinghouse system and the Department’s Background
Screening Unit prior to their five-year anniversary date and each was submitted at least ten
days prior to the expiration date.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 61 (Revised August 2025)
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 outlining the provision of an abuse-free environment
for both staff and youth and outlining the process of how management responds to allegations
of physical, psychological, and emotional abuse. A tour of the program reflected postings of 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
were present in all program common areas. The program has documented steps for youth and
staff to report abuse. The program director (PD) additionally reported all incidents are tracked in
the program’s incident report tracker and all calls to the CCC and abuse hotline are to be
discussed daily in management meetings and shift briefings, which includes professional staff in
the medical and clinical departments. Five reviewed staff records included a signed code of
conduct which include expectations for ethical and professional behavior, and for staff
interactions to promote the youth’s emotional and physical safety, while also incorporating
trauma-responsive practices. The program completed the Trauma Responsive and Caring
Environment (TRACE) self-assessment on April 28, 2025. A review of internal incidents found
the program had no incidents of physical, psychological, or emotional abuse reported during the
annual review period.
All five interviewed youth replied they feel safe at the program. All five youth stated program
staff were responsible for their feelings of safety. All five youth confirmed they have not been
stopped from calling the abuse hotline or the CCC since arriving at the program, and all were
aware of the hotline phone number and how to locate it. Three of five youth reported the staff
are respectful when speaking to youth, two said staff are sometimes not respectful. Three out of
five youth stated staff do not use curse words when speaking to youth, two youth report staff
use curse words often, but could only recall one incident each. None of the five youth have ever
exchanged emails, telephone numbers, or social media contact information with staff. Five staff
were interviewed and asked to explain the process for allowing youth or staff to call the Florida
Abuse Hotline or CCC to report suspected abuse. All five staff stated youth and/or staff are
allowed to call the abuse hotline if they request. All five reported the supervisor is notified and
take the youth to make the call. Four staff said they can make the call with the youth if required.
None of the interviewed staff reported they have ever observed another staff telling a youth they
could not call the Florida Abuse Hotline. When asked if staff use profanity while speaking with
youth, all five staff said they never hear staff using profanity while speaking with a youth. The
PD was interviewed and explained the code of conduct includes how staff will represent the
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Department and the program. Conduct which interferes with operations, discredits the company,
or is offensive to employees, youth, and their families is not tolerated. The program uses
progressive corrective action systems and does not tolerate offenses of physical abuse, threats,
or profanity towards youth.
1.04 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 regarding notification to the Department’s Central
Communications Center (CCC) of reportable incidents. The program had a total of three
reportable incidents during the annual compliance review period. All three incidents were
reported within the required two hours from when the time the reporter became aware of the
incident, and each incident was documented in the facility logbook. There were no additional
internal incidents or grievances which should have been reported to CCC and were not. The
program has not seen an increase in reportable incidents since the last annual compliance
review. The program director stated in an interview program management takes immediate
action to address incidents when they occur.
1.05 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program has a policy and procedures outlining the use of Right Interactions (RI). Monthly
summaries of all RI incidents from the annual compliance period were maintained by the
program and submitted to the Department’s regional office by the fifteenth of each month. The
program’s RI Plan was updated on December 10, 2024, and approved by the Department on
December 13, 2024. The program’s PAR rate during the annual compliance review period was
0.38, which is below the statewide Residential PAR rate of 2.57. The program reported one RI
incident during the annual compliance period. The RI report was completed by the end of the
staff’s workday and included statements from all staff involved. The one incident did not require
mechanical restraints, there was no injury, and no accusation of abuse. The RI report was
reviewed by a supervisor and an RI-certified supervisor and was reviewed by the program
director (PD) within seventy-two hours.
All five interviewed staff reported they are trained to utilize RI when necessary. Each of the five
staff were able to explain the process of RI to include verbal de-escalation and physical
intervention. In an interview with the PD, it was reported all use of force incidents are to be
communicated with the supervisor and administrative staff immediately. During times the
administration is not on-site, RI reports are required to be scanned to administrators prior to
completion of the shift. All RI incidents and use of force incidents are monitored daily in the
morning meetings, and the facility has an internal monitoring process to address all trends
regarding RI and use of force.
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1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has a policy and procedures outlining the pre-service training and certification
requirements for all new staff. In addition to direct care staff, titled coach counselors, the
program considers any appropriately trained staff who is not responsible for other duties as
direct-care staff and can be counted in the staff-to-youth ratio. The exceptions to this are the
medical and clinical staff, who may not be utilized for supervision. A review of documentation
indicated the program’s instructors were qualified to deliver the training provided. The program
submitted a pre-service training plan prior to implementation of the plan, which was approved by
the highest ranking official at the location, the assistant secretary for residential services, and
the director of the Department’s Talent, Leadership, and Culture. The program had six newly
hired staff during the annual compliance period. Five of these staff were past the first 180 days
of employment and had completed the required trainings with the exceptions of two staff; one
new staff was missing Professionalism, Interpersonal Communication, and Ethics, including
Standards of Conduct, Active Shooter Preparedness, and Quality Report Writing; another staff
was missing Civil Rights training, and another staff was missing Quality Report Writing. Four of
the five staff had over the required 120 hours of training. One new staff did not have 120 hours;
however, this staff is a nurse who is not required to complete the same training as direct care
staff. One of the six new staff was still within the first 180 days of training, and it was discovered
the staff was scheduled for, but did not have Protective Action Response (PAR)/Right
Interactions (RI) training. This staff was removed from youth contact until the training was
completed.
1.07 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.
The program maintains an annual in-service training calendar and submitted an in-service
training plan prior to implementation. The training plan was approved by the highest-ranking
official at the location, the assistant secretary for the Office of Residential Services, and the
director of the Department’s Talent, Leadership, and Culture. A review of documentation
indicated the program’s instructors were qualified to deliver the training provided. Five staff
training records were reviewed for the annual compliance period. The five selected staff each
completed well over the required twenty-four hours of in-service training; however, the following
training was not completed: two staff did not complete Active Shooter Preparedness, two did not
complete Information Security Awareness, two were missing Mental Health and Substance
Abuse training, and one was missing Professionalism, Interpersonal Communication, and
Ethics. All other required trainings were completed by each reviewed staff. Two of the reviewed
staff records were the only program shift supervisors, each of whom had eight hours of
supervisory training. Some of the instructor led trainings were not recorded in the Department's
Learning Management System (SkillPro); however, the program retains documentation of all
staff training in a hard copy record at the facility.
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1.08 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. The program director reported in an
interview the director of group living is the grievance officer and monitors the grievance process.
The first phase includes an attempt to process the issue with staff to learn pro-social
communication skills. In the second phase of the grievance process is the supervisor on-site will
conduct an attempt to provide a resolution. The final phase in the grievance process allows the
youth to meet with the administration to find a solution. Thirteen grievances were submitted from
youth during the annual compliance period, all of which were maintained in a binder. Nine of
these were submitted in the same day, all referencing a meal. In all thirteen instances, the
grievance was submitted and responded to within twenty-four hours, and all were resolved by
the supervisor during the formal phase of the process. All five interviewed youth were familiar
with how to submit a grievance, from locating it on the wall of the dorm to submitting it to the
grievance box or a supervisor. All five youth stated they could receive help completing the
grievance, if needed. Five interviewed staff were asked about the grievance process. All five
were aware grievance forms are placed throughout the program and youth can request
assistance in completing the form. Four of five staff reported the supervisor reviews grievances,
and one stated the program director reviews the grievances. Further, three of five staff
understood the grievance process had three phases and two staff understood the phases had
associated timeframes.
1.09 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.10 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 ensuring life and social skills interventions are being
provided to youth. The interventions include evidence-based Life Skills Training (LST),
Aggression Replacement Training (ART), Pathways: A Guided Workbook for Youth Beginning
Treatment, and Skillstreaming the Adolescent. These services are provided through treatment
team planning by clinical staff. Non-clinical staff and direct care staff model pro-social behaviors
through daily interactions with youth to help youth function responsibly and successfully in
everyday life situations. The Health Education Record of five youth and the health services
training calendar confirmed the program incorporates additional life skills interventions to
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include dental hygiene, nutrition basics, personal hygiene, and physical fitness, provided by the
nursing staff. Five interviewed youth reported they have participated in life skill groups in anger
management, coping strategies, recreational therapy, and hygiene.
1.11 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.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at Daytona Juvenile Residential Facility. For details related specific to IOC
service delivery, please refer to the annual SPEP report.
1.12 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures to determine how new alerts are identified,
documented, updated, and communicated to staff. This program has established a continually
updated internal alert system easily accessible to program staff and keeps them alerted to youth
who pose a risk to security or safety including escape, sexual offending and other assaultive or
violent behavior risks, suicide, and other mental health as well as health related concerns,
including food allergies and special diets. When risk factors or special needs are identified
during or following the classification process, staff shall immediately update the internal program
alert information and shall enter this information into the Department’s Juvenile Justice
Information System (JJIS). Only appropriate staff may recommend downgrading or
discontinuing a youth’s internal alert status. Upon recommendations from appropriate staff, JJIS
alerts shall be downgraded or discontinued. The program has an alert board in the
administration wing displaying youth photos with color-coded alert stickers reflecting each
youth’s alert. The alert board is covered by a fabric panel keeping it concealed when not being
reviewed by staff. Five youth records which were identified for being applicable for alerts were
reviewed. Each of the eighteen youth’s alerts were entered or updated on the alert board and in
JJIS as specified in the program’s written procedures. All of the documented alerts were entered
in the facility logbook, including updates and discontinuations. In an interview, the program
director reported alerts are monitored and discussed daily in the morning management meeting.
The department heads also assist with ensuring the internal alert board is updated with all
pertinent information from each department. This information is then shared with all staff during
the daily briefing in which representation from each department is in attendance. Five
interviewed staff reported they are informed of youth alerts through shift briefings, master
control logbooks, an alert board, and through email or verbal communication.
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1.13 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 Case Management Record
The program maintains an official case record for each youth, which consists of three separate
records for each program area to include case management, healthcare, and mental health and
substance abuse services. All reviewed individual management records contained the youth’s
name, Department identification number (DJJID), date of birth, county of residence, and
committing offense. Each individual management record contained the required sections to
include legal information, demographics and chronological information, correspondence, case
management and treatment team activities, and a miscellaneous section. All youth records were
labeled “Confidential” and secured in a locked room and file cabinet clearly identified as
confidential which is inaccessible to youth.
1.14 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 an advisory board consisting of a law enforcement representative, a member
of the judiciary community, members of the business community, a representative of Florida
Scholar’s Academy, members of the local faith community, other community partners, a victim
advocate, and a former youth’s parent or guardian. The program has held four quarterly
advisory board meetings since the last annual compliance review. A review of invitations and
sign-in documents reflect all invitees were contacted for each meeting and most of the invited
members of the board attend regularly. A member from the advisory board was contacted, and
the board member reported they participate in quarterly meetings and believe the board is a
benefit to the youth at the program. The program director (PD) reported the program has an
active community advisory board which meets once a quarter on the third Thursday of the
designated month. The individuals assist in program planning of activities and speakers, along
with providing mentor services to the youth. The community advisory board members
communicate recommendations during the quarterly meeting or by contacting the PD or
recreation therapist directly. The board will assist in finding resources for our youth in the
program to include mentoring and vocation.
1.15 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures to ensure staff are evaluated, at ninety days and
annually, on established performance standards. A review of five position descriptions, to
include coach counselor, night coach counselor, case manager, recreation manager, and shift
supervisor found performance standards were clearly identified and matched the job description
for each staff and whose job function included implementation of the program’s behavior
management system. The program has maintained all contractually required positions including
the recreational therapist. A review of documentation for the recreational therapist indicated all
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requirements were met. Five staff records were reviewed for performance evaluations. Each
record contained either a ninety-day or annual evaluation. The program director (PD) stated in
an interview, the program has not faced many challenges when it comes to staff turnover. The
program has a morale committee to address the needs of the staff. The staff participate in pro-
social activities off campus as well as activities during all campus meetings. Additionally, the PD
reported all staff within the program who have been employed for a year will receive an annual
evaluation in the month of their initial date of hire. Identified in these evaluations are the staff's
strengths, weaknesses, and identified goals. Upon completion of the evaluation, the staff meet
with their supervisor and discuss the areas of improvement to develop a plan for success. Three
of five interviewed staff reported they receive annual evaluations. Three staff stated they receive
quarterly performance evaluations and one staff stated they received both quarterly and annual
evaluations.
1.16 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.
There are five special contract conditions. The first special contract condition states graduates
may qualify to receive a scholarship from Rite of Passage’s Passageway Scholarship
Foundation. The foundation provides graduates with funding for post-secondary education and
training which is available to all graduates who have earned a high school diploma or a high
school equivalency diploma. Initial scholarships may be up to $1,500.00, which increases each
semester if they maintain a grade point average of 2.0 or greater. Working with Florida Youth
College, the transition services coordinator and teachers will conduct workshops with post-
secondary youth regarding how to complete scholarship applications to include passageway
scholarships and completing the Free Application for Federal Student Aid (FAFSA) application.
During the annual compliance review period there were not any youth who were interested or
have applied for the scholarship. The second special contract condition requires the program to
sponsor on-site Career Day events twice a year to offer additional career choices to youth.
During the annual compliance review period, the program sponsored on-site career days with
the assistance of the Junior Achievement liaison, which took place in June and October of this
year. The third special contract condition requires youth to have the opportunity to participate in
the Social Justice Alliance, a local civic group. The program indicated all youth have an
opportunity to take part in the Social Justice Alliance through The Throw Away Kids Network
and Hope for the Hood Network. Documentation reviewed, which included pictures of the
activities, verified a group of volunteers came on-site quarterly to provide discussions on gun
violence, suicide, and bullying. The fourth special contract condition requires the program to
provide nutritious, well-balanced meals and three snacks a day, which are prepared and served
in a manner ensuring each youth are taken into consideration. The program indicated all meals
are delivered from their sister program, Hope Forest Academy, which was observed during the
annual compliance week. A snack is provided along with each of the three meals, as required.
The final special contract condition requires the program is to employ a community liaison to
ensure its visibility in local and surrounding communities. The program employs a recreation
therapist whose job duties include identifying guest speakers from the community and recruiting
and training volunteers and community members to bring additional opportunities to youth
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through art, drama, and faith-based opportunities. The program director (PD) interview
confirmed the special contract conditions.
1.17 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 of data trends in
decision-making practices. The program’s trend analysis and data-driven decision making are
made through an internal collection of multiple data trends which include analysis on youth
restraints, assaults and fights, runaways, total incidents, intakes, length of stay, workers
compensation, referrals and trainings, staff exits including terminations, and turnover rate. The
corporate management team compiles weekly information from all of their programs in a
monthly report which combines monthly totals in a statistical report for each program. These
reports are provided to the regional team and program management for the purposes of tracking
trends and informing risk management, which is shared in management meetings to discuss
solutions for any noted issue. Corporate has a weekly call with all administration teams from
each program to discuss data trends and ways they can improve areas of concern. Information
is discussed in daily meetings with administrative staff and department heads. Staff are updated
throughout the month during the daily staff meetings, weekly staff meetings, and monthly staff
meetings. The program sends the data report to the Department monthly. The program
participates in quarterly advisory board meetings and corporate senior management meetings
are held monthly. The findings from trend data analyses are utilized to determine recruitment
strategies, positive morale approaches, policy and procedures, youth supervision techniques,
restorative justice programs, and individual and family services. The program provided
documentation to support these activities to include meeting minutes, shift reports, and site
operations summaries completed by the corporate management team.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a written policy and procedure regarding initial contacts to the parent/guardian
and court notification. A review of five youth case management records indicated the program
notified each parent/guardian by telephone within twenty-four hours of admission and in writing
within forty-eight hours. All five reviewed youth records included documentation the juvenile
probation officer (JPO), court, and applicable post residential services counselor were notified of
the youth’s admission in writing within five working days.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a written policy and procedures regarding youth orientation. A review of five
youth case management records indicated the program provided each youth an orientation on
the day of admission. Each reviewed case management record documented a signed receipt
acknowledging the youth received an orientation packet including a copy of the youth handbook.
The program’s orientation included services available, daily schedule, expectations and
responsibilities of the youth, written information on the program’s behavior management system
including rules governing conduct and positive and negative consequences for behavior,
information on how to access medical and mental health services, access to the Florida Abuse
Hotline or the Department’s Central Communications Center (CCC) if the youth is over eighteen
years of age, the program’s zero-tolerance policy regarding sexual misconduct including how to
report incidents or suspicions of sexual misconduct, special accommodations, the right to be
free from sexual misconduct, the right to be free from retaliation for reporting such misconduct,
the agency’s sexual misconduct response policies and procedures, and items considered to be
contraband including illegal prohibited items, and possession which may result in the youth
being prosecuted. Additionally, the youth orientation included information on the performance
plan process, dress code and hygiene requirements, procedures regarding visitation, mail, and
use of the telephone, expectations for release from the program, including the youth’s
successful completion of individual performance plan goals, recommendation to the court for
release based on the youth’s performance in the program, and the court’s decision to release,
community access, grievance procedures, emergency procedures, procedures for fire drills and
building evacuation, a program tour and a general layout of the program which focuses upon
those areas not accessible to youth, and assignment to a living unit and room, treatment team,
and a staff advisor or youth group. Information is conveyed verbally to youth with limited reading
skills or who are visually impaired, deaf, or otherwise disabled. Observations of a youth
orientation were not conducted due to the program not having an admission during the annual
compliance review week. An interview with five youth was conducted, each youth stated their
orientation to the program included program rules, procedures, and schedules and all five youth
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were able to explain the process in detail. All five youth stated their orientation took place within
twenty-four hours of program admission.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a written policy and procedures which address obtaining written consent of
youth who are eighteen years of age or older. A review of five youth case management records
indicated one youth record was applicable for youth who were eighteen years of age or older,
the program provided an additional two youth case management records for review. A review of
all three youth’s records found a consent form signed by each youth prior to any release of
information related to the youth’s physical or mental health screenings, assessments, or
treatments.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a written policy and procedures regarding the classification process for youth
upon admission to the program and completion of reassessments as warranted. A review of five
youth case management record’s documentation confirmed each record contained an
admission classification form including all required elements outlined by Florida Administrative
Code. The program’s classification form included physical characteristics of the youth, age and
maturity level, identified special needs, history of violence, gang affiliation, criminal behavior,
sexual aggression or vulnerability to victimization, youth’s perception of vulnerability, youth’s
history of potential or verified human trafficking, suicide risk, medical risk, escape risk, and
security risk. Five youth case management records documented the date of the youth’s
classification, included all elements on the classification form, and confirmed they were
completed on the day of admission. A review of the Department’s Juvenile Justice Information
System (JJIS) alerts, and the programs internal alerts indicated three of the five youth had a
security alert due to aggression, one of the five youth reviewed were applicable for suicide risk,
and four youth were applicable for medical risk. Each of the five youth were classified for
purposes of assignment to a living area, sleeping room, and youth group or staff advisor. All five
of the youth with medical, mental health, substance abuse, security risk factors, and/or special
needs identified during or subsequent to the classification process were immediately entered
into the program’s internal alert system and JJIS. Reclassification was conducted for one of the
five youth reviewed and revealed there was an increase in the youth’s privileges or freedom of
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movement. The program’s policy regarding reassessment ensures all program youth may be re-
classified at intervals throughout their length of stay. Staff shall reclassify youth when warranted
based upon changes in the youth’s supervision status, new or updated alerts, behavioral
concerns, and relevant information to the treatment team to ensure safety and security of the
youth and program. An interview with the program director (PD) confirmed information is shared
during the intake process in the classification meeting. The information is used to determine the
best placement for the youth to ensure safety and the well-being of the youth. This information
is also used throughout the course of the youths stay as they may move rooms according to the
Positive Performance System as they level up and earn more incentives.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a written policy and procedures regarding gang identification including
notification to law enforcement. A review of five youth case management records indicated none
of the youth were applicable for notification to law enforcement of suspected gang association.
One youth case management record was provided by the program, due to only having one
youth applicable during the annual compliance review period. The one youth case management
record documented local law enforcement was notified of suspected gang activity prior to the
annual review notification. Reviewed documentation confirmed the youth’s home county law
enforcement program was notified of the youth’s gang affiliation. Reviewed documentation
reflected all gang alerts were maintained in the Department’s Juvenile Justice Information
System (JJIS) and updated as required, and upon identification and documented gang
information was shared with the educational staff at the program and the youth’s juvenile
probation officer (JPO). The applicable youth did not have a post-residential services counselor.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a written policy and procedures regarding a youth’s participation in gang
prevention and/or intervention activities. The program’s policy addresses providing youth an
opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang. The
program utilizes Gang Resistance and Drug Education (GRADE) as their main curriculum and
gang intervention groups such as Impact of Crime (IOC) as part of the gang prevention and
intervention curricula. A review of five youth case management records was conducted. None of
the youth were applicable for being identified as a gang member, or affiliated. The program was
able to provide one additional applicable youth record for the annual compliance review period.
Documentation supported the youth participated in gang prevention and intervention strategies
on a monthly basis. The youth’s performance plan included goals and objectives related to gang
intervention strategies to be completed prior to release from the program. A review of the
program’s sign-in sheets reflected the youths’ participation in the gang prevention services. An
interview with the program director (PD) confirmed the program will provide the students with
resources to disaffiliate from the criminal street gang should the youth want to do so. Youth will
have the opportunity, if desired, to develop a plan to dis-affiliate with criminal street gang.
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2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a written policy and procedures to ensure a Residential Assessment for Youth
(RAY) is completed for each youth within thirty days of admission. A review of five youth case
management record’s documentation showed all youth records contained a RAY which was
completed within thirty days of admission to the program. Each initial RAY was maintained in
the Department’s Juvenile Justice Information System (JJIS). Five youth case management
records revealed each youth was applicable for reassessments. All five youth records indicated
RAY Reassessments were completed at least every ninety-days. Each initial RAY and
reassessments were maintained in the youth’s official case record. Each youth case record
documented the dates of the youth’s reassessment, and any other updates or reassessments
were completed when deemed necessary by the intervention and treatment team to effectively
manage the youth’s case.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a written policy and procedures regarding the completion of the Youth Needs
Assessment Summary (YNAS). A review of five youth case management record’s
documentation supported all five youth’s YNAS was completed within thirty days of the youth’s
admission. Each youth’s YNAS was documented in the Department’s Juvenile Justice
Information System (JJIS).
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program has a written policy and procedures outlining performance plan development,
goals, and transmittal. A review of five youth case management record’s documentation
confirmed each youth’s Individualized Performance Plan (IPP) was developed within thirty days
of the youth’s admission and developed after the completion of the initial Residential
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Assessment for Youth (RAY) and the Youth Needs Assessment Summary (YNAS). Each of the
five reviewed IPPs were developed and signed by the treatment team leader, youth,
administrative representatives, living unit representatives, treatment staff, education staff, the
Department of Children and Families (DCF) counselor, when applicable, and all parties who had
significant responsibility in goal completion. A review of documentation showed each of the five
completed IPPs were mailed to each youth’s parent/guardian requesting a signature. Each of
the five IPPs had the signature sheet of parties who had significant responsibility in goal
completion filed in the youth’s official case record. Each reviewed IPP included the youth’s
individualized goals based upon the prioritized needs identified during the initial assessment,
addressed the youth’s three top criminogenic needs, specific delinquency interventions based
on RAY results, court-ordered sanctions, and transition activities targeted for the last sixty-days
of the youth’s anticipated stay. Each IPP outlined program staff responsibilities and target dates
for goal completion. Each of the five IPPs were sent to each youth’s committing court judge,
juvenile probation officer (JPO), and parent/guardian. None of the five youth were involved with
DCF. Five interviewed youth confirmed they participated in the development of their
performance plan, treatment goals, and received a copy of their performance plans.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a written policy and procedures in place ensuring revisions to a youth’s
performance plan. A review of five youth case management records revealed none of the youth
were applicable for Individualized Performance Plan (IPP) revisions. Each of the five reviewed
youth had additional plans, to include academic or treatment plans, included in their
performance plans. None of the five youth were applicable for a case plan through the
Department of Children and Families (DCF).
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program has a written policy and procedures ensuring the completion of performance
summaries and transmittals. A review of five youth case management records indicated all
youth were applicable for initial Performance Summaries. Four of the five youth had
performance plan summaries completed within ninety calendar days, the remaining youth’s
summary was completed one day late. None of the reviewed youth were applicable for a
performance summary completion prior to release. All five Performance Summaries included all
required elements to include the youth’s status on each performance goal, overall treatment
progress, academic status, credits earned in the program, performance and behavior in school,
youth’s behavior, level of motivation and readiness to change, interaction with peers, interaction
with staff, overall behavior adjustment to the program, and significant positive and negative
events. Each youth’s Performance Summary included documentation which was signed
confirming the youth read and was allowed to add comments to the Performance Summary.
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Each youth was provided a copy of the signed summary, and the original summary was filed in
the youth’s case management record. Each Performance Summary was signed and dated by
the treatment team leader, staff preparing the summary, program director (PD) or designee, and
the youth. Documentation showed each Performance Summary was sent to the youth’s
committing court, juvenile probation officer (JPO), youth, parent/guardian, and the Department
of Children and Families (DCF), when applicable.
Three closed case management records were reviewed for release summaries. Each record
included a copy of the youth’s original summary, along with justification for release, sent with the
Pre-Release Notification (PRN) to the JPO. Reviewed documentation showed the release
summary and PRN was sent within seventy-two hours prior to release. Signed copies were
retained in each of the three records. Once the PRN was approved, the program provided a
written notification to the youth’s parent/guardian regarding the planned release and the
program completed a Residential Assessment for Youth (RAY) exit assessment. None of the
three records were applicable for the court objecting to the youth’s release. None of the three
reviewed youth were applicable to being referred for the sexual violent predator program
(SVPP). Reviewed documentation verified victim notification was sent for all three youth, more
than ten days before release of youth.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a written policy and procedures regarding parental/guardian involvement in
case management services. Documentation supported the program makes efforts to include the
parent/guardian in the assessment process, development of the youth’s performance plan,
progress reviews, formal treatment team meetings, and transition planning. If the
parent/guardian is unable to attend the meetings in person, they are afforded the opportunity to
participate by telephone or conference call or are able to provide verbal or written input prior to
the meeting. A treatment team meeting was not observed during the annual compliance review
week due to none being scheduled. A review of the youth’s progress notes revealed the
program reaches out to the parent/guardian to facilitate involvement by telephone, by email,
and/or a letter will be sent to the residence. An interview was conducted with the program
director (PD), who stated during intake and throughout the course of the youth's stay the case
management department sends notification requesting the parent's involvement in all treatment
teams and meetings related to the youth. Monthly calls are also made to update parents on the
youth's progress or lack thereof and any upcoming events or meetings. The program also
conducts monthly family days. The case management team also offers bus passes and hotel
stay for parents to be able to participate in youth meetings. All five interviewed youth report their
parents/guardians are involved in their treatment by participating in treatment teams and family
therapy.
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2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a written policy and procedures regarding treatment team meetings. A review
of five youth case management records was conducted. Three youth records determined formal
treatment team meetings were held every thirty days for each youth, and informal meetings
were held bi-weekly, as required. One youth had thirteen formal treatment team meetings and
two of those meetings were conducted twelve days late. A second youth had fifteen formal
treatment team meetings and one of those meetings was conducted eighteen days late.
Documentation for each of the formal and informal treatment team review meetings included the
youth’s name, date of review, required attendees, comments from treatment team members or
others, a brief synopsis of the youth’s progress, performance plan revisions, performance plan
goals, positive and negative behaviors, behaviors resulting in physical interventions, the youth’s
documented opportunity to demonstrate skills acquired in the program, treatment progress, and
Residential Assessment for Youth (RAY) Reassessment results. All five records contained
formal treatment team documentation in the youth case management record. All required
parties were present either in person or by telephone during the formal and informal treatment
team meetings. A treatment team meeting was not observed during the annual compliance
review due to no meetings scheduled during the annual compliance review week. All five
interviewed youth reported staff have discussions with them about their performance to include
progress on performance plan goals, positive and negative behavior, and treatment progress.
Each of the five youth reported they are given a form to complete prior to treatment team which
included their input on progress towards performance plan goals, behavior, and educational
progress. This form is utilized as talking points for treatment team meetings and all five youth
stated this process allows them to demonstrate the skills they have learned in the program.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has a written policy and procedures addressing transition planning, conferences,
and Community Re-Entry Team (CRT) meetings. A review of three closed youth case
management records was conducted and the transition conference was held at least ninety
days prior to the youth’s targeted release date. Each record documented the youth, treatment
team leader, program director (PD) or designee, and other team members attended the
transition conference. There was documentation provided to support the program invited and
encouraged the youth’s juvenile probation officer (JPO), parent/guardian, education staff, and
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any other additional pertinent parties to participate in the youth’s transition conference. None of
the three youth were determined to have a human trafficking history. Documents supported
each transition conference included a review of transition activities on the youth’s performance
plan, necessary performance plan revisions, additional transition activities as needed, target
completion dates, and persons responsible for transition activities. The treatment team leader
obtained attendees’ dated signatures, representing their acknowledgement of the transition
goals and accountability for completion. A copy of the plan was sent with a request for return
with signature to anyone not in attendance who had a responsibility for completion of transition
goals; however, none were returned. All of the forms were transmitted electronically. Reviewed
documentation found a CRT meeting was conducted prior to each youth’s release and the youth
and case manager participated. Documentation revealed there was evidence of an invitation to
participate in the CRT meeting for each of the three closed case management records.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a written policy and procedures outlining the requirements of the exit portfolio.
A review of three closed youth case management record’s documentation showed each youth’s
exit portfolio was discussed during the transition conference. All three reviewed exit portfolios
contained a state-issued identification card, social security card, and birth certificate. Each exit
portfolio contained a copy of the youth’s transition plan, a calendar of upcoming appointments,
vocational certificates earned at the program, school transcripts, résumé, and a sample
employment application. Documentation supported each youth’s exit portfolio was verified
during the exit conference, and documentation indicated the exit portfolio was given to the youth
upon release and forwarded to the youth’s juvenile probation officer (JPO). The program’s
contract did not include any additional requirements for the exit portfolio.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a written policy and procedures to ensure the completion of each youth’s exit
conference. Three closed youth case management records were reviewed and determined
there was documentation each youth’s exit conference was conducted after the program notified
the youth’s juvenile probation officer (JPO) of the youth’s pending release, and at least fourteen
days prior to the youth’s release date. Reviewed documentation indicated the date of the
conference, signatures, and a summary pending transition goals were included. Each youth’s
date of admission and date of termination were documented in the case record and correlated
with the Department’s Juvenile Justice Information System (JJIS). Each record had
documentation reflecting the status of transition activities established at the transition
conference and the plans were finalized for the youth’s release. Documentation revealed
provisions for continuation of education and employment. Each youth’s parent/guardian and
JPO were aware of the vocational plan for the youth. Two of the three exit conferences had
documentation to confirm the treatment team leader, parent/guardian, education representative,
JPO, youth, and other pertinent parties participated in the exit conference, with one record
showing all but the education representative participated in the exit conference. All three
records indicated the exit conference was held separately from the transition conference and
Community Re-Entry Team (CRT) meetings.
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2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a written policy and procedures regarding written provisions for youth input.
The program has a formal process to promote constructive input by youth through giving them a
Request to Speak form, which will be filled out and submitted. This form is located on each
youth living unit. Additionally, the program provides town hall meetings once a month and
student government board meetings, which are held monthly for each living unit. There was a
review of the program’s sign-in sheets, agendas, and meeting minutes to confirm the meetings
were being held as required. Five youth were interviewed and they indicated youth may submit
a grievance form about a concern or can request to speak to a supervisor, use town hall
meetings to express concerns, or speak with the program director, if needed. An interview with
the program director indicated the youth are able to provide input during treatment team
meetings. Youth can submit request to speak to provide input as well as participate in town hall
meetings.
2.18 Educational Access (Residential Contract Provide) Limited 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 addressing educational access. A review of
the program’s activity schedule and the daily academic schedule revealed they align with each
other. All five interviewed youth stated educational services are being provided and reported
there are few interruptions, which are usually due to youth acting out. A review of monthly
randomly selected days in the logbook since the last annual compliance review indicated
education classes started fifteen minutes late one month and ended fifteen minutes early in
another month. The review also showed the morning break period lasted twelve to twenty-five
minutes longer than the scheduled fifteen minutes in three reviewed months. Observations of
the program's video were conducted for three days. The footage showed school started an
average of one to two minutes late on all three days, and the morning breaks went over the
allotted fifteen minutes by fourteen to seventeen minutes. Lunch period started eight to nine
minutes early and returned between three and twelve minutes late for all three days, and school
ended eleven to twelve minutes early on all three reviewed days. The average loss of
educational time across all three days ranged from fifteen to forty-six minutes.
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2.19 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The compliance review confirms the provider is delivering and documenting the contract
mandated foundational credentials of Occupational Safety and Health Administration-10 (OSHA
10, with forklift content comparable to OSHA 30), Florida Ready to Work (Soft Skills Credential),
and cardiopulmonary resuscitation (CPR)/first-aid. Records for these completions were verified
on file, and the program’s partnerships with the Orlando branch of Junior Achievement and
Flagler Extension for 4H strengthen its soft-skill and experiential learning offerings. The
availability of a national retail credential further expands immediate employment pathways for
youth, reflecting positive stakeholder feedback on program delivery. The career and technical
education (CTE) services were provided according to the program’s schedule, contract, and
CTE requirements. Three reviewed youth records confirmed they received OSHA-10, Florida
Ready to Work Soft Skills, and CPR/first-aid courses within the required time frames.
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Office of Accountability and Program Support Page 28 of 61 (Revised August 2025)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program has a policy and procedures which provides for a single licensed mental health
professional 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 DMHCA is a licensed mental health counselor (LMHC) with a clear and active
license which expires on January 31, 2027. There have been no other DMHCAs during the
annual compliance review period. The back-up DMHCA is a LMHC with a clear and active
license which expires on March 31, 2027. The DMHCA is on-site forty hours a week and is in
on-call for emergencies as required by contract. The position description for the DMHCA
confirms the required hours for services. An interview with the DMHCA confirmed their role is to
ensure appropriate coordination, implementation, and oversight of mental health and substance
abuse services in the program as well as providing oversight of non-licensed clinical staff.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures to ensure mental health and substance abuse
services are provided by staff with the appropriate qualifications. The program has no licensed
clinical staff except for the designated mental health clinician authority. Licenses of all mental
health professions and qualified professionals were reviewed, which are available on-site.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures to ensure mental health and substance abuse
services are provided by staff with the appropriate qualifications. The designated mental health
clinician authority (DMHCA) must ensure clinical staff working under their supervision are
performing services the staff are qualified to provide based on education, training, and
experience. A review of the three non-licensed clinical staff all had master’s degrees and
appropriate training and experience to provide mental health and substance abuse services for
the program. The Department’s Licensed Mental Health and Professionals Direct Supervision
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Log form is used to document clinical supervision hours. All logs were reviewed and found
weekly supervision was present for the entire annual compliance review period, with the
exception of one week which was had ten days between supervision. The program has a
Chapter 397 license which expires on March 22, 2026. The contract requirements for hours and
days of the week are being met by the three non-licensed clinical staff. There have been no
vacancies during this annual compliance review period. Each of the three non-licensed clinical
staff who conducted Assessments of Suicide Risk completed the required twenty hours of
training and supervised experience.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a policy and procedures to ensure 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 needs or are identified as possible
suicide risk. The program director (PD) developed a policy and procedure for the
implementation of standardized admission/intake mental health and substance abuse screening
process which included a comprehensive screening protocol, outlined staff training
requirements on mental health and substance abuse issues, including proper administration of
the MAYSI-2, and defined a standardized referral process for youth requiring further evaluation
or immediate intervention. The program screens all newly admitted youth utilizing the
Massachusetts Youth Screening Instrument-Second Version (MAYSI-2) in the Department’s
Juvenile Justice Information System (JJIS). Document review confirmed the admitting staff
reviewed the commitment packet, reports, and existing documentation of mental health and/or
substance abuse problems, as well as history of human trafficking. All five records reviewed
have a MAYSI-2 fully completed in JJIS on the date of admission by trained clinical staff. All five
reviewed MAYSI-2s required further assessment, which documentation confirmed a referral to
the designated mental health clinician authority (DMHCA) was completed, with the PD also
being notified. Three required an Assessment of Suicide Risk (ASR); however, one record was
missing the ASR referral. All five youth required a Comprehensive Evaluation, which was the
documented reason for the referral. None of the five reviewed youth required immediate
assessment or emergency services for youth in crisis. The three youth requiring suicide risk
assessments were placed on precautionary observation at the time of assessment. All four
clinical staff are trained in administering the MAYSI-2. During an interview with the PD, it was
confirmed the PD is aware a MAYSI-2, ASR, and Comprehensive Evaluation is completed on all
newly admitted youth. The program has a process for referral of youth identified as in need of
further mental health and/or substance abuse evaluation to an appropriate service provider or
when immediate attention is needed, to a hospital or Baker Act or Marchman Act receiving
facility.
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3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a policy and procedures to ensure youth identified by screenings, staff
observations, or behaviors post-admission as in need of further evaluation will be referred for a
combined Comprehensive Mental Health and Substance Abuse Evaluation. Five youth mental
health and substance abuse records were reviewed. All five youth had a new combined
Comprehensive Mental Health and Substance Abuse Evaluation completed within thirty
calendar days of admission. Each record had a signed substance abuse consent for services
signed by the youth. All five evaluations were completed by a non-licensed clinical staff and
were reviewed and signed by the clinical director who is a licensed qualified professional within
the ten-day timeframe. All five evaluations had all required elements of a Comprehensive
Mental Health and Substance Abuse Evaluation.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has policy and procedures to ensure youth determined to have a mental disorder
or substance abuse impairment and are receiving mental health or substance abuse treatment
in a program, shall have an Initial or Individualized Mental Health or Substance Abuse (MHSA)
Treatment Plan. All five reviewed records had an initial MHSA Treatment Plan developed within
seven days of admission. The initial MHSA Treatment Plan was initiated at admission, and the
onset of treatment was on the same date. The plan was documented on a form which included
all required components and addressed the youth’s psychiatric needs, including medication
dosing and frequency of monitoring by the psychiatrist for those youth taking psychotropic
medication. Initial treatment plans were signed by the mental health clinical staff, when
completed by non-licensed staff they were reviewed by the licensed clinical supervisor within
ten days, signed by the youth, treatment team leader, program management, and living unit
representative, with parents/guardians being contacted telephonically. All five records had an
individual treatment plan which included all required components and addressed the youth’s
psychiatric needs, including medication dosing and frequency of monitoring by the psychiatrist
for those taking psychotropic medication, completed within thirty days, with all reviews being
completed every thirty days thereafter on the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan Review form. All individualized treatment plans and
reviews had all required signatures from treatment team members except parent/guardians and
juvenile probation officers who were contacted or attempted to contact telephonically.
Prescribed services were individualized for each youth and confirmed based on the group sign-
in rosters.
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3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
The program has a policy and procedures which directs treatment and discharge planning. Five
youth mental health and substance abuse records were reviewed. Each youth was assigned to
a multidisciplinary treatment team upon admission to the program, which contained all required
members. All five youth records had a properly executed Authority for Evaluation and Treatment
(AET) in their record. Each record contained signed consent for substance abuse treatment
services. All five records contained treatment progress notes which contained all elements of
the Department’s form. Documentation confirmed each youth was receiving individual and
psychosocial skills training as well as other services as stipulated in their treatment plans. Three
closed youth records were reviewed for discharge summaries. The discharge summaries were
completed on the Department’s Mental Health and Substance abuse Discharge Summary form.
None of the records reviewed required notifications for suicide alerts/precautions. Future
services were indicated on the discharge summary in all three records. All three records
reflected the documents were discussed with the youth, parent/guardian, and juvenile probation
officer (JPO) during the exit conference. A copy of the Mental Health and Substance Abuse
Treatment Discharge Summary form was provided to each youth, parent/guardian, and JPO.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program has a policy and procedures which require specialized treatment services to be
provided to youth. The program’s required clinical groups according to the contract are
Pathways: A guided workbook for youth beginning treatment, Footprints: Steps to a healthy life,
and supplemental groups included Aggression Replacement Therapy, Cannabis Youth
Treatment, and Sexual Education/Healthy Sexuality and Healthy Boundaries. Five youth were
interviewed and each confirmed they participate in individual, group, and family therapy. Youth
interviews of all five youth confirmed they have family counseling twice a month and individual
counseling sessions weekly. Interviews of five staff confirmed none of the direct care staff
conduct clinical groups. An informal interview with the designated mental health clinician
authority (DMHCA) confirmed all youth receive Juvenile Sexual Offender Treatment Services
(JSO) and individual, group, and family therapy, as well as supportive counseling according to
their individualized treatment plan. The interview with the program director confirmed JSO
treatment is provided and Pathways: A guided workbook for youth beginning treatment is the
primary JSO clinical group. The program maintains a one to ten youth to therapist ratio for
clinical groups. Review of group sign-in sheets confirmed groups are completed four days a
week with at least three groups being JSO clinical groups. All non-licensed clinical staff have a
master’s degree in social work or counseling, have completed the required training to conduct
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JSO groups, and are authorized by the Office of Health Services (OHS) to conduct those
groups. Progress notes confirmed the youth were provided individual therapy once a week and
family therapy every two weeks. The psychiatrist provided services at least once every two
weeks. The program did not have any youth applicable for needing services during medical
quarantine.
3.09 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 to ensure the program follows a suicide plan to safely
assess and protect youth with elevated risk of suicide in the least restrictive means possible.
The program has a written suicide prevention plan which includes identification and assessment
of youth at intake, 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 include a review of the
circumstances surrounding the event, facility procedures relevant to the event, relevant training
received by involved staff, pertinent medical and mental health services involving the victim,
possible precipitating factors, and recommendations, if any, for changes in policy, training,
physical plant, medical, or mental health services, and/or operational procedures. The suicide
prevention plan was reviewed by the program director and the designated mental health
clinician authority on February 20, 2025.
3.10 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
The program has a policy and procedures which address suicide prevention services. This
policy defines suicide precautions as methods utilized for supervising, observing, monitoring,
and housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. It requires any youth exhibiting suicide risk behaviors to be placed on
suicide precautions, and a minimum of constant supervision. Five youth mental health and
substance abuse records were reviewed for suicide prevention services and three were found to
be applicable for services. All three youth were found to be at-risk during their admission
screening. Each youth had an Assessment of Suicide Risk (ASR) completed within twenty-four
hours, and each indicated contact or attempted contact with parents/guardians and assigned
juvenile probation officer. Records indicated each youth was provided supportive services by
mental health clinical staff and each ASR was completed by a clinical staff under the
supervision of a licensed mental health professional. All three youth remained on constant
supervision following the suicide risk assessment. The ASRs confirmed when the clinical staff
conferred with the program director (PD) and designated mental health clinician authority
(DMHCA). Each youth had a follow-up assessment of suicide risk (FASR) on the Department’s
form completed prior to the removal of the youth from precautionary observation. Each youth
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was maintained on close supervision until it was determined it was no longer necessary by the
DMHCA and the PD. A review of the Department’s Juvenile Justice Information System (JJIS)
determined a suicide alert was initiated for each youth upon being placed on suicide precautions
and closed upon step down as indicated on the FASR. A review of program logbooks confirmed
suicide precautions were documented in the logbook and notation of when youth were removed
was also present for all three youth. While on precautionary observation, each of the three
youth were allowed to participate in select activities with other youth in designated safe
housing/observation areas of the program. A review of video footage of youth placed on
precautionary observation was unable to be completed due to no youth being on precautionary
observation within the maintained video recording of thirty days.
3.11 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
3.12 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’s Suicide Prevention Plan requires staff to maintain one-to-one or constant
supervision of youth placed on suicide precautions. Five youth mental health and substance
abuse records were reviewed. Three of the youth were applicable for suicide prevention
services. Documentation confirmed Department Suicide Precaution Observation Logs were
maintained for each youth for the duration the youth was on suicide precautions. Each log
documented the appropriate level of supervision and observations of each youth’s behavior in
real time, not exceeding thirty-minute intervals, as well as each log being reviewed and signed
by each shift supervisor and mental health clinical staff. Each log documented safe housing
requirements. Warning signs were not present on any of the logs reviewed.
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 has policy and procedures which ensure all staff who work with youth shall be
trained to recognize verbal and behavioral cues indicating suicide risk, suicide prevention, and
implementation of suicide precautions. Five pre-service and five in-service records were
reviewed for completion of suicide prevention training. All five pre-service and five in-service
records indicated staff completed the required training. The program has two suicide response
kits which are co-located with first aid kits in the administration break room and in master control
located on the dormitory. The suicide response kits include a knife-for-life, a needle nose plier,
and wire cutters. A review was conducted of the program’s mock suicide drills which confirmed
the program completed the required quarterly drills on each shift. An observation of video
camera confirmed drills are simulated. Each drill included a response to a suicide attempt or
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serious self-inflicted injury, and all drills included the use of cardiopulmonary resuscitation. All
staff were provided with an opportunity to review each drill scenario and procedures. An
interview with the program director confirmed the program conducts monthly mental health
drills. Five staff were interviewed and all five stated they notify mental health staff if a youth
expresses suicide thoughts and place the youth on constant supervision until further direction
from clinical staff. They also advised they would document the constant supervision. All five staff
were aware of where the suicide response kits are located and reported they participate in
mental health drills monthly.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has policy and procedures which require a response to youth in crisis in the least
restrict means possible to protect the safety of the youth and others, while maintaining control
and safety of the program. The program has a written combined crisis intervention and
emergency response plan which includes a notification and an alert system, means of referral,
including youth self-referral, communication, supervision, documentation, and review.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a policy and procedures ensuring the program responds to youth in crisis in
the least restrictive means possible to protect the safety of the youth and others, while
maintaining control and safety of the program. The program shall be able to differentiate a youth
who has an acute emotional problem or serious psychological distress from one who requires
emergency services. Five youth mental health and substance abuse records were reviewed.
None of the youth records were applicable for requiring a Crisis Assessment. Three additional
records were requested however only one example was available from the annual compliance
review period. The youth had a crisis assessment completed on the same date of the referral,
and the crisis assessment included the reason for the assessment, mental status examination,
determination of danger to self and/or others, initial clinical impressions, supervision and
treatment recommendations, and recommendations for follow-up or further evaluation. The
youth was not applicable for parent/guardian notification due to the youth’s age. The crisis
assessment was conducted by a licensed mental health professional. The youth did not require
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a mental health alert, not determined to pose a safety and security risk, nor required off-site
crisis assessment services. The youth was an alleged victim in a PREA event, and the crisis
assessment was completed immediately upon gaining knowledge of the allegation by the
designated mental health clinician authority and was offered ongoing mental health treatment
services.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a policy and procedures which govern youth determined to be an imminent
danger to themselves or others due to mental health or substance abuse emergencies occurring
in the program require emergency care provided in accordance with Florida Administrative Code
and the program’s emergency response plan. The program has a written combined crisis
intervention and emergency response plan which includes immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health and substance abuse services, transport for Baker and Marchman Acts, documentation,
training, and review.
3.17 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedures to conduct an on-going safety planning process for
each youth. The safety plan shall be designed to identify stimuli which have both positive and
negative effects on the youth. Five youth mental health and substance abuse records were
reviewed. All five youth had a safety plan completed within fourteen days of admission which
contained all required elements. Each youth’s plan was jointly prepared by the youth,
parent(s)/guardian(s) or family member, and the program’s clinical staff. Documentation
confirms each safety plan incorporated recommendations from previous or current clinical
assessments or screening instruments and incorporated trauma responsive practices. All five
youth had the plans reviewed at least every thirty days. All five youth’s plans were reviewed and
updated as necessary following any significant behavioral or mental health event identified by
the youth’s intervention and treatment team. Safety plans are filed in the youth’s records and the
safety binder located in the administration break room where direct care staff may access them.
Five youth were interviewed and confirmed they participated in the development of their safety
plan. An interview with the program director confirmed safety plans are reviewed monthly or as
needed.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a policy and procedures confirming the designated health authority (DHA)
shall be clinically responsible for the medical care of all youth at the program. The program’s
DHA is an osteopathic physician who holds a clear and active license with an expiration date of
March 31, 2026. The physician’s specialty training is in family practice. Upon review of the
DHA’s record, there were no disciplinary or public complaints found. The program does not
utilize a physician’s assistant or advanced practice registered nurse. Reviewed sign-in and sign-
out logs for annual compliance review period confirmed the DHA was on-site for two hours each
week, as required by contract. The program has a back-up physician in the event of the DHA’s
absence who holds a clear and active license with an expiration date of January 31, 2026.
During the annual compliance review period, the back-up physician was utilized for one week
and provided the clinical services on-site while the actual DHA performed the administrative
duties. A review of the program’s contract found the program does not utilize telemedicine or
telehealth for medical services. The DHA was interviewed and stated they are on-site weekly to
conduct intake physicals, medication management, and records review. The DHA stated they
are available to review important medical issues with nursing staff by telephone, email, or when
on-site. The DHA stated if they are on a scheduled absence, they utilize the back-up DHA. The
DHA stated they have no concerns with healthcare at the program.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a policy and procedures stating the designated health authority (DHA) shall be
clinically responsible for all healthcare services provided to youth at the program. Daily clinical
care shall be performed by licensed medical staff according to developed and authorized
protocols which shall include intake evaluations, assessments, health education, medication
management, and other assigned duties according to the program’s facility operating
procedures and nursing protocols approved by the DHA. The program does not utilize any
licensed practical nurses. The program’s contract indicates they will have a full-time health
services administrator (HSA), who works forty hours a week, one full-time registered nurse
(RN), who works forty hours a week, and one part-time RN, who works twenty hours a week.
During the annual compliance review period, the program’s nursing staff maintained compliance
with the contracted hourly requirements. A review of nursing licensure credentials confirmed
each RN’s license was clear and active and each nurse also has a current cardiopulmonary
resuscitation certification card.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The medical FOPs were signed by the designated health
authority (DHA) on July 30, 2025, the psychiatrist on August 1, 2025, and the program director
on July 29, 2025. The health services administrator (HSA) did review, sign, and date the cover
page on which all FOPs, healthcare protocols, and other procedures were listed on August 24,
2025. The annual review of medical FOPs and protocols was conducted on August 24, 2025.
The program did not have any newly hired healthcare personnel during the annual compliance
review period. Approval of treatment protocols and standing procedures were written and
authorized by the DHA and were not delegated to any other person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures ensuring the completion of the Department’s
Authority for Evaluation and Treatment (AET) authorizing specific treatment for youth in the
custody of the Department. Five youth Individual Healthcare Records (IHCRs) were reviewed.
All five records contained a valid AET form. Each AET was a copy with the word “copy” legibly
stamped on the form. Each AET was signed by a parent/guardian and a department
representative. One youth was eighteen years of age and had a documented release of
information in their IHCR. An interview with nursing staff found the policy for obtaining a new or
current AET is by retrieving the most recent AET from the Department’s Juvenile Justice
Information System (JJIS) and verifying all required signatures are present as well as the
guardian’s address and phone number being documented. For youth eighteen years of age or
older, nursing staff stated those youth can consent to treatment for themselves.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure parents/guardians are informed of
significant changes in youth’s conditions and obtain consent when new medications and
treatments are prescribed. Five youth Individual Healthcare Records (IHCRs) were reviewed.
Four were applicable for parent/guardian notification, as the remaining youth was eighteen
years of age at the time of admission. Three youth IHCRs were applicable for parent/guardian
notifications for over-the-counter (OTC) medications beyond those covered by the Authority for
Evaluation and Treatment (AET). All three IHCRs contained documentation of parent/guardian
notification and consent for each OTC medication. The remaining youth did not receive any
OTC medications beyond those covered by the AET. New medication was ordered for all four
applicable youth. Documentation of notification to the parent/guardian for each new medication
was in three of the four youth’s IHCR. The remaining youth was not applicable due to being
eighteen years of age. All written notifications were sent utilizing the correct forms. Two youth
were taking psychotropic medications at the time of admission, and two additional youth were
prescribed psychotropic medications while at the facility. All four youth had a new psychotropic
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medication prescribed, discontinued, or had the dosage significantly changed while at the
program. Documentation in three of the four IHCRs found parent/guardian verbal consent was
documented on page three of the Clinical Psychotropic Progress Note (CPPN). The remaining
youth was not applicable due to being eighteen years of age. All five reviewed youth had
vaccinations verified on the day of admission. None of the reviewed youth were applicable for
an exemption for a vaccination nor did they require a vaccination while at the program. An
interview with nursing staff found parental notifications are sent when youth under eighteen
arrive to the facility. A phone call is made to the parent/guardian to confirm conditions, allergies,
and medications. A notification is also sent when the youth meets with the designated health
authority (DHA), the psychiatrist for an initial assessment, when meds are started or changed,
and/or when there’s a new referral. Nursing staff stated notifications are mailed out at the same
time the practitioner orders are mailed to parents, which is when the youth arrives at the
program, and a copy is placed in the IHCR. When emergency services are needed, a call is
made to the parent/guardian, the youth is sent out with a transfer packet, the DHA is notified,
and a Department Central Communications Center (CCC) call is placed. Nursing staff confirmed
when new psychotropic medications are ordered, discontinued, or changed, the psychiatrist
calls the parent to receive verbal consent with a witness present for the call. The witness signs
the third page of the CPPN. Nursing staff indicated vaccinations are not provided on-site.
Immunization records are obtained from either Departments Juvenile Justice Information
System (JJIS) or the Florida Shots website. The records are reviewed within twenty-four hours
of admission. If a parent/guardian is requesting exemption from an immunization, they must
provide the appropriate documentation from the Department of Health.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures to ensure youth are screened upon admission for
healthcare concerns which may require a referral for further assessment by healthcare staff.
Five youth Individual Healthcare Records (IHCRs) were reviewed. Each youth’s IHCR contained
the Department’s Facility Entry Physical Health Screening (FEPHS) form completed by the
registered nurse (RN) on the day of their admission. No youth had a change in physical custody
greater than twenty-four hours. An interview with nursing staff found youth are seen upon arrival
by the medical department prior to any other department seeing the youth. When a youth is
admitted, nursing staff state they are notified through email with the youth’s name, date of birth,
and their Department of Juvenile Justice Identification number (DJJID). If there is a change in
custody, a new FEPHS form is completed upon the youth’s return to the program.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures to guarantee all youth are oriented to the general
process of healthcare delivery services at the program. Five youth Individual Healthcare
Records (IHCRs) were reviewed for healthcare orientation and confirmed each youth received a
general care orientation on the day of admission to the program. The program’s healthcare
orientation included 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
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how it is documented, what to do in the case of a sexual assault or attempted sexual assault,
the non-disciplinary role of the health care providers, and standard universal precautions. Each
youth’s IHCR included a signed Health Education Acknowledgment form indicating they
reviewed medical care education and were able to ask any questions. A Health Education
Record was also located in each youth’s IHCR. The program’s contract indicates they must
provide health education monthly and reviewed documentation in each youth’s IHCR confirmed
they receive monthly education on all the required topics.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to ensure the designated health authority (DHA) or
their designee is notified when a youth admitted requires emergency care or routine notification
in accordance with Department’s requirements. The program’s practice is to notify the DHA of
each admission. Five youth Individual Healthcare Records (IHCRs) were reviewed. Each youth
had a known or suspected chronic condition and there was a referral to the DHA in each record.
None of the reviewed youth were identified as in-need of emergency care upon admission. Each
youth’s IHCR contained documentation of notification to the DHA within twelve hours of
admission. Two youth were taking psychotropic medication upon admission to the program.
Both IHCRs included documentation of the psychiatrist being notified. An interview with nursing
staff confirmed the DHA is notified of youth admitted with serious or chronic conditions
immediately after admission screening is complete. Nursing staff completing the screening
completes this notification and documents it on the nursing admission note.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedure to ensure the standard Department’s Health-Related
History (HRH) form is used for all youth admitted into their physical custody. Five youth
Individual Healthcare Records (IHCRs) were reviewed for completion of the HRH. Each youth’s
IHCR contained a new HRH form completed within seven calendar days of admission and prior
to completion of the Comprehensive Physical Assessment (CPA). Each HRH form was
reviewed by the designated health authority (DHA). During an interview, nursing staff stated
they are responsible for completing the HRH during admission and the form must be completed
within seven days.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures to make certain the standardized Comprehensive
Physical Assessment (CPA) form is utilized for all youth admitted into the physical custody of
the program. A review of five youth Individual Healthcare Records (IHCRs) found a new CPA
form was completed on the Department’s CPA form by the designated health authority (DHA)
within seven days of admission for each youth. Each youth’s Medical Grade was documented
on the CPA with four youth being identified as Medical Grade five and one being identified as
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Medical Grade four. All sections of the CPA were marked with an “O” or an “X.” Those sections
marked with an “X” had comments by the DHA in the comments section of the form for each
youth elaborating on the abnormality. All youth refused a part of the exam, and the DHA wrote,
“Youth Refused” on each youth’s CPA. Each youth’s IHCR had a signed refusal form which the
reflected the refused portion on the CPA exam and matched the date of the exam. The
Department’s Problem List was updated, as required, for each youth. A review of all five youth’s
IHCRs verified each youth had at least one verified Tuberculosis Skin Test (TST) completed
and documented within the last year. Each youth’s results were documented on the CPA and
Infectious and Communicable Disease (ICD) form, and each youth’s test results matched on
both forms. An interview with nursing staff found the DHA completes a new CPA annually and
Tuberculosis screenings are completed annually.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures to ensure all youth are evaluated and treated, if
necessary, for sexually transmitted infections (STIs). Five youth Individual Healthcare Records
(IHCRs) were reviewed. Only one youth was applicable for review and was screened and
evaluated for STIs on the date of admission. Further evaluation was not required; therefore,
testing was not ordered. Nursing staff stated there were no other youth records applicable for
being screened and evaluated for STIs. The one applicable youth was not out of the
Department’s physical custody nor required a rescreen for any reason. Consent forms in all five
reviewed IHCRs reflected each youth was offered counseling, testing, and if indicated,
treatment/referral for human immunodeficiency virus (HIV). Each youth refused HIV testing and
a refusal was documented. The program’s policy and procedures indicate youth HIV test results
are only disclosed to entities as outlined in Florida Administrative Code. The health services
administrator (HSA), who is certified in HIV counseling, provides HIV pre and post-test and
counseling services. If they are not available, a certified staff from the Health Department will
provide counseling. Five interviewed youth stated they can ask for a HIV test. An interview with
nursing staff found youth are screened for STIs through a urine test. If the screening indicates a
need for further evaluation, nursing staff indicated the designated health authority (DHA) creates
an order and the Health Department is notified. Nursing staff confirmed the STI screenings,
evaluations, referrals, and testing are documented on the Infectious and Communicable
Disease (ICD) form in the youth’s IHCR. If the youth has been out of the Department’s physical
custody for more than thirty days and/or symptoms are present, a new admission and screening
is conducted. The youth’s HIV testing results are kept in their IHCR on the ICD form. Youth are
asked during admission if they would like HIV counseling and testing services. Nursing staff
confirmed they are the ones providing the counseling and if they are not available, certified staff
at the Health Department can provide the services. This entire process is documented in an HIV
binder, and results are sealed and placed in each IHCR.
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4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program maintains a policy and procedures to ensure all youth can submit sick call
requests and have complaints treated appropriately through the program’s sick call system. Five
youth Individual Healthcare Records (IHCRs) were reviewed and three were applicable for sick
calls. One of the three youth was applicable for presenting with a similar sick call complaint
three or more times within a two-week period. This youth made the similar complaint three
times, and a referral was made to the designated health authority and the situations were
treated as emergencies and an immediate referral was made to a licensed healthcare
professional. In the three applicable records, each youth completed a Sick Call Request form,
and each form was completed by the registered nurse (RN). Each youth’s Sick Call Request
forms were filed in their IHCR in reverse chronological order. Each Sick Call Request form was
documented in accordance with Florida Administrative Code. Each youth’s sick calls were
documented on their Sick Call Index in their IHCR and on the program’s Sick Call Referral Log.
All dates listed on the Sick Call Indexes corresponded to the completed Sick Call Request forms
located in the IHCRs. None of the youth were in restricted housing. A review of the daily posted
schedule and nurse interview found sick call is held every day of the week at 7:30 a.m., which
meets the contract requirement of providing sick call seven days a week. Sick call hours are
posted on the dorms and on the medical office door. Only licensed nurses conduct sick call.
Sick Call Request forms are available to youth on the dorm. An exam table and equipment are
in the medical office to utilize during sick call. Five youth were interviewed. Two of the five
stated they see a nurse immediately upon submitting a sick call request. Three youth stated
they never submitted a sick call request while at the program. During an interview, nursing staff
indicated youth should be seen for a sick call request within twenty-four hours and for an
episodic (emergency) event, youth should be seen immediately. The RN on duty routinely
conducts sick call. Nursing staff indicated sick call is conducted at 7:30 a.m. daily in the medical
office. If youth present with repeated similar complaints three times, youth will be seen by the
DHA. Nursing staff advised the program does not utilize room restriction. A sick call was not
observed as no sick calls took place during the annual compliance review week.
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 to ensure they have a comprehensive process for the
provision of episodic care and first-aid care. Five youth Individual Healthcare Records (IHCRs)
were reviewed and four were applicable for episodic care. On-site care was provided by
licensed healthcare staff for each event. Each event was documented in the required subjective,
objective, assessment, and plan (SOAP) format. An episodic care event was not observed, as
one did not take place during the annual compliance review week. During an interview, nursing
staff indicated on-site episodic care is documented using the SOAP format and the designated
health authority (DHA) is notified according to severity and need for orders. Nursing staff track
youth who are sent off-site for emergency care by calling the hospital or facility youth was sent
to obtain daily updates and place updates on the Episodic Care Log.
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The program maintains seven first-aid kits. The kits are kept in kitchen one, kitchen two, master
control, maintenance, two for transport, and case management. The two for transport are kept in
master control when not on a transport. Nursing staff regularly inventory the contents and
restock if needed. If staff determine a kit needs to be restocked, they shall bring it to nursing
staff to restock. Three first-aid kits were checked and each contained DHA approved items. A
review of documentation for the last year found first-aid kits were inspected monthly by nursing
staff, as required. Nursing staff was interviewed and indicated there are seven first-aid kits at
the program and confirmed their locations. The program has two automated external
defibrillators (AEDs), which are in master control and kitchen one. Instructions are located with
both AEDs. On-site nursing staff check to ensure the AED batteries and pads are operable. A
review of documentation for the last year found checks were conducted monthly. Nursing staff
conducted a self-test on both AEDs during the annual compliance review week, with no issues
being noted. The green light was flashing on both AEDs during the annual compliance review
week. The batteries for the master control AED were last changed in February 2023 and expire
in February 2027. The batteries for the kitchen one AED were last changed May 2023 and
expire in May 2027. The pads for the master control AED were last changed March 25, 2025,
and expire on January 28, 2027. The pads for the kitchen one AED were last changed on June
8, 2025, and expire on May 11, 2027. Nursing staff confirmed in an interview there are two
AEDs in the facility and instructions are kept with both AEDs. Nursing staff also confirmed they
check to ensure the AEDs are operable and confirmed the expiration dates for the batteries and
pads. The program has a list of emergency numbers, inaccessible to youth, located in
administration and in the program director’s (PDs) office. Authorized direct-care staff are
appropriately trained on the administration of the epinephrine auto-injector by the registered
nurse on-site. A review of six pre-service and five in-service staff training records found each
staff was trained in episodic, first-aid, and emergency care.
A review of drill documentation found all direct-care staff participated in a drill which included the
use of cardiopulmonary resuscitation (CPR) during the past year. A video review of emergency
drills confirmed drills were simulated. A review of emergency drill documentation for the last
year found the program has conducted drills, which simulate an episodic care event which calls
for immediate first aid and/or administration of cardiopulmonary resuscitation (CPR) techniques
and the initiation of the emergency procedures to follow when a life-threatening emergency
occurs, at least monthly on each shift. An episodic care event could not be observed for one did
not happen during the annual compliance review week. During an interview, nursing staff
indicated emergency drills are conducted monthly. Nursing staff stated emergency numbers are
inaccessible to youth and located in master control and the medical office. All five interviewed
staff stated they can call 9-1-1 if a youth has a medical emergency. Five of five interviewed
youth stated they can see a dentist or doctor if needed
The program has a policy on the use, access, and inventory of Narcan. The policy indicates the
program will maintain at least one prescribed stock of Narcan. The kit is maintained in the
medication cart located in the medical area and can be accessed by nurses and supervisors. A
perpetual/weekly inventory of medication utilization must be maintained. It must be stored at
room temperature away from light and avoid extremes of heat or cold. A registered nurse (RN)
will inspect the Narcan kits weekly and ensure kits are current and in good condition. Kits will be
inventoried, dated and initialed at the time of the inspection. Shift supervisors may administer
Naloxone. Nursing staff and supervisory staff shall be trained on administration of Naloxone.
Training and refreshers must be conducted for all new supervisory staff and at least annually by
a RN or higher. The program stores Narcan in the medical office, administration, and master
control. Nursing staff and supervisory staff have access to the Narcan. All staff with access to
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Narcan have been trained on when and how to use Narcan. A review of documentation found
Narcan is inventoried daily.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures ensuring the program provides timely referrals and
coordination of medical services to an off-site healthcare provider. Five youth Individual
Healthcare Records (IHCRs) were reviewed and three were applicable for off-site care. The
Department’s Summary of Off-Site Care Consultation Report form was utilized for each off-site
care event. All events were documented on the Episodic Care Log. Two of the three records
were applicable for parental notification efforts, and both had documentation of such. The
remaining youth was eighteen years of age. The discharge and other applicable documents
were filed in all three IHCRs. The designated health authority (DHA) reviewed all off-site care
findings, instructions, and information and signed each Summary of Off-Site Care Consultation
Report form acknowledging their review. Two youth required follow-up care. Evidence indicating
both youth received appropriate follow-up care was provided, with both youth having one follow-
up appointment. During an interview, nursing staff stated youth who are sent off-site for first-aid
or emergency care are tracked by calling the hospital or facility the youth was sent to for
updates and notating the event on the Episodic Care Log. Nursing staff ensure hospital orders
are followed by sending them to the DHA for confirmation and having them write a verbal order.
Nursing staff place all off-site care findings, instructions, and information, in the DHA’s weekly
visit binder. Follow-up testing, referrals, and appointments are tracked on an internal calendar.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures ensuring youth who have chronic conditions receive
regularly scheduled evaluations and necessary follow-up. Five youth Individual Healthcare
Records (IHCRs) were reviewed. Four of the youth were applicable for chronic conditions. All
four youth were identified on the Department’s Facility Entry Physical Health Screening
(FEPHS) form as having a chronic condition. None of the reviewed youth had a communicable
disease. All four youth were taking prescribed medication on an on-going basis. Only one youth
was undergoing treatment for a physical health condition and was classified with Medical Grade
two through four, the remaining three youth were taking psychotropic medication however also
have been diagnosed with a chronic conditions. All four youth were placed on the program’s
chronic illness list. A review of progress notes found each youth received periodic evaluations at
least every ninety-days. There were no youth taking anti-tuberculosis medication. All periodic
evaluations were conducted on-site, and periodic evaluations were conducted prior to renewing
a prescription medication which expired for the three youth taking prescribed medications.
There were no instances of lapses in care or periodic evaluations. The Department’s Problem
List was updated, as required, for each youth. The program director (PD) was interviewed and
indicated administration meets daily with medical staff to discuss all medical issues pertaining to
youth. All discussions occur in the morning meeting along with the review of the previous day’s
documentation. The information discussed will include transports, follow-ups, and all other
concerns. An interview with the designated health authority (DHA) confirmed periodic
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evaluations for youth with chronic conditions occur every ninety days and they are tracked on an
internal medical tracker by the nursing staff. During an interview, nursing staff also confirmed
youth with chronic conditions are monitored using an internal medical tracker.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a policy and procedures indicating they shall receive, store, inventory, and
provide medication in a safe and effective manner which shall be demonstrated by observation,
as well as review of documentation of procedures and processes. Five youth Individual
Healthcare Records (IHCRs) were reviewed. Four youth were identified on the Department’s
Facility Entry Physical Health Screening (FEPHS) form and in the progress notes as admitted to
the program with medication. All four youth had documentation of the medication being verified
prior to be admitted to the program utilizing the required Department form. The designated
health authority (DHA), and when applicable, the psychiatrist, were contacted to obtain the order
to resume the specified medications prescribed prior to admission for all four youth. All
medications for all four youth were observed to have a current, valid order and administered
pursuant to a current prescription. Each time a medication was continued, changed, or a new
one was ordered, the DHA placed an order on a Practitioner Order form. None of the youth
were in restricted housing. Three youth were applicable for over-the-counter (OTC) medications
not listed on the Authority for Evaluation and Treatment form. All medications for all three youth
were administered according to approved protocols or practitioner’s order. The program utilizes
a preprinted pharmacy Medication Administration Record (MAR), which includes all required
elements. In the four reviewed records, the MARs clearly indicated start and stop dates. A
review of the MARs found youth and staff initialed each administered medication and side-effect
monitoring was documented at least weekly for each youth. There were no undocumented
explanations for lapses or errors in medication administration. No youth refused any
medications. All four MARs reviewed contained the youth’s name, the Department’s Juvenile
Justice Identification number (DJJID), date of birth, youth allergies, precautions, Medical Grade,
medical alerts, and current picture. None of the youth required parenteral medication. There
were no standing orders, emergency treatment orders, or pro re nata (PRN) orders for
psychotropic medications.
Medication pass was observed for one youth during the annual compliance review week.
Medication delivery was the sole responsibility of the nurse during the time of administration.
The youth was escorted to medication pass by direct-car staff and approached the nurse
administering medication individually. The nurse identified themselves and stated the youth was
there for medication pass. The same staff prepared and administered the medications. The
nurse verified the youth’s allergy and alert status, and both the staff and youth initialed the MAR.
Staff observed the youth take their medication to ensure it was swallowed, and the nurse had
the youth cough and had direct care staff check to ensure the medication was swallowed. Over-
the-counter medication administrations were documented. The medication was not pre-poured
from its original packaging and placed in another container for subsequent administration. The
six rights of medication delivery/administration were verified by nursing staff. Five of the five
interviewed youth reported taking medications. All five youth stated the nurse dispenses
medications except for one youth stating a supervisor dispenses medications for the one
medication call occurring when medical staff is not on-site. Each of the five youth were able to
provide a detailed account of the medication process to include youth and prescriptive
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medication identification, staff and youth signatures, and mouth checks completed after
medication are dispensed. In an interview, nursing staff stated the process for verifying a
youth’s medication regimen when they are admitted with medications is through verification of
the MAR sent with the youth and by the prescription medication verification checklist. Nursing
staff stated the program utilized a preprinted pharmacy MAR. All non-healthcare staff who
administer medications are trained by nursing staff. Nursing staff indicated medication pass
takes place daily at 8:00 a.m., 12:00 p.m., and 5:00 p.m. Medications are ordered through a
vendor and are procured within twenty-four hours. Nursing staff confirmed there is a psychiatrist
on-site for medication management.
4.17 Psychiatric Services Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program maintains a policy and procedures to ensure psychiatric services include a
psychiatric evaluation, psychiatric consultation, medication management, and medical
supportive counseling provided to youth with a diagnosed mental disorder and for each youth
receiving psychotropic medication in the program. Psychiatric services are provided by a
psychiatrist with a clear and active license in the state of Florida with a license expiring on
January 31, 2027. The psychiatrist is available for emergency consultation twenty-four hours a
day, seven days a week. The psychiatrist briefs a representative of the treatment regarding the
psychiatric status of each youth receiving psychiatric who is scheduled for treatment team
review. The psychiatrist’s evaluation and recommendations for the youth are incorporated into
the mental health clinical staff’s evaluations of the youth and the youth’s individualized mental
health or substance abuse treatment plan. The program does not utilize a psychiatric advanced
practice registered nurse (APRN). A review of sign-in/out logs confirmed visits during the annual
compliance review period were conducted as required by the contract or agreement. The
psychiatrist actively participates in, manages, and supervises psychotropic medication services
in the program. The program does provide tele-psychiatry services and the program utilized
these services during the annual compliance review period. Permission was granted by the
Office of Health Services (OHS) as was evidenced by e-mails in the youth’s Individual Health
Care Records (IHCRs). An interview with the psychiatrist confirms their role at the program is to
provide supportive psychotherapy and medication management services including evaluations,
and follow-up visits once a month for each youth on medication. They are on-site twice a month
and meet with the designated mental health clinical authority (DMHCA) each time they are at
the program. They meet with program staff during team meetings and prior to each evaluation of
a youth. Communication with staff is face-to-face while on-site and telephonic when off-site. An
interview with the DMHCA confirmed they met with the psychiatrist bi-weekly, and the
psychiatrist is available by phone for consultation between visits if needed.
Five youth Individual Healthcare Records (IHCRs) were reviewed for psychiatric services. Four
were applicable for being prescribed psychotropic medications. Of those four, two were
applicable for entering the program on psychotropic medications. It is the process of the
program for all youth to be referred for a psychiatric interview upon admission. All five youth
were referred for a psychiatric interview. For both youth admitted on psychotropic medications,
each youth received a diagnostic interview within fourteen days of admission, as required. One
other youth was placed on psychotropic medications the day of their admission to the program
after the initial diagnostic interview was completed. The other youth was placed on psychotropic
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medications after admission to the program after an initial diagnostic interview was completed.
For all four applicable youth reviewed, the Initial Diagnostic Psychiatric Interview included all the
required elements. The interview was completed on the Department’s Clinical Psychotropic
Progress Notes (CPPN) form in all four IHCRs and was clearly identified as the “Initial
Diagnostic Psychiatric Interview.” For all four youth, the initial psychiatric diagnostic interview
resulted in the prescription of psychotropic medications or changes to the youth’s existing
psychotropic medication regime and page three of the CPPN was completed in all four IHCRs
as required. The reviewed documentation supported the youth were seen for a medication
review by the psychiatrist, at a minimum, every thirty days in all four IHCRs reviewed. For each
youth, documentation on page three of the CPPN was completed when psychotropic medication
was prescribed/dispensed/administered by the psychiatrist, which included all required
elements. One IHCR was applicable for tele-psychiatry and the standard of psychiatric care
delivered was the same as rendered in-person and was only utilized as the youth agreed to
participate in the tele-psychiatry session and their parent/guardian provided consent.
4.18 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures ensuring any medical equipment classified as sharps,
as well as stock medications, shall be secured and inventoried utilizing a routine perpetual
inventory descending count as each sharp is utilized and disposed of or when the medication is
administered. The medical equipment classified as sharps (syringes, needles, scissors, and
suture removal kits) were secured and inventoried utilizing a routine perpetual inventory
descending count as each sharp was utilized and disposed, as required. All medications were
identified and secured in the locked area designated for storage of medications, and different
medications such as injectable, topicals, drops, liquids were separated. The medication cart was
clean and organized with stock items separate from youth-specific medications. All controlled
substances had a perpetual inventory and were stored separately from other medications. All
medications were stored in a separate, secured (locked) area, inaccessible to youth. Narcotics
and other controlled medications were stored behind two locks. Medications which require
refrigeration are stored in a secured refrigerator, which is used for medication only. The nurse
sends expired or discontinued medications to the pharmacy for destruction and disposal.
Perpetual and weekly inventories of all sharps and stock over-the-counter (OTC) medications
were completed as required. Pursuant to Board of Pharmacy regulatory requirements, there are
shift-to-shift inventory counts of all controlled substances documented on the youth’s
Individualized Controlled Medication Inventory Record when applicable. Five supervisory-level,
non-healthcare staff are trained in the delivery and oversight of medication self-administration,
which was delivered by the program’s registered nurse (RN). Counts were conducted of three
controlled medications, OTC medications, and three sharps, and all counts match the ending
inventory numbers. The reporting criteria and procedures regarding inventory discrepancies
includes completing a recount, reporting the discrepancy to the supervisor and program director,
and calling the Department’s Central Communications Center (CCC) to report the discrepancy.
An interview with the nurse confirmed the program utilizes a pharmacy consultant and maintains
a copy of the consultant’s Consultant Pharmacy License (CPH) on-site. The nurse confirmed
medication is disposed of with the pharmacy consultant as needed. The nurse also confirmed
controlled medications are kept away from youth in a locked drawer on the medication cart.
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4.19 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 procedure ensuring Infection Control procedures have been
implemented including prevention, containment, treatment, and reporting requirements related
to infectious diseases, as according to Occupational Safety and Health Administration (OSHA)
federal regulations and the Centers for Disease Control and Prevention (CDC) guidelines. The
facility operating procedures (FOPs) were signed by the program’s designated health authority
(DHA) on July 30, 2025, the program director (PD) on July 29, 2025, and the program’s
psychiatrist on August 1, 2025. The infection control procedures include all the required
elements. Hepatitis B immunizations are not available for staff; however, staff do have access to
protective equipment. There were no instances in which the local county health department,
CDC, and/or Department’s Central Communication Center (CCC) should have been notified of
an infectious disease. The PD/designee has established a separate file used for containing all
documents for youth and staff who have experienced a facility/occupational exposure.
The exposure control plan was written in accordance with OSHA standards and is available to
all staff. The plan was reviewed and signed annually by the administration of the program and/or
designees and was signed July 30, 2025. The program’s process for needle stick post-exposure
evaluation includes the nurse documenting the route of exposure and circumstances under
which the exposure occurred; identifying and documenting the source individual; collecting and
testing of exposed individuals for Hepatitis B and human immunodeficiency virus (HIV) with the
consent of the exposed individual; providing post-exposure prophylaxis when medically
indicated, following accepted guidelines; providing counseling; completing an evaluation of the
reported illness; and providing the following information to the individual who was exposed: a
copy of the OSHA standard, a description of the exposed individual’s duties as they relate to the
exposed incident, documentation of the route of exposure and circumstances under which it
occurred, results of the individual’s blood-testing, and all medical records relevant to the
individual’s treatment. The PD established a separate file maintained for youth and staff who
have experienced a facility/occupational exposure. There were not three or more cases of any
reportable infectious diseases which needed to be reported to the local county health
department and/or CDC during the review period. An interview with the PD confirmed the
exposure control and infection control plans are in the medical office and maintenance office.
Both plans are reviewed with all staff on an annual basis. An interview with the nurse confirmed
the exposure control plan is available to staff in the biomedical waste binder. The nurse
confirmed they provide infection control training and exposure control training to both the youth
and staff.
4.20 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 for maintaining 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 program's
behavior management system (BMS). The program defines active supervision as interacting
positively with youth, engaging in a full schedule of constructive activities, closely observing
behavior of youth and changes in behavior and consistently applying the behavior management
system, and being able to account for the whereabouts of youth under their supervision at all
times. The program’s staff to youth ratio is one to eight during daytime activities and one to
twelve during the evening and sleeping hours. Observations of youth supervision were made
during the annual compliance week and included education, recreation, meals, breaks, dorm
cleaning, and line movements. Positive interactions were observed throughout the week without
exception. An interview with three direct care staff revealed each were immediately aware of the
number of youth they were supervising. Schedules and staffing plans reflect the program
provided appropriate levels of physical sight and sound presence of staff in compliance with the
minimum one to eight ratio outlined in the contract. The daily schedule is posted on the youth
dorm and in several youth common areas, so it is accessible to all youth. According to the
schedule, the youth are engaged in a full schedule of activities and are not just sitting around
idly. Documentation reflects youth are supervised while in their sleeping rooms and youth room
windows are not obstructed by any objects preventing staff from a direct line of sight of youth.
There were no escapes or attempted escapes during the annual compliance period.
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 written policy and procedures detailing the collaborative behavior
management system (BMS). The BMS includes promoting safety, respect, and fairness,
protecting youth rights, positive and negative consequences, constructive, non-punitive
disciplinary actions, opportunities for positive reinforcement, and recognition of
accomplishments and positive behaviors at a four-to-one ratio. The BMS also includes
promoting socially acceptable means for youth to meet their needs, a process for explaining to
youth the reasons for any sanctions imposed, youth having the opportunity to explain his
behavior, opportunities for staff and youth to discuss the impact of behavior on others,
reasonable reparations for harm caused to others, discussions of alternate behaviors, and
promoting dialogue and peaceful conflict resolution. The BMS does not include an increased
length of stay, group discipline, punishment of youth by other youth, or disciplinary confinement.
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The BMS is conspicuously posted and provided in the student handbook allowing easy access
for youth, including rules governing conduct and positive and negative consequences for
behavior. It is documented the appropriate parties are involved in the development,
implementation, and on-going maintenance of the BMS. The policy includes a protocol where
staff are provided feedback regarding the implementation of the BMS. There is a joint
agreement between the school and the program in regard to the BMS in the classroom. The
program director is responsible for training the education staff in the jointly combined BMS plan
during education hours. Five youth case management records were reviewed to confirm youth
orientation included a review of the program’s BMS. Five position descriptions were reviewed
for staff whose job functions includes implementation of the program’s BMS, and each
description included the required elements. Five reviewed pre-service staff records reflect new
staff completed training in the program’s BMS. Postings of the program’s BMS were observed
throughout the program in several common areas, including the dorm, cafeteria, hallways and
education and included which included the rules governing conduct and positive and negative
consequences.
Staff and youth interactions were observed during the annual compliance week for adherence to
the above elements of the BMS, including rewards and negative consequences. Observed
interactions were positive and followed the program’s BMS. The program’s BMS includes a
process wherein staff explain to the youth the reason for any sanction imposed, the youth is
given an opportunity to explain his behavior, staff and the youth discuss the behavior’s impact
on others and reasonable reparations for harm caused to others, and then discuss alternatively
acceptable behaviors. The program provides a variety of rewards and incentives to include food
or candy items from the points store, staying up late, special activities, and meals from local
fast-food restaurants.
Five staff were interviewed and all five were very familiar with the behavior management system
used at the program. Each understood the level expectations, timeframes, and point system.
The five staff reported youth rewards include incentives for meeting goals, food or candy items
from the points store, staying up late, activities or special meals from local fast food restaurants.
All five staff confirmed basic rights cannot be taken away from youth as a consequence. The
interviewed staff explained youth are informed of the consequences and are they able to explain
their behavior in special treatment team meetings, conducted by the youth’s regular treatment
team. All five interviewed youth were exceptionally familiar with the level and point system used
at the program. Each youth was able to explain, in detail, each level’s expectations and how to
progress in the behavior management system. All five stated youth are never allowed to punish
other youth. The interviewed program director confirmed the program utilizes the Measurable
Achievement Plan (MAP) as their BMS, which is an incentive based system consisting of five
levels. The recreational therapist monitors rewards to endure consistency and tracks all
consequences daily.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, and contract state the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; 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 requiring staff to observe youth at least every ten
minutes while the youth are in their rooms, either during sleep time or at any other times, such
as during an illness. The program has fifty-eight cameras, confirmed by the interviewed program
director, and all fifty-eight were working at the time of the annual compliance review. The
program’s video recording system maintains thirty days of recordings. A sample of security
tapes and corresponding logs was reviewed to verify ten-minute checks. The sample included
nine samples of thirty-minute increments, at different times of the evening, covering both shifts.
The review confirmed checks were being conducted within the required ten-minute time frames.
As practice, the program conducts these checks every eight minutes. A comparison of the
checks viewed on video with the hard copy check sheet revealed the checks were documented
in real time. Staff who completed the checks initialed the check sheet. All checks were met with
fidelity, and staff ensured to observe each youth while conducting these checks. A review for the
annual compliance review period was conducted by reviewing ten-minute check sheets for one
day each month on each shift. This review verified all checks were being conducted as required.
Five interviewed staff reported checks are completed every eight minutes when youth are in
their rooms for sleeping or non-punishment reasons.
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 to ensure youth are always accounted for through a
system of physically counting youth at various times throughout the day. The program is
required to conduct and document youth counts at the beginning of each shift, after each
outdoor activity, and during emergency situations such as escapes or riots. The program must
maintain a chronological record of events as they occur. If an event disrupts the safety and
security of the program, the chronological record of events must be updated as soon as it is
feasible after order has been restored. The program tracks daily census information including
the total daily census count, new admissions, releases or direct discharges, transfers, and youth
temporarily away from the program. The program's Continuity of Operations Plan (COOP)
requires staff to always account for the whereabouts of youth. This includes the need for
continual headcounts to be conducted minimally at the beginning of each shift, during any
emergency, and at regular intervals. Headcounts of youth shall be conducted before and after
each use of vehicles and before and after group movements. Formal counts were observed
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during the annual compliance review week and were completed as required, with all movement
stopping and the census matching to the counts called into master control. A review was
conducted of randomly selected dates each month from the time of the last annual compliance
review, with one full day being reviewed each month. Staff documented counts at the beginning
of each shift, after each outdoor activity, during emergency situations, the total daily census
counts, formal head counts, youth movement, new admissions, and releases or discharges.
There were no transfers conducted during the annual compliance review period. The logbooks
also have a section where hourly counts are documented. Five interviewed staff stated census
counts are conducted every thirty minutes by master control, with some informal counts
conducted throughout the day. If the count cannot be reconciled, all five staff report all youth are
recalled to their rooms, the staff conducts a physical count of each youth, and a search will
begin with available staff if a youth cannot be located. All five staff responded emergency
checks are conducted after emergencies and drills.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, and ensures direct-care staff, including each supervisor,
are briefed when coming on-duty. A sample of a full day from each month during the annual
compliance period was reviewed. All of the logbooks were bound with numbered pages and all
entries were made in ink with no erasures or white-out areas. No entries were destroyed or
removed and no errors with a strikethrough were observed. All entries included the dates and
times of the events, with the names of the staff and youth involved, brief descriptions of the
events, and the names and signatures of the staff making the entries. The logbook contained
documentation of internal incidents reported to the Florida Abuse Hotline and/or the
Department’s Central Communications Center (CCC). The activity schedule and logbook
documented there is minimal interference of educational instruction and education classes were
conducted, as scheduled. Logbooks confirmed youth arrived and departed school on time. The
logbook also indicated recreation was conducted as scheduled, and program’s reviewed shift
reports summarize the events, incidents, and activities documented in the program’s central
logbook. The incoming staff sign and date the logbook to document they have reviewed the
contents for the previous two shifts.
The program documents the following events, incidents, and activities in a central logbook,
which is maintained in master control: emergency situations, incidents, special instructions for
supervision and monitoring of youth, population counts at the beginning and end of each shift,
and any other population counts conducted during a shift, perimeter and other security checks
conducted, transports away from the facility, and admissions and releases with details.
Requests by law enforcement to access youth, removal of any youth from the mainstream
population, and information relating to escapes or attempted escape incidents are also required
to be entered, however none were observed in program logbooks because they did not occur.
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5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures which outline the key control process. The process
governs the control and use of keys, to include key assignment and usage, restrictions on
usage, inventory and tracking of keys, and secure storage of keys not in use. The procedures
also address missing or lost keys and reporting and replacement of damaged keys. A
distribution of keys was not observed during the annual compliance review week due to the
times the program has shift change. A key inventory was conducted with no discrepancies
found. Three informal interviews found each staff new the number of keys on their key ring and
the function of each. Keys are stored in a locked cabinet, which is in the master control room,
and this is also secured and inaccessible to youth. Permanent issued keys are kept to a
minimum and must be authorized in writing by the program director (PD). The PD, maintenance,
human resources, and the clinical director are the only staff with permanent keys. The program
has a broken key report which is to be completed whenever a key is broken. This report, along
with the broken key, are forwarded to the maintenance staff, who is responsible for replacing the
broken key. Since the last annual compliance review, the program did not have any incidents
reported to the Department’s Central Communications Center (CCC) regarding keys. An
informal interview was conducted with the master control operator (MCO). The MCO reported
keys for areas such as medical, youth and staff records, and youth property lockers are
restricted to staff working those areas. The program reconciles and track keys by ensuring keys
are checked out of the locked box in master control. When staff are checking out keys, they turn
in their personal keys and check out the key ring they are using for the day. This is documented
on the Key Control Log. Five staff were interviewed. Each of the five staff reported their
personal keys are securely stored in master control upon entry and they are given assigned
program keys. All five staff mentioned there is a daily tracking log, an inventory for keys and
youth should not have access to keys. Three of the five staff understood the process for
reporting damaged or missing keys.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include 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
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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 requiring them to address illegal contraband and
prohibited items. The policy defines and list items and materials considered contraband. The
program’s policy and procedures address any staff who is found in possession of contraband in
the program will be subject to disciplinary action up to and including dismissal as outlined in
Florida Administrative Code. Law enforcement is contacted in the event any item found which
would be considered illegal as defined in Florida Statutes. The program’s policy and procedures
clearly delineate items which are considered contraband. Contraband lists are given to youth,
staff, and visitors through handbooks, the orientation process, and visitor log which contacting
the required attestation statement. The procedures also advise staff who are found in
possession of contraband in a program will be subject to disciplinary action and, if applicable,
notification to law enforcement. The program ensures this is accomplished by searching the
physical plant, facility grounds, youth, visitors, staff, and incoming and outgoing mail. Six new
hire staff records were reviewed, and all contained completed attestation forms. The program
conducts random room searches daily and provided logbooks, incident reports, and search
reports which verified the frequency of searches and confirmed the confiscation of contraband
and its disposition. This documentation was maintained in the youth case record, as applicable.
There were no instances of illegal contraband which was required to be turned over to law
enforcement or reported to the Department’s Central Communications Center (CCC) during the
annual compliance review period. The program director (PD) was interviewed and advised all
contraband items are delivered to the shift supervisor for proper locked storage or elimination.
Visitors in possession of contraband will be asked to lock items in their vehicle or leave the
facility. The PD confirmed illegal contraband will be confiscated and held until law enforcement
arrives at the scene, at which time it will be turned over to law enforcement. Five interviewed
staff reported the staff search youth rooms twice weekly and log the findings.
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 which require staff to conduct searches to ensure no
contraband is being introduced into the facility. During the annual compliance review week,
youth were observed being searched before and after movement. An observation of a youth
transport and youth cleaning the day room was also completed. In each observation, searches
were conducted in accordance with policy and Right Interaction training manual, and youth were
treated with dignity and respect to minimize stress and embarrassment. These searches were
conducted by the appropriate number of staff and gender, and all searches were thorough, with
appropriate instructions given to youth. There were no visitation or off-campus trips during the
annual compliance review week; therefore, observations of searches during these events were
not made. A video review of five separate days was conducted, which showed ten staff and
fourteen visitors being searched when entering the facility. All observed searches were
conducted as required. Five interviewed staff report youth searches are conducted prior to all
movements. Five interviewed youth stated they are searched prior to any movements.
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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 which ensure all vehicles used to transport youth are
properly maintained and all maintenance is documented. The program acquired two new
vehicles for transport. During the annual compliance review week, an inspection revealed the
vehicles contained all required safety equipment. During the annual compliance review week,
five random staff vehicles were checked in the parking lot. All five vehicles were found locked
and secure.
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 which ensure the appropriate minimum staff-to-youth
ratio is maintained, while youth are transported off facility grounds to ensure safety and security
is maintained for youth, staff, and the public. One medical transport was observed during the
annual compliance review, in which staff properly searched the vehicle and secured the youth
with the seatbelt. A ratio of one to five was met with one staff member and a driver. All
emergency equipment was present in the vehicle, including a cell phone and radio. The
program’s human resource department reported reviewing monthly driving records of all staff
from the Department of Highway Safety and Motor Vehicles to ensure all staff have a current
driving license and no violations have been reported. Four of the five interviewed staff report
youth are secured with seatbelts within the vehicle. The remaining staff had never conducted a
transport. All five interviewed staff stated there is a transportation phone given to staff prior to
transporting youth. Each of the five staff explained transporters bring a “tackle box” containing a
first aid kit, window punch, seatbelt cutter, knife for life and a fire extinguisher. All five staff
reported transport vehicles are searched before and after each use and youth are not allowed to
be transported in personal vehicles. All five staff relayed in case of an emergency on a
transport, they would notify the facility and contact law enforcement and/or emergency services,
if needed. Five of five staff were aware of the youth-to-staff ratio requirements for transports.
Five youth were interviewed. None of the youth had been on a transport since being committed
to the program and none of the five youth stated they have been handcuffed to a transport
vehicle or witnessed anyone placing contraband in a transport vehicle.
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 to secure and maintain a safe physical plant, its
grounds, and perimeter. The program director (PD) is responsible for ensuring the weekly safety
and security audits are completed, as required, and will develop and implement any corrective
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action. An internal system has been developed to verify and correct all deficiencies, to which
none have been reported from the time of the last annual compliance review. The PD was
interviewed and advised the shift supervisor completes daily perimeter checks and walk-
throughs to identify any deficiencies to the physical plant and reports such to the physical plant
manager and PD. Any deficiencies identified would result in a work order to be generated to
address the deficiencies.
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 regarding tool management which ensure youth do
not use tools as weapons or to breach security. The program has an inventory system which
ensures all tools are inventoried and any tool issued for work are monitored and controlled for
safety and security. All sharp-edged tools are inventoried daily and all machetes, bowie knives,
and long bladed knives are prohibited. In the event of a missing tool, staff shall immediately
notify the program director and maintenance supervisor and an investigation would ensue to
locate any missing items. A tool tag is placed on the shadow board until the tool is recovered.
Ten tools were inventoried, and all were accurate in count, secure, and easily identified.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures to ensure youth use tools safely and are
appropriately supervised. The procedures include the supervision requirements when youth use
tools, the issuance of tools to youth and staff, including an assessment to determine the risk of a
youth to self or others if they are issued tools, ratios, tool distribution and collection, and search
criteria during work projects. Three youth were observed during the week of the annual
compliance review with cleaning tools cleaning the day room of the unit. One staff was observed
supervising the youth and confirming the completion of chores, which is an appropriate youth-to-
staff ratio. Youth are searched after each work period. Five youth case management records
were reviewed, and all contained documentation which confirmed youth were trained on the
intended and safe use of tools. All five youth also had a risk assessment in their records, which
were completed prior to the use of tool. Five out of five interviewed staff reported youth are only
allowed to use scrub brushes, mops, and brooms. Five out of five youth reported they are
allowed to use scrub brushes, mops, and brooms.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures with guidelines for outside contractors, which include
information regarding tool control and restrictions. Maintenance staff are assigned to an outside
contractor while at the program and are responsible to account for all tools used before and
after the work is completed. While contractors are on-site, youth are not permitted to be present
in the work area. All sign-in sheets and instruction sheets for outside contractors were reviewed
from the time of the last annual compliance review, and all were properly completed. The
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guidelines for repairment and external worker tools include checking the tools upon arrival and
departure, tool restrictions while in the facility, restricting youth from the work area, and follow-
up procedures for any missing tool. Three project invoices were reviewed. A complete inventory
of all tools were checked upon arrival and departure of each contractor. The program also
provided policies to the vendor regarding prohibited personal cellular telephones and electronic
equipment capable of taking pictures and taking audio recordings, including smart watches.
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 which require they conduct fire, safety, and
evacuation drills to ensure youth and staff are prepared for immediate implementation or
mobilization in the event of an emergency or disaster. The program’s Continuity of Operations
Plan (COOP) addresses fire, safety, and evacuation emergency processes and drills, as well as
the frequency of conducting drills. Fire drills are to be conducted monthly on each shift and
COOP drills are required to be conducted quarterly. A review of the program’s drill log confirmed
all fire drills and COOP drills were conducted, as required. Documentation for all drills contained
the type of drill, date and time, participants, brief scenario, and findings and recommendations.
During the tour the week of the annual compliance review, fire evacuation routes and egress
plans were observed throughout the facility. The program has seventeen fire extinguishers
which were last inspected in March 2025. Five interviewed staff recounted having participated in
fire, medical, and escape drills in the last twelve months. Four of the five staff reported being
involved evacuation drills and three of the five in youth disturbance (code blue) drills. Five youth
were interviewed. All five interviewed youth stated they have been instructed on what to do in
case of a fire, and each report they have participated in fire drills at least monthly. The program
director was interviewed and confirmed the various drills conducted at the program as well as
the frequency in which they are conducted.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program has a policy and procedures requiring they maintain a coordinated disaster plan
and a Department approved Continuity of Operations Plan (COOP). The plan provides for the
basic care and custody of youth in the event of an emergency or disaster, while ensuring the
safety of staff, youth, and the public. Copies of the program’s COOP are maintained in the
master control room, the administration area, the case management area, and the program
director’s (PD) office. The plan is available for all staff to review, as needed. The program’s
coordinated disaster plan and COOP are a combined plan and address alternate relocation
sites which reviewed and updated on February 24, 2025, and submitted to the Department’s
regional director for approval on March 5, 2025. The program maintains equipment and supplies
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for continuous operation and services during an emergency in the kitchen, master control,
storage closet, maintenance, and in outdoor storage unit. Supplies include water, flashlights,
bedding, batteries, tape, clothing, and hygiene items. Emergency food supplies are kept off-site
at the program’s sister location. In the event of an evacuation, youth records are sent to the
temporary location with youth. The PD was interviewed and confirmed the COOP is available for
staff in master control, administration, PD’s office, and case management. The program
maintains an administrative hard-copy file containing youth information, in the event of an
evacuation. These records include youth name, Department identification number (DJJID),
admission date, date of birth, gender, race, contact information, emergency contact, juvenile
probation officer (JPO), committing judge, victim information, physical description, health status,
and a photograph. A review of five youth records in the file confirmed all required documentation
was available if needed.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures which require the program director (PD) or designee
to maintain strict control of flammable, poisonous, and toxic items and materials and a complete
inventory of all such items. The maintenance personnel, or other trained staff who have the
safety equipment for diluting, handling, and disposing of hazardous and/or solid waste, shall be
responsible for disposing of hazardous items and toxic materials. The program’s policy states all
flammable, poisonous, and toxic materials and any substances labeled "keep out of reach of
children" or "harmful if swallowed" shall be kept under strict control, stored in a secure area
inaccessible to youth, and an accurate inventory must be always maintained. During the annual
compliance review, all flammable, poisonous, and toxic items were found secured in the
maintenance shop, which is inaccessible to youth. Maintenance staff is the only authorized
position to handle these items. Maintenance staff are responsible for disposal of flammable,
toxic, caustic, and poisonous items in accordance with local, state, and federal requirements. A
review of the program’s disposal log and an informal interview with maintenance staff revealed
there have been no items disposed of since the time of the last annual compliance review. The
program does not have a fully functioning kitchen; therefore, does not have a need to dispose of
kitchen grease and waste. The program has not had a chemical spill from the time of the last
annual compliance review. An inventory was conducted of the six different chemicals the
program uses. All the inventories matched the actual count of what was on hand. All of the
items were secured, and all contained Safety Data Sheets (SDS). The program director
reported in an interview all chemicals needing disposal must be reported to the maintenance
manager, at which time he will store the chemicals in a safe place and contact appropriate
vendor to dispose.
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
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program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures which prohibit youth from using, handling, or
accessing dangerous or hazardous chemicals or responding to chemical spills. The procedures
state all flammable, poisonous, and toxic materials, and any substances labeled "keep out of
reach of children" or "harmful if swallowed" shall be kept under strict control, stored in a secure
area inaccessible to youth. During the tour and throughout the annual compliance review week,
observations were made which confirmed all flammable, poisonous, and toxic items and
materials were kept secured and inaccessible to youth. Youth did not handle, use, or clean-up
dangerous, hazardous chemicals, bio-hazardous materials, or human waste. Youth were
observed cleaning, using a broom, dustpan, dust mop, and mop. Staff were supervising each
youth, and at no time were youth allowed to handle chemicals. Five youth were interviewed, and
all said they do not handle any cleaning products or chemicals.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
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5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures which allow for youth to have visitation and
communication with family members while in the program. During orientation, youth are
informed of visitation and communication processes. The program encourages visitation from
parents/guardians, and they send a welcome letter upon admission of each youth, which
outlines the days and time of visitation, who is allowed to visit, and the rules of visitation. The
visitation schedule is posted at the main entrance of the facility and in the youth dormitory. The
program offers visitation on Sundays from 2:00 p.m. through 5:00 p.m. Family days are held
quarterly, on designated days, from 11:00 a.m. through 2:00 p.m. Holiday visitation is also
provided and scheduled depending on which day of the week a particular holiday occurs. A list
of authorized visitors and correspondence is maintained in each youth’s case management
record and updated as needed. Intake calls are made within twenty-four hours of arrival. Each
youth is permitted to successfully make one call each week. Calls are allowed for approximately
fifteen minutes and are scheduled by the shift supervisor or designee. Youth may correspond
with individuals on an approved correspondence list. They are also provided an opportunity to
correspond with attorneys, case managers, clergy, and other officials. Youth are encouraged to
correspond with parents/guardians at least once a week. Five youth case management records
were reviewed, and each record contained an approved correspondence, visitation, and
telephone log. It was documented all outgoing mail is searched. An informal interview with case
management the program has a policy for youth with a history of human trafficking to request
clarification information from the juvenile probation officer. Five youth were interviewed
regarding corresponding with their family, and all said they were able to call or send a letter to a
parent/guardian. The program director was interviewed and advised the program has an
agreement with a third party service for translations.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a policy and procedures requiring they provide a variety of recreation and
leisure activities. A review of the program’s activity schedule confirmed the program holds
supervised and structured indoor and outdoor recreation and leisure activities for youth for at
least one hour daily, which included large muscle activities. A review of the logbook confirmed
youth were receiving recreation and leisure activities in accordance with the daily activity
schedule. Activities promoted social and cognitive skill development, creativity, teamwork,
healthy competition, mental stimulation, and physical fitness. During the week of the annual
compliance review, the review team observed youth engaged in physical activities, and the
program was taking precautionary measures to ensure youth did not overexert themselves and
did not suffer from heat stress or dehydration. The program has a recreation therapist, and a
review of the recreation therapist’s credentials revealed all position requirements were met. Five
youth records were reviewed, and all contained recreational therapy in their Individualized
Treatment Plan. Five youth were interviewed, and all said they have at least one hour of
recreation daily. Five interviewed staff stated youth are given an hour or more of recreation time
every day. The staff communicated youth participate in structured activities such as three mile
runs, calisthenics, football, and basketball, or free time activities such as capture the flag,
kickball, weightlifting, or board and video games.
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5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 61 (Revised August 2025)

source: DJJ

program_name_raw: Daytona Juvenile Residential Facility

rule: Indicator 2.18