summary: QI Residential - FY24-25 - 1 finding

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Britt Technical Youth Academy
Wayne Halfway House, Inc.
(Contract Provider )
3001 26th Avenue North
Saint Petersburg, Florida 33712
Review Date(s): February 25-28, 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:
Amanda Nelson, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Jillian Cumbo, Office of Education, Workforce Education Coordinator (Standard 6)
Cheryl Francis, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Evan Hald, Office of Education, Federal Grants Manager and Southwest Education Coordinator
(Standard 6)
Tamara Mahl-Adkins, Office of Accountability and Program Support, Regional Monitor
(Standard 4)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Interviews)
Demarcus Richardson, Office of Accountability and Program Support, DJJ Operations
Coordinator, (Standard 5)
Luis Rodriguez, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Sandra Thompson, Office of Accountability and Program Support, Regional Monitor (Standard
1)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Britt Technical Youth Academy Contract Number: 10845
Provider Name: Wayne Halfway House, Inc. Number of Beds: 24
Location: Pinellas County / Circuit 6 Lead Reviewer Code: 177
Review Date(s): February 25-28, 2025
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, (5) Safety and Security, and (6) Educational
Services which are included in the Residential Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
1.15 Advisory Board
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 66 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Non-Applicable
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Limited
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 66 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 66 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Non-Applicable
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 66 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 66 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 66 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Satisfactory
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Non-Applicable
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Non-Applicable
6.08 Florida Youth College (Post-Secondary Contract) Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 66 (Revised September 2022)
Program Overview
The Britt Technical Youth Academy is a twenty-four bed program, for sixteen to twenty-one year
old males, located in Saint Petersburg, Florida. The program is operated by Wayne Halfway
House, Inc., through a contract with the Department. The program provides the following
services: Mental Health Overlay Services and Substance Abuse Treatment Overlay Services. In
addition, the program fosters each youth by providing Moral Reconation Therapy, Impact of
Crime, Dialectical Behavioral Therapy, Living in Balance, and Process Group. Additional
treatment services provided include family and individual therapy, therapy groups, and
recreational therapy. Program administration is comprised of a facility administrator, human
resources, clinical director, and a health services manager. Case management services are
provided by one case manager and two career and technical education intake coordinators.
Mental health staff at the program includes one licensed clinical director, two unlicensed
therapists, and one contracted psychiatrist. Medical services are offered 7:00 a.m. to 6:00 p.m.
daily and are provided by a health services administrator who is a registered nurse (RN), one
additional full-time RN, three part-time RNs, and one contracted medical doctor. Educational
services are provided by Florida Scholars Academy, Florida Youth College, and Pinellas
Technical College. Youth who have received their diploma or general equivalency diploma have
the opportunity to attend classes at Pinellas Technical College. The layout of the program
includes: one large building which houses administration, classrooms, case management, a
medical clinic, dormitory rooms, a cafeteria, and a day room. The program also has two outside
portables which can be used for classes. The program has forty-six operating security cameras
providing coverage, and all were operational. At the time of the annual compliance review, the
program had four vacant positions: two youth security officers, one shift supervisor, and one
recreation therapist.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 66 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures addressing pre-employment background screenings.
The program also has a policy and procedures for volunteers, mentors, and interns who work
with youth less than ten hours a month requiring sight and sound supervision. The program’s
policy requires a staff, who is background screened, to always be in the presence of and within
the line of sight of the volunteer who is not background screened. A review of the program’s
staff, volunteers, and contractor rosters found thirty staff were applicable for an initial
background screening during the annual compliance review period. Each of the thirty applicable
staff had a completed and eligible background screening, as required, prior to contact with youth
and confidential youth records. Reviewed documentation validated a criminal history report was
reviewed for each staff. A pre-employment assessment tool was administered for each direct
care staff and a pre-employment assessment passing score was documented in each reviewed
direct care staff record. Twenty-five of the thirty staff were added to the program’s roster in the
Agency for Healthcare Administration’s Clearinghouse system, as required. The remaining five
staff and both volunteers were added to the program’s roster after the program received
notification of the annual compliance review. Two of the thirty staff had a break in service as
indicated in the Department’s Staff Verification System (SVS) and both had a new background
screening completed. An Annual Affidavit of Compliance with Level 2 Screening Standards was
completed and submitted to the Department’s Background Screening Unit (BSU) on December
19, 2024, meeting the annual requirement. Teachers who are paid by the school board, or
funding provided by the school board or Department of Education, receive an annual screening,
which was completed on January 28, 2025.
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/renewal for staff. There was one staff member applicable for a five-year
rescreening/renewal during the annual compliance review period. The five-year
rescreening/renewal was completed prior to the Clearinghouse prints expiration date. The
program submitted the rescreening/renewal at least ten business days prior to the retained
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 66 (Revised September 2022)
print’s expiration date. There were no volunteers or contracted staff who were applicable for
requiring a five-year rescreening/renewal.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to ensure program-related incidents, which place at-
risk or have the potential to place at-risk, the health, safety, or welfare of the public or of youth,
staff, visitors, the security of the facility, or the reputation of the provider are reported and
handled appropriately and in a timely fashion. The program has a zero-tolerance policy
regarding any abuse. All staff shall immediately report any knowledge or suspicion regarding an
incident of abuse which occurred in the program by calling the Florida Child Abuse Hotline, and
additionally notification is made to the Department’s Central Communications Center (CCC) and
the program’s facility administrator or supervisor on duty as soon as possible. The program had
no incident reports of a claim against staff for physical, psychological, or emotional abuse during
the annual compliance review period. The program has not yet conducted the Trauma
Response and Caring Environment (TRACE) due to the program not being open in Spring 2024;
however, the TRACE is scheduled to be completed March 2025. Staff adhere to a code of
conduct, as acknowledged by the review and signing of a code of conduct form during their
orientation and is maintained in the staff personnel records. Five staff code of conduct forms
were reviewed, and all were signed by staff during orientation. During the facility tour the week
of the annual compliance review, the Florida Abuse Hotline and CCC telephone numbers were
observed to be posted throughout the facility. Five youth were interviewed and all reported they
feel safe in the program. Each youth reported they have never been prevented from making a
call to the Florida Abuse Hotline or the CCC since they have been at this program. All five youth
reported knowing the telephone number for the Florida Abuse Hotline and the number is posted
throughout the program. All five youth reported staff are respectful when talking with youth. Four
of the youth indicated they have never heard staff use curse words when speaking to youth. The
remaining youth stated he has heard a staff use a curse word occasionally. The youth stated the
profanity was used in conversation and not directed at any youth. None of the five youth have
ever exchanged emails, telephone numbers, or social media contact information with staff. Five
staff were interviewed and each were familiar with and able to articulate the program’s abuse
reporting procedures. All five staff reported they have never observed a coworker denying a
youth the right to report abuse to the Florida Abuse Hotline, and all reported they have not
witnessed their coworker’s using profanity while speaking with youth. An interview with the
facility administrator confirmed the program’s code of conduct.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 66 (Revised September 2022)
1.04 Management Response to Allegations (Critical) Non-Applicable
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had no incidents of physical, psychological, or emotional abuse during the annual
compliance review period; therefore, this indicator is rated non-applicable.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a policy and procedures addressing the process for contacting the
Department’s Central Communications Center (CCC). The program reported eighteen incidents
to the CCC during the annual compliance review period. A review of five reportable CCC
incidents revealed all five incidents were reported to the CCC within the required two hour time
frame, and each incident was documented in the center’s logbook. There were no additional
internal incidents or grievances during the annual compliance review period which should have
been reported to the CCC and were not. The program did not have an annual compliance
review last year; therefore, the program was not applicable for experiencing an increase of
reportable incidents to the CCC since the last annual compliance review.
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program has a policy and procedures requiring Right Interactions (RI) as the Department
approved Protective Action Response (PAR) curriculum. A RI Incident Report will be completed
and filed in accordance with the Florida Administrative Code any time staff uses a physical
intervention technique, such as countermoves, control techniques, takedowns, or application of
mechanical restraints (other than for regular transports). The program had one RI incident
during the annual compliance review period. A review of the RI incident confirmed the report
was completed by the end of the staff’s workday and included statements from all staff involved;
however, two staff forgot to write the date next to their signature on their statements. The
incident did not require the use of mechanical restraints, result in injury to the youth or staff, nor
did the youth allege abuse. The RI Report was reviewed by a supervisor, a RI instructor, and
the facility administrator within seventy-two hours of the incident. The post-RI interview did not
indicate the need for a RI medical review. Monthly summaries of all RI incidents were submitted
to the Department’s regional office by the fifteenth of each month and are maintained by the
program during the annual compliance review period. The program last updated their RI plan on
September 25, 2024, and the Department approved the plan on October 3, 2024. The program
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Office of Accountability and Program Support Page 13 of 66 (Revised September 2022)
has not previously had an annual compliance review; therefore, program is not applicable for RI
incidents during the previous annual compliance review. The program’s RI rate during the
annual compliance review period was 0, which is below the statewide Residential RI rate of
1.71. The facility administrator was interviewed and confirmed the program’s practice. Five staff
were interviewed and all five were able to articulate the program’s RI process; however, each
staff indicated they had not personally utilized RI at the program.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has a policy and procedures outlining the pre-service training and certification
requirements for all new staff. Youth security officers and career and technical staff are
considered direct care staff and are counted in the staff-to-youth ratio. Documentation confirmed
all instructors are qualified to deliver training provided. Program submitted a pre-service training
plan which was approved by the facility administrator, the Department’s regional residential
director, the Department’s assistant secretary of residential services, and the director of the
Department’s Office of Talent, Leadership, and Culture. Five staff training records were
reviewed for pre-service certification requirements. All five staff completed all required essential
skills training prior to contact with any youth. One staff was a rehire who completed all required
trainings. The remaining four staff have not completed all required trainings as they are still
within their first 180 days of hire; however, they are on pace to complete all their training as
required within the 180 day time frame. All five staff completed trainings as required by other
Rules or manuals. None of the five staff have yet completed specialized training on stress
management, adolescent healthcare, positive reinforcement techniques and strategies, or risk
factors and triggers relating to youth with a history of victimization. The program only had one
staff member who was applicable for supervisory training, all sixteen hours of required
supervisor training in the required topics was completed. There was one training for one staff
member which was not documented in the Department’s Learning Management System
(SkillPro), all other staff trainings for all five reviewed staff was documented in SkillPro.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a policy and procedures outlining the in-service training requirements for staff.
There were no staff applicable for in-service training due to all staff being new hires during the
annual compliance review period. The program maintains an annual in-service training calendar
which is updated as changes occur. The program submitted an in-service training plan to the
Department’s Office of Talent, Leadership, and Culture and the training plan was approved and
signed by the director of the Department’s Office of Talent, Leadership and Culture, the
Department’s assistant secretary of residential services, the Department’s regional residential
director, and the facility administrator.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 66 (Revised September 2022)
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures which includes training requirements for the
grievance process, as well as the informal, formal, and appeal phase. Youth are encouraged to
resolve issues and complaints through informal communication with program staff utilizing a
Request to Talk form. This form is placed in the grievance box and reviewed by the facility
administrator. The program maintained a grievance binder which contained all grievances for
each month of the annual compliance review period. There were six formal grievances
submitted during the annual compliance review period. A review of five formal grievances was
conducted and each was resolved within one day of youth submitting a grievance and none
reviewed were applicable for requiring an appeal. Five youth were interviewed and all indicated
they knew where to find a grievance form and each knew what to do with the form upon
completion. All five stated they could ask for assistance in completing a grievance form. Five
staff were interviewed and all were able to accurately describe the grievance review process,
indicated grievance forms are placed throughout the program, and the process had three
phases. All five indicated the facility administrator reviews the grievances. One indicated the
supervisor can also review grievances. All five stated youth can request assistance in
completing the grievance forms. An interview with the facility administrator confirmed the
program’s grievance practice.
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures ensuring the program provides instruction to youth
focusing on developing life and social skill competencies. The interventions include Dialectical
Behavior Therapy and Process group. Non-clinical staff/direct care staff model pro-social
behaviors through daily interactions with youth to help youth function responsibly and
successfully in everyday life situations. The services address communication, interpersonal
relationships and interactions, non-violent conflict resolution, anger management, and critical
thinking skills, including problem-solving and decision making. The health education record of
five youth confirmed the program incorporates additional life skills interventions to include dental
hygiene, nutrition basics, personal hygiene, and physical fitness, provided by medical staff. In
addition to the life skills intervention services, the program works with each youth to create a
portfolio to include a resume, cover letter, practice job applications, and determine career
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 66 (Revised September 2022)
choices, finances, and budgeting. Five youth were interviewed and each confirmed they
participate in groups and complete workbooks relating to life and social skills. All five youth
confirmed they role play the skills they learn in their groups. An interview with the facility
administrator confirmed youth receive skills to address their identified needs; however, the
program does not provide a gender-specific group to youth. An interview with the designated
mental health clinician authority confirmed youth are offered daily opportunities to utilize the
skills they learn in their groups.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program has a policy and procedures ensuring the provision of activities and instruction
intended to increase youth awareness and empathy for crime victims/survivors and to increase
personal accountability for youth’s criminal actions and harm to others. The program provides
restorative justice awareness to youth through Impact of Crime (IOC). The program also has
youth participate in community service projects and had a victim impact speaker speak at the
program to provide additional restorative justice activities to youth. The annual compliance
review team was unable to observe restorative justice awareness activities or groups during the
annual compliance review week. An interview with the facility administrator confirmed the
program’s restorative justice group is IOC and youth also participate in community service
projects such as helping with hurricane recovery efforts. Five youth were interviewed and all
confirmed they participate in IOC.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures to determine how new alerts are identified,
documented, updated, and communicated to staff. Any staff can identify and place a youth on
alert status; however, only medical, mental health, and facility administrator/designee can
update or close medical, mental health, and safety and security alerts. All alerts will be entered
and updated in the Department’s Juvenile Justice Information System (JJIS). Suicide alerts will
be updated or closed by the mental health clinical staff or a licensed mental health professional.
Medical alerts will be updated or closed by medical staff. Safety and security alerts are updated
or closed by the facility administrator or designee. The program maintains an internal alert board
in the staff break room and an internal alert binder in master control and alerts are reviewed
daily. Five youth records were reviewed to address the program entering alerts into JJIS and all
were applicable for alerts. Documentation reflected ten alerts for the five youth were entered
into JJIS, updated, and closed, if required, recorded on the alert board, and in the logbook, if
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applicable. An interview with the facility administrator confirmed alerts are documented on the
alert board and alert binder. An interview with the health services administrator confirmed
nurses are the only staff who update or close medical alerts. Five staff were interviewed
concerning location of alerts and three stated alerts are posted on the alert board and two staff
stated they also review the alert binder. One staff stated alerts can be found in master control
and medical. One staff stated alerts are located in the JJIS.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual 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 of Juvenile Justice identification number, date of birth, county of residence,
and committing offense. Each individual youth case 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 or file cabinet also
labeled “Confidential” and inaccessible to youth.
1.15 Advisory Board Limited Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a policy and procedures ensuring the program has a community advisory
board meeting at least once every ninety to 120 days. The program had an advisory board
meeting on September 30, 2024, with program staff; however, the program has not had a
meeting since September 2024, which exceeds the 120 day requirement. The program did have
a meeting scheduled for January 18, 2025; however, the meeting was not held due to the
program not having any board members; and the meeting was not rescheduled. A review of
meeting invites reflected the program did not solicitate a representative from law enforcement,
the judiciary, the LGBTQIA+ community, a victim or victim advocate, or a parent/guardian
whose child was previously involved in the juvenile justice system. An interview with the facility
administrator (FA) stated a meeting was scheduled for January 18, 2025; however, when no
board members attended, the program had an informal meeting between the FA and the
designated mental health clinician authority. The FA stated he continues to solicit potential
members to be a part of the program’s advisory board. The annual compliance review team was
unable to interview a board member during the annual compliance review week due to the
program not currently having any board members.
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1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures to ensure staff are evaluated, at least annually, on
established performance standards. The program reviews staff competency on an annual basis
according to their position descriptions/performance standards. Three position descriptions were
reviewed, and each staff member’s performance standards were clearly identified. The annual
compliance review team could not review a sample of performance evaluations due to no staff
being applicable for an annual evaluation as no staff have been at the program for a year. Three
position descriptions were reviewed for staff whose job functions include implementation of the
program’s behavior management system (BMS). None of the three position descriptions
included explicit mention of the BMS; however, position descriptions do include following all
program policies and procedures. The program has maintained all contractually required
positions, except for the recreation therapist position which has been vacant since October 14,
2024. The program continues to interview and recruit to fill this position. The facility
administrator (FA) was interviewed concerning how the program boosts staff morale and how
staff are evaluated on their performance. The FA stated the program has a spirit calendar with
fun activities for staff as well as a staff appreciation day. The FA stated staff are evaluated
annually according to their job description. Five staff were interviewed and three stated they
have not received a performance evaluation. The remaining two staff stated they had each
received one evaluation.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program 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. The program did not have a Memorandum of Negotiation. There are six special
contract conditions not covered by the Monitoring and Quality Improvement indicators.
The first special contract condition requires three nutritious meals and snacks daily. A review of
the program’s menu and an interview with two youth and the facility administrator confirmed the
program is providing nutritious meals and three snacks daily.
The second special contract condition requires the program to establish peer-to-peer mentoring
whereas a youth who is doing well in the program will mentor a newly admitted youth. An
interview with the facility administrator (FA) stated the program has just begun informally to
implement this special contract condition due to not having any youth until recently who had
been in the program long enough to provide mentorship. The program currently has two youth
acting as a mentor to newly admitted youth. An informal interview with the two youth mentors
confirmed this practice.
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The third special contract condition requires seven levels to the program’s behavior
management system (BMS). Additionally, once youth have reached level four or five, youth are
allowed to access the commissary. Documentation of five youth BMS point cards, as well as a
review of the BMS policy confirmed this practice. Five youth were interviewed and confirmed the
program’s BMS levels and rewards.
The fourth special contract condition requires a meeting to be held at least once a month for
youth to provide feedback about the program which is in addition to the youth advisory council.
A review of video camera observation and informal interviews with the FA and two youth
confirmed the program has a “townhall” meeting at least once a month, or immediately if
needed, to allow youth to provide feedback about the program.
The fifth special contract condition requires the program to offer family visitation on the weekend
and at least one weekday after 5:00 p.m. A review of visitation documentation confirmed the
program offers weekend and weekday evening visitation; however, no parents have chosen to
attend weekday visitation.
The sixth special contract condition requires a thirty day supply of non-perishable food items
and products available at the facility. This was confirmed during observation of the kitchen
during the program tour.
1.18 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 to review and analyze data in decision-making
practices. The program tracks various operation and safety and security data to include Right
Interactions (RI), incident reports, grievances, and census. This information is shared weekly
during supervisor meetings and monthly with all staff during the all-staff meeting. The program
shares data with the Department monthly and will share data with the community advisory board
once a board is established. Documentation of supervisor staff meeting minutes and emails to
the Department confirmed this practice. All-staff meeting agenda documentation covers broad
data topics; however, the program was not documenting meeting minutes for all staff meetings;
therefore, the annual compliance review team was unable to confirm the exact details of any
data shared during all-staff meetings. The program has utilized data to determine areas to
retrain their staff to improve their interactions with youth after several grievances were made
relating to youth and staff interactions.
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Office of Accountability and Program Support Page 19 of 66 (Revised September 2022)
Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures to notify each youth’s parent/guardian by telephone
within twenty-four hours and in writing within forty-eight hours of each youth’s admission into the
program. The policy further requires the program to send written notification and specific
program information to the youth’s committing judge, juvenile probation officer (JPO), and post–
residential service case manager, when applicable within five working days of any youth’s
admission into the program. Five youth case management records were reviewed, and each
contained documentation indicating the youth’s parent/guardian was notified by telephone within
twenty-four hours and in writing, within forty-eight hours of the youth’s admission into the
program. Each record included written notification to the committing judge and JPO within five
working days of the youth’s admission into the program. None of the reviewed youth were
applicable for written notification to the post–residential service case manager.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to ensure all youth are orientated to the program. A
review of five youth case management records found the program provided an orientation for
each youth on the day of admission. The orientation included services available, daily schedule,
expectations and responsibilities of the youth, written information on the program’s behavior
management system, access to medical and mental health services, zero-tolerance regarding
sexual misconduct, access to the Florida Abuse Hotline or the Department’s Central
Communications Center if the youth is over eighteen years of age, and items considered
contraband. The youth orientation also 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, community access, grievance
procedures, emergency procedures, physical design of the facility with a tour, and assignment
to a living dormitory. Each reviewed record documented a signed checklist acknowledging the
youth received an orientation packet, including a copy of the youth handbook. A youth
admission was observed during the annual compliance review week which verified orientation is
completed on the day of admission and included all elements in the program’s policy. Five youth
were interviewed and stated they received an orientation to the program within twenty-four
hours of admission which included program rules, procedures, schedules, and all other pertinent
information.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures which address obtaining written consent of youth who
are eighteen years of age or older. Written consents are required for any youth eighteen years
of age or older prior to providing or discussing any information with the youth’s parent/guardian.
Five youth case management records were reviewed and two were applicable for youth
eighteen years of age or older. An additional record was requested to meet the minimum
sample of three. All three records contained consent forms signed by the youth allowing the
program to share with the parent/guardian, any information related to the youth's physical or
mental health screening, assessment, or treatment.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a policy and procedures outlining the classification process. The program
utilizes a classification system to promote safety and security as well as effective delivery of
treatment services based on the youth’s individual needs and identified risk factors. A review of
the program’s classification form confirmed the form included all required elements. A review of
five youth case management records found documentation indicating each record contained an
admission classification form including all required elements outlined by Florida Administrative
Code and completed on the day of each youth’s admission to the program. Documentation
confirmed a new screening for Vulnerability to Victimization and Sexually Aggressive Behavior
was completed for each youth. All five youth were classified for the purpose of assigning them
to a living area, sleeping room, and youth group. The program maintains an updated internal
alert system in Department’s Juvenile Justice Information System documenting any medical,
mental health, substance abuse, security risk factors, and/or special needs identified during or
subsequent to the classification process. The program also maintains an alert board in the staff
break room, which is updated as needed. The program’s policy and procedures address
reassessment and reclassification of youth prior to an increase of a youth’s privileges or
freedom of movement, participation on work projects or other activities which involve the use of
tools, or a youth’s participation in any off-campus activities. Two of the five reviewed youth had
suspected security risk factors and all five records included documentation for the
reclassification of the youth prior to engaging in certain activities. An interview with the facility
administrator confirmed the program’s classification and reassessment practice.
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Office of Accountability and Program Support Page 21 of 66 (Revised September 2022)
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures to address gang identification including notification to
law enforcement. Five youth case management records were reviewed. None of the five records
were applicable for gang notification to law enforcement. Additional youth case management
records were requested to meet the minimum sample of three. The program confirmed there
was only one youth applicable for gang notification during the annual compliance review period.
The one applicable youth case management record confirmed the program notified local law
enforcement and the youth’s home county law enforcement agency in writing of the youth’s
gang affiliation. Documentation confirmed gang information was shared with the educational
staff at the program and the youth’s juvenile probation officer. The youth was not applicable for
notification of a post-residential services counselor. The program identifies youth who are
suspected gang members at intake and enters any applicable alert in the Department’s Juvenile
Justice Information System (JJIS). Reviewed documentation reflected the youth’s gang alert
was maintained in JJIS and updated as required.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures to ensure youth who are identified as or are
suspected gang members or at high risk of gang involvement are provided intervention services
and activities. The program’s policy and procedures also include providing a youth the
opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang. The
program utilizes the ARISE curriculum and Impact of Crime intervention groups as part of the
program’s gang prevention and intervention services. Gang prevention/awareness efforts may
include education and/or guest speakers, when applicable. Five youth case management
records were reviewed, and none were applicable for participation in gang prevention and
intervention activities. Three additional youth case management records were requested to
meet the minimum sample of three. The program only had one youth applicable for gang
prevention and intervention activities during the annual compliance review period and provided
the applicable youth’s case management record for review. Documentation in the youth record
confirmed the youth’s attendance in an individual gang intervention group. The youth was
recently admitted to the program; therefore, the youth’s performance plan and goals have not
yet been developed to include a gang intervention goal. An interview with the facility
administrator confirmed the program’s gang intervention and prevention strategies.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
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team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures to ensure a Residential Assessment for Youth (RAY)
is completed for each youth within thirty days of admission. A review of five youth case
management records indicated each record contained a RAY which was completed within thirty
days of admission. Each initial RAY assessment was maintained in the Department’s Juvenile
Justice Information System. None of the five youth were applicable for reassessments. Each
initial RAY was in the youth’s case management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures to address the completion of a Youth Needs
Assessment Summary (YNAS) within thirty days of each youth’s admission. Five youth case
management records were reviewed for completion of a YNAS. Each record contained a
completed YNAS within thirty days of the youth’s admission into the program and was
documented in the Department’s Juvenile Justice Information System. Reviewed documentation
supported all five youth records included the youth’s top three criminogenic needs.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program has a policy and procedures addressing the development of the Individualized
Performance Plan (IPP) with each youth within thirty days of admission. Five youth case
management records were reviewed and all five records contained an IPP completed within
thirty days of the youth’s admission to the program and after the completion of the initial
Residential Assessment for Youth and Youth Needs Assessment Summary. Each reviewed IPP
was developed and signed by the treatment leader, youth, treatment staff, and all parties who
have significant responsibility in goal completion. Three of the five completed IPPs were mailed
to the parent/guardian. Two were not applicable to be sent to the parent/guardian due to youth
being eighteen years old. None of the records reviewed had a returned parent/guardian
signature sheet. All five reviewed IPPs documented the youth’s top three criminogenic needs
and individualized goals based upon the prioritized needs reflecting the risk and protective
factors identified in the initial assessment process, to include delinquency interventions,
recreation plan, identified transition activities, youth’s responsibilities to accomplish goals,
program staff responsibilities to enable youth to complete goals, and target dates for goal
completion. None of the reviewed youth were in the care of the Department of Children and
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Families upon creation of the initial IPP. All five IPPs were sent to each youth’s committing court
judge, juvenile probation officer, and three of the five applicable youth their IPP was sent to the
parent/guardian within ten days of completion. The remaining two youth records were not
applicable to be sent to the parent/guardian. Five youth were interviewed, and each indicated
they participated in the development of their performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a policy and procedures in place to address performance plan revisions. The
treatment team may revise the youth’s Individualized Performance Plan based on the
Residential Assessment for Youth Reassessment results if newly acquired information warrants
a revision. A review of five youth case management records confirmed youth had performance
plan revisions completed as needed. Four of the applicable records contained revisions which
were a result of the youth demonstrating progress toward completing a goal or newly
acquired/revealed information. One youth was not applicable for revisions to the Individualized
Performance Plan as the youth was recently admitted into the program. All five youth IPPs
included incorporation of additional plans including academic or treatment. None of the youth
have behavior support plans or case plans through the Department of Children and Families or
Agency for Persons with Disabilities.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program has a policy and procedures in place regarding the completion of performance
summaries for each youth at ninety-day intervals, beginning ninety days from the signing of the
performance plan, or at shorter intervals when requested by the courts. None of the five youth
case management records reviewed were applicable for performance summaries due to not
meeting the ninety-calendar days following the signing of the performance plan due to being
newly admitted to the program. There were no additional applicable youth at the program for
performance summaries.
A review of three closed youth case management records supported an original release
summary, along with justification for release and Pre-Release Notification (PRN), was sent to
each youth’s assigned juvenile probation officer. All three release summaries and PRNs were
sent at least forty-five days prior to the planned release date and a signed copy was retained in
each youth’s closed record. One of the three youth PRNs were denied by the court. The
program reported they were not provided justification for the denial. The program resubmitted a
second PRN a month later, which was approved by the court. Reviewed documentation in each
closed record verified, once the PRN was approved, the program provided written notification to
the youth’s parent/guardian regarding the planned release and completed an exit Residential
Assessment for Youth. None of the reviewed youth were applicable for the sexually violent
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predator program (SVPP). None of the reviewed closed records were applicable for a Victim
Notification of Release letter.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures which address the encouragement of parent/guardian
involvement in the case management process. Five youth case management records were
reviewed and two of the five were not applicable for parent/guardian involvement due to youth
being eighteen years old. The remaining three youth records confirmed the program
encouraged and facilitated the involvement of each youth’s parent/guardian in the assessment
process, performance planning and development, progress reviews, treatment team meetings
and family sessions. The program provides all parents/guardians advanced notice of the
scheduled formal treatment team meetings and conferences with dates and times. Each letter
also indicated if the parent/guardian could not attend by telephone or video conference on the
day of the meeting, they may participate by providing verbal or written input prior to the meeting.
During the annual compliance review week, an observation of a treatment team meeting
confirmed parent/guardian’s participation by telephone. Five youth were interviewed, and each
confirmed their parent’s involvement in the case management process to include treatment
team meetings and plan development. An interview with the facility administrator confirmed the
programs practice regarding parent/guardian involvement.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a policy and procedures outlining treatment team meeting requirements. The
program’s policy requires the treatment team to meet every thirty days. Five youth case
management records were reviewed and four included documentation reflecting formal
treatment team meetings were held once every thirty days and informal treatment team
meetings were held bi-weekly. The one remaining youth was not applicable for treatment team
meetings as he was recently admitted to the program. Reviewed documentation for formal and
informal treatment team meetings confirmed documentation included all the required elements.
All required parties were present either in person or by telephone during the formal and informal
treatment team meetings apart from the recreational therapist due to the position being vacant.
During the annual compliance review week, an observation of treatment team meetings was
conducted. All required program participants were in attendance or provided written input. The
youth was observed demonstrating skills acquired in the program. Five youth were interviewed
and indicated staff review their performance through progress on performance plan goals,
positive and negative behaviors, and treatment progress. Four youth confirmed they are able to
show the skills they learn in the program during treatment team meetings. The remaining youth
is newly admitted and has not participated in a treatment team meeting yet.
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2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has a policy and procedures ensuring the intervention and treatment team is
planning for the youth’s successful transition to the community upon release from the program.
A review of three closed youth case management records found the program held a transition
conference at least sixty days prior to each youth’s anticipated release date. The program
invited all required members to the transition meetings through mail correspondence or email.
Transition conferences were attended by the youth, parent/guardian, juvenile probation officer,
facility administrator, treatment team leader, and other treatment team members. None of the
reviewed youth records required a human trafficking specific service provider. During the
transition conferences, the team discussed all required topics including transition activities,
completion dates, and parties responsible for completion of goals. All attendees signed each
transition conference form, and the forms were mailed to all parties for their signature with a
request to return signature sheet to anyone not in attendance who had a responsibility for
completion of transition goals. Each youth record contained a return email acknowledgement
receipt printed and filled with the plan for plans electronically transmitted to juvenile probation
officer and, if applicable, Department of Children and Families counselor. Documentation in
each record confirms a community re-entry (CRT) meeting invite and the CRT meeting was
conducted prior to the youth’s release and youth and case manager participated in the CRT
meeting.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures for the assembling of an exit portfolio for each youth
to assist the youth after release and transition back into the community. Exit portfolios are to
include a state-issued identification card, social security card, birth certificate, all educational
documentation, school transcripts, résumé, sample employment applications,
educational/vocational certificates earned in the program, along with a calendar of upcoming
appointments. Three closed youth case management records were reviewed and documented
each youth’s exit portfolio was discussed during the transition conference. One youth had a
completed exit portfolio with all required elements as outlined in the policy. The remaining two
youth records contained all required elements except for the state issued identification card. The
program reported they will request the required documentation from the parent/guardian and
retain proof of the request for the needed items. Each youth’s Exit Portfolio included signed
documentation indicating each youth was given a copy of the Exit Portfolio upon release from
the program. All three youth records included documentation the program staff forwarded the
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exit portfolio documentation to the juvenile probation officer. The program’s contract does not
require 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 policy and procedures to ensure an exit conference is conducted to finalize
release plans and prepare each youth for re-entry back to the community. Three closed youth
case management records were reviewed. All three records confirmed an exit conference was
conducted at least fourteen days prior to the youth’s release date and after notifying the juvenile
probation officer (JPO) of the youth’s release. Each record had documentation indicating the
exit conference date, signatures, and a summary of pending transition goals. All three records
contained documentation to confirm the treatment team leader, parent/guardian, education
representative, therapist, JPO, youth, and other pertinent parties participated during the exit
conference. Each record had documentation reflecting the status of transition activities and
finalized plans for the youth’s release to include education/employment and notification to the
parent/guardian and JPO of the vocational plan for youth, if applicable. The date of admission
and date of release correlated with the Department’s Juvenile Justice Information System for
each youth. Each Exit Conference was held separate from the Transition Conference and
Community Re-Entry Team meeting.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to promote constructive input by youth. The program
promotes active participation through opportunities to make choices, assume meaningful roles,
including team membership and leadership roles, and give input into the rules and operation of
their residential community. Reviewed documentation verified the program solicited input from
youth through the monthly school youth surveys, and quarterly youth surveys. The program
indicated the first youth advisory board meeting will be held at the end of February 2025, as
there have not been any eligible youth. The facility administrator interview confirmed the
program’s formal process to solicit input from youth is through the Youth Advisory Board and
when applicable, Let’s Talk forms, grievance forms, youth surveys, and meetings with
administration. Five youth were interviewed and stated they provide input regarding what
happens at the program through request to speak forms, town hall meetings, group meetings
with the facility administrator, and talking to staff.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program has a policy and procedures which provides for 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 DMHCA is a licensed mental health counselor (LMHC) with a clear
and active license which expires on March 31, 2025. 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, 2025. The DMHCA is on-site forty hours a week and on-call
twenty-four hours a day for emergencies. A review of the DMHCA’s position description
confirms required hours for DMHCA. An interview with the DMHCA confirmed their responsible
are coordination, implementation, and oversight of mental health and substance abuse services
at the program. The DMHCA provides weekly supervision for 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 designated mental health
clinician authority (DMHCA) ensures the licensed clinical staff working under their supervision
are performing services they are qualified to provide based on education, training, and
experience. The program currently does not utilize a Chapter 397 license. All substance abuse
services are provided by the DMHCA whose license expires on March 31, 2025, and a back-up
DMHCA if needed whose license also expires on March 31, 2025. The DMHCA and back-up
DMHCA are the only licensed clinical staff for the program.
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 individuals with appropriate qualifications. The program has two non-
licensed mental health and substance abuse clinical staff. There were no mental health clinical
staff vacancies during the annual compliance review period. Each of the two non-licensed
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clinical staff hold a master’s-level degree in the field of counseling, psychology, social work, or a
related human services field. The designated mental health clinician authority (DMHCA) assures
the non-licensed clinical staff are performing services they are qualified to provide based on
education, training, and experience. A review of weekly clinical supervision confirmed each non-
licensed clinical staff received one hour a week of on-site, face-to-face direct supervision by a
licensed mental health professional during the annual compliance review period. Each clinical
supervision was documented on a form similar to the Department’s supervision log, which
included all required elements. The program currently does not utilize a Chapter 397 license. All
substance abuse services are conducted by the DMHCA whose license expires on March 31,
2025. The non-licensed clinical staff are on-site forty hours a week. Each of the two non-
licensed clinical staff completed twenty hours of Assessment of Suicide Risk training and
supervised experience in assessing suicide risk, mental health crisis intervention, and
emergency mental health services.
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 abuse needs or are identified as a
possible suicide risk. The program’s policy and procedures include staff training in mental health
and substance abuse issues and administration of all screening tools. The program screens all
youth utilizing the Massachusetts Youth Screening Instrument-Second Version (MAYSI-2) in the
Department’s Juvenile Justice Information System (JJIS). Five youth mental health and
substance abuse records were reviewed and all five reflected a MAYSI-2 was completed for
each youth in full on the day of admission by a staff member qualified to complete the
screening. Documentation confirmed staff reviewed all available information for each youth to
include commitment packet, and reports and/or records for existing documentation of mental
health or substance abuse problems or history of human trafficking. All five reviewed records
were completed in JJIS on the day of admission. Each of the five reviewed youth’s MAYSI-2
indicated further assessment was needed and the reason for the referral was documented. All
five youth were referred for an Assessment of Suicide Risk (ASR) and a Comprehensive
Evaluation, as the program policy requires all youth have an ASR and a Comprehensive
Evaluation completed upon admission to the program. The facility administrator (FA) and
designated mental health clinician authority (DMHCA) were notified of the need for an
assessment in each youth record as documented on the mental health and substance abuse
referral form. The ASR was completed on the day of admission for each youth. None of the five
reviewed youth were applicable for needing to be placed on precautionary observation. An
interview with the FA confirmed the program utilizes the MAYSI-2 and ASR to screen youth for
mental health and substance abuse needs.
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.
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The program has a policy and procedures to ensure youth identified by screenings, staff
observations, or behaviors post-admission 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 and all had a new combined
Comprehensive Evaluation completed within thirty calendar days of admission. Each record
contained a substance abuse consent for services signed by each youth. All five reviewed youth
were applicable for completion of their Comprehensive Evaluation by licensed clinical staff. In all
five records, the licensed clinical staff reviewed and signed the Comprehensive Evaluation
within ten calendar days. Each youth’s Comprehensive Evaluation contained all required
elements. None of the reviewed youth were applicable for needing an updated Comprehensive
Evaluation. An interview with the designated mental health clinician authority confirmed the
program’s assessment and evaluation practice
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures in place requiring an Initial or Individualized Mental
Health or Substance Abuse Treatment Plan for youth determined to have a serious mental
disorder or substance abuse impairment and are receiving mental health or substance abuse
treatment in a program. Five youth mental health and substance records were reviewed. and in
all records an initial treatment plan was developed within seven days of treatment initiation on a
form which contained all elements of the Department’s Initial Mental Health/Substance Abuse
Treatment Plan form. All five initial treatment plans were signed by the licensed clinical staff
completing the form, as well as all treatment team members who participated in the
development of the plan and each youth. Only three youth were applicable to have the
parent/guardian signatures because the remaining two youth were eighteen years of age. Two
of five reviewed youth were applicable for having psychiatric needs and in both the plan
included each youth’s psychiatric needs, as well as medication and frequency of monitoring by
the psychiatrist. The remaining three youth did not take psychotropic medications. Each of the
five mental health and substance abuse records contained an individualized treatment plan
which was developed within thirty days of admission on a form which contained all elements of
the Department’s Individualized Mental Health/Substance Abuse Treatment Plan form. All five
individualized treatment plans were signed by the licensed clinical staff completing the form, as
well as all treatment team members who participated in the development of the plan, and each
youth. In two of the five reviewed records, the parent/guardian did not participate; however, both
youth were eighteen years of age The remaining three youth records reflected the
parent/guardian signed the individualized treatment plans. Two of the five youth were applicable
and received psychotropic medications and each individualized treatment plan included
psychiatric services, as well as psychotropic medication and frequency of monitoring by the
psychiatrist. In all five records the individualized treatment plan reviews were completed on a
form which contained all elements of the Department’s Individualized Mental Health/Substance
Abuse Treatment Plan Review form. Four of the five individualized treatment plan reviews were
conducted every thirty days, the remaining one youth has not been in the program long enough
yet to require an individualized treatment plan review. In all five records the goals and objectives
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were individualized for each youth. Video camera observation was conducted during the week
of the annual compliance review to verify clinical groups are being held for the required amount
of time and follows the daily activity schedule. A total of three mental health groups were viewed
for three randomly selected days and each group adhered to the daily activity schedule and
adhered to the duration time in accordance with the contract. All groups were documented in the
program logbook and matched the sign-in sheet
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 governing mental health and substance abuse
treatment and discharge planning. Five youth mental health and substance abuse records were
reviewed and each youth was assigned to a treatment team upon arrival to the program and
was comprised of all required members. All five youth records reflected mental health treatment
notes or substance abuse notes were documented on the Department’s Counseling/Therapy
Progress Notes form. Each of the records indicated an individual psychotherapy or counseling
were being provided to youth. All five youth received psychotherapy skills training and each
youth’s progress notes confirmed each received services as stipulated on the treatment plan. All
five records contained a signed Youth Consent for Substance Abuse Treatment form. All five-
youth received mental health treatment each record contained a properly executed Authority for
Evaluation and Treatment (AET) form.
Three youth closed mental health and substance abuse records were reviewed and each of
indicated the discharge plan was documented on the Department’s Mental Health/Substance
Abuse Treatment Discharge Summary Form. None of the three youth were released on
precautionary observation. Each of the three records indicated the discharge summary
contained documentation regarding future services needed. Each of the three records showed
the discharge plan was discussed with the youth, parent/guardian, and juvenile probation (JPO)
officer during the exit conference. Each of the three youth records indicated the JPO and
parent/guardians were provided a copy of the discharge summary.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program has a policy and procedures which requires mental health overlay services
(MHOS) and substance abuse overlay services (SAOS) to be provided to youth. The designated
mental health clinician authority (DMHCA) is on-site for forty hours each week and the clinical
staff are on-site seven days each week. A review of the therapist to youth caseload ratio
documentation confirmed each therapist was assigned to six youth. Each of the two non-
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licensed clinical staff held a master’s-level degree. The program provided individual therapy at
least once bi-weekly and family therapy at least twice a month. The psychiatrist provided
services weekly on site as documented by sign-in sheets. The DMHCA, who is a licensed
mental health counselor ensures coordination of services provided to youth. The program
provided four groups each week which included mental health and substance abuse groups
during the annual compliance period. According to the program contract, the program’s clinical
groups are Moral Reconation Therapy, Dialectical Behavior Therapy Manual for Adolescents,
Living in Balance and sign-in sheets and progress notes confirmed these groups are being held
as required. No youth were applicable for missing services due to being on medical quarantine.
Five youth were interviewed and three reported participating in family and individual counseling.
Two were newly admitted to the program and have not had any sessions yet. Three youth
stated they receive family sessions once a month, and they receive individual sessions bi-
weekly. Five staff were interviewed and each indicated direct care staff do not facilitate any
mental health or substance abuse groups. The facility administrator (FA) reported youth with
substance abuse history receive specialized treatment programming in the form of SAOS based
on their individualized performance plans. The FA also stated youth who require mental health
services are provided MHOS according to their individualized treatment plan. The DMHCA was
interviewed and confirmed the program provides MHOS and SAOS to youth in the program.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a psychiatrist with an active and clear license under Chapter 459, with the
State of Florida, which expires on January 31, 2026. The psychiatrist is available for emergency
consultation twenty-four hours a day, seven days a week. A review of sign-in/out logs confirmed
the psychiatrist was on-site at least two hours a week as required. There was documentation
the psychiatrist communicates with the treatment team regarding the psychiatric status of youth
receiving psychiatric services who are scheduled for treatment team reviews. The psychiatrist
evaluation and recommendations for youth were incorporated into the mental health clinical
staff’s evaluations and individualized mental health and/or substance abuse treatment plans. A
review of medication management reviews confirms the psychiatrist actively participates in,
manages, and supervises psychotropic medication services in the program. The program did
not utilize an advanced practice registered nurse during this annual compliance review period.
The program has a back-up psychiatrist, with an active and clear license, with the State of
Florida, which expires on December 31, 2026; however, the back-up psychiatrist was not
utilized during the annual compliance review period. The contract was reviewed for tele-
psychiatry inclusion; however, this was not utilized during the annual compliance review period.
During the interview with the psychiatrist, the psychiatrist confirmed responsibilities of
communicating with clinical staff, conducting medication management reviews, and psychiatric
evaluations for youth upon admission. The designated mental health clinician authority reported
the clinical staff and case management team meet with the psychiatrist on a weekly basis to
discuss youth needs. Five youth mental health and substance abuse records were reviewed
and two were applicable for entering the program on psychotropic medications; therefore, an
additional record was requested for review for a minimal sample of three records. The remaining
three reviewed youth did not enter the program on psychotropic medication. All three applicable
youth were referred for a psychiatric interview and received a diagnostic interview within
fourteen days of admission as required. Each initial diagnostic psychiatric interview included all
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required elements. Two of the three applicable youth had medication management reviews
every thirty days as required with the psychiatrist. The remaining youth has not been at the
program long enough to require a medication management review. None of the youth had any
medication modifications or had a psychiatric evaluation completed within six months of their
admission requiring an updated psychiatric evaluation. Page three of the Clinical Psychotropic
Progress Note (CPPN) included all required elements for each youth and if a new prescription
or a change of prescription occurred it was documented. Each of the applicable records
included an initial diagnostic psychiatric interview and was documented and clearly identified as
the initial diagnostic psychiatric interview on the CPPN. Each CPPN included the signature of
the psychiatrist and date. Monitoring for Tardive Dyskinesia was documented monthly as
indicated on the CPPN by the psychiatrist for each youth.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a suicide prevention plan in place, which received an annual review by the
designated mental health clinician authority on January 1, 2025, and the facility administrator on
November 18, 2024. The plan included procedures for identification and assessment of youth at
risk of suicide, staff training, suicide precautions, levels of supervision, referral, communication,
notification, documentation, immediate staff response, and a review process. The review
process included all required elements.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
The program has a policy and procedures which governs suicide prevention services. This
policy defines suicide precautions as methods utilized for supervising, observing, monitoring,
and housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. It requires any youth exhibiting suicide risk behaviors to be placed on
suicide precautions, and a minimum of constant supervision. No youth were placed on
precautionary observation during the annual compliance review period; therefore, no youth
documentation was reviewed for precautionary observation.
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
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3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program’s Suicide Prevention Plan requires staff to maintain one-to-one or constant
supervision for youth placed on suicide precautions. The program has not placed any youth on
precautionary observation during the annual compliance review period; therefore, no youth
mental health and substance abuse record documentation was reviewed.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a policy and procedures outlining suicide prevention training. A review of five
pre-service staff training records confirmed completion of suicide prevention training. The
program has three suicide response kits which are co-located with first-aid kits and contain a
knife-for-life, a needle nose plier, and wire cutters. The suicide kits are in master control,
medical, and the laundry room on the dorm.
A review of suicide mock drills and medical drills during the annual compliance review period
was conducted. The mock suicide drills were held quarterly on each shift, for all staff who
encounter youth including kitchen and maintenance staff. A review of written suicide mock drills
confirmed the program provided semi-annual training on emergency response procedures
which include mock training on emergency response to a suicide attempt or incident of serious
self-inflicted injury using cardio-pulmonary resuscitation for each shift. The mock mental health
drills were in response to a suicide attempt and/or incident of serious self-injury and were written
as if simulated. The program reviews drills during staff meetings to give staff who are not
present during drills the opportunity to review each drill scenario and procedures. The facility
administrator reported the program conducts suicide drills on each shift and they are reviewed
during staff monthly meetings. Five staff were interviewed and each reported medical and
mental health drills are conducted monthly for each shift.
Video observation of two suicide mock drills were able to be conducted within the thirty-day
recording period. Both drills were conducted on the same day, and both reflected the same
scenario. One drill was conducted and simulated as required and one drill was not simulated;
however, it was observed on video the designated mental health clinician authority approached
each of the staff on shift and went through the scenario of the drill and had the staff sign a
training roster. The program stated the drill was not simulated due to staff overseeing showers
for youth during the drill.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
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does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a crisis intervention plan which was reviewed annually by the facility
administrator and designated mental health clinician authority on February 3, 2025. The plan
included notification, an alert system, means of referral including youth self-referral,
communication, supervision, documentation, and review.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a policy and procedures 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. The program has had no crisis assessments during the annual compliance
review period.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has an emergency mental health and substance abuse services plan separate
from the crisis intervention plan in place. The plan includes immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health or substance abuse services including Baker Act and Marchman Act, documentation,
training (including mock drills) and review.
3.18 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
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3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedures to conduct an on-going safety planning process for
each youth. The safety plan shall be designed to identify stimuli which have both positive and
negative effects on the youth. Five youth mental health and substance abuse records were
reviewed and each had a safety plan completed within fourteen days of admission which
contained all required elements. Each youth’s plan was jointly prepared by the youth,
parent/guardian or family member, and the program’s clinical staff. Documentation confirmed
each safety plan incorporated any recommendations from previous or current clinical
assessments or screening instruments and incorporated trauma responsive practices. All five
youth had their safety plan reviewed and updated at least every thirty days. None of the youth
reviewed were applicable for needing their plan updated following any significant behavioral or
mental health event identified by the youth’s intervention and treatment team. Safety plans are
located in master control for direct care staff to review as well as in the youth’s mental health
and substance abuse record. Five youth were interviewed and each youth confirmed they
participated in the development of their safety plan. An interview with the facility administrator
confirmed safety plans are updated monthly and on an as needed basis.
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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 stating the designated health authority (DHA) shall be
clinically responsible for the medical care of all youth at the program. The program has a
designated health authority (DHA) who is a licensed physician holding an unrestricted license
and meets all requirements for independent and unsupervised practice in the State of Florida.
The DHA had no disciplinary cases/public complaints, the specialty training is in pediatrics, and
the license expires on January 31, 2027. The program does not have a physician assistant or
advanced practice registered nurse. A review of the DHA sign-in/out logs during the annual
compliance review period confirmed the DHA was on-site at least once a week with one
exception and confirmed the back-up DHA was on-site in lieu of the DHA. The DHA’s contract
does not outline specific required hours to be on-site. The back-up DHA is a medical doctor
holding an unrestricted license and meets all requirements for independent and unsupervised
practice in the State of Florida. The back-up DHA had no disciplinary cases/public complaints,
the specialty training is in internal medicine, and the license expires on January 31, 2027. The
program does not utilize tele-health.
The DHA interview confirmed the DHA is on-site once every seven days to address health
concerns of the youth at the program, completing intakes and addressing medical issues. The
DHA stated when not on-site communication with the program staff occurs through text
messages and telephone calls with twenty-four hours, seven days a week availability. The DHA
provides on-site clinical services, and reviews and signs off-site care findings, instructions, and
information, which are maintained in the youth Individual Healthcare Record. Important medical
issues are addressed by the DHA as soon as they arise either in-person or on the telephone,
and follow-up is scheduled as needed and promptly. The DHA arranges coverage when on
vacation or during scheduled absences by contacting the nursing director and the back-up DHA
will cover.
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 indicating the designated health authority is clinically
responsible for all healthcare services provided to youth at the program. The program has five
registered nurses (RN) providing on-site nursing coverage from 7:00 a.m. to 6:00 p.m. daily.
Two are full-time RNs and three are pro re nata. One of the full-time RNs is the health services
administrator (HSA). All five RNs had clear and active licenses: three expiring on April 30, 2025,
and two on July 31, 2026. Program does not utilize licensed practical nurses. All nursing staff
had current cardio-pulmonary resuscitation certificates. The program’s contract requires nursing
coverage ten hours a day, eighty hours weekly, with the HSA and at least one other RN each
working forty hours a week. The contractual nursing coverage was met.
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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) and treatment protocols which were
reviewed and signed annually by the designated health authority (DHA) on August 21, 2024,
and the facility administrator and psychiatrist on August 16, 2024. The nursing staff reviewed,
signed, and dated a cover page on which all FOPs, healthcare protocols, and other procedures
were listed. All newly employed registered nurses (RN) received a comprehensive clinical
orientation to the Department’s health care policies and procedures, given by a RN. The DHA
authorized and wrote the treatment protocols or standing procedures.
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 Authority for
Evaluation and Treatment (AET) authorizing specific treatment for youth in the custody of the
Department. A review of five Individual Healthcare Records (IHCRs) indicated two youth were
eighteen years old at the time of admission and both had a release of information contained in
their IHCR and neither required an Authority for Evaluation and Treatment (AET) form. The
remaining three youth had a valid AET with the word “COPY” stamped on the form filed in each
IHCR including each parent/guardian and Department representative signature. None of the
youth required a court order or were in the care of the Department of Children and Families.
The nursing interview indicated all youth under the age of eighteen arrive to the program with a
signed AET. Any youth aged eighteen or older will provide consent 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 to obtain consent when new medications and
treatments are prescribed. A review of five youth Individual Healthcare Records (IHCRs)
indicated two were not applicable for parental notification due to each youth being eighteen
years old. The remaining three youth IHCRs included parental notifications for over-the-counter
medications beyond those covered by the Authority for Evaluation and Treatment and each
parent/guardian provided consent. Documentation in the progress notes included attempts to
contact each parent/guardian for any new medication ordered, as well as written notifications
sent utilizing the Department’s Parental Notification of Health-Related Care: General, or
Parental Notification of Health-Related Care: Medications forms, or the Acknowledgement of
Receipt of the Clinical Psychotropic Progress Note (CPPN). Two of the three applicable youth
were taking psychotropic medications at admission and each IHCR maintained documentation
of staff witnessing all telephone call attempts and conversations for psychotropic medications. In
both applicable IHCRs whenever a new psychotropic medication was prescribed or
discontinued, or the drug dosage was significantly changed, the parent/guardian verbal consent
for psychotropic medication was documented on page three of the CPPN. None of the youth
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were in the care of the Department of Children and Families requiring a court order for
treatment. Four of the five youth IHCRs reflected vaccinations were verified within thirty days of
each youth’s admission. The remaining youth had an exemption due to medical reasons and the
IHCR contained a copy of the letter signed by the youth’s physician provided to the program
which indicated the reason for the exemption. The program obtains immunizations records from
Florida Shots upon each youth’s admission.
The nursing interview indicated parental notifications are made verbally and followed up with a
written notification to be returned and signed by the parent/guardian. When the nurse receives a
new order or a change in medication, the parent/guardian is telephonically notified. Any
changes in psychotropic medications, including new orders, discontinued medications, or
changes in medication dosage require parent/guardian consent. The parent/guardian is called to
receive verbal consent with a witness present, and then written consent is sent along with the
third page of the CPPN. When a youth has an illness or injury requiring emergency medical
services the parent/guardian is contacted, the Department’s Central Communications Center
(CCC) is called within two hours, and the designated health authority is immediately notified.
The nursing interview revealed the program does not provide vaccinations but will review
immunization records during youth admission. If a parent/guardian claims exemption and does
not give consent for vaccinations, then the Department’s Religious Exemption from
Immunization form needs to be signed by the parent/guardian and submitted to the program.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures which ensure youth are screened upon admission for
healthcare concerns which may require a referral for further assessment by healthcare staff. A
review of five youth Individual Healthcare Records (IHCRs) indicated a Facility Entry Physical
Health Screening Form (FEPHS) was completed on the day of admission by a registered nurse
(RN) for each youth. None of the youth had a change in physical custody for more than twenty-
four hours since admission.
The nursing interview stated youth are seen immediately upon arrival to the program by a RN.
The nursing staff are notified by the commitment manager through email when a youth is placed
at the program, and the RN will complete the admission screening. If a direct care staff must
complete the screening, a RN will review and sign the FEPHS within twenty-four hours. Any
youth with a change in physical custody has a new FEPHS completed by a RN.
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 maintains a policy and procedures to ensure all youth are oriented to the general
process of healthcare delivery services at the program. A review of five youth Individual
Healthcare Records (IHCRs) indicated all youth received a general care admission orientation,
which was documented on a sign-in orientation sheet and on the health education record. Youth
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
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and how it is documented, what to do in the case of a sexual assault or attempted sexual
assault, the non-disciplinary role of the health care providers, and standard universal
precautions. The program’s health education covered seatbelt usage, alcohol and drug related
problems, sexually transmitted disease/infections, tobacco products, dental hygiene and dental
care, basic personal hygiene, immunizations, infection control, prevention of sexual and other
physical violence, nutrition, physical fitness, breast and testicular self-examinations, and
parenting skills.
The program’s contract requires health education to occur monthly in recurring cycles.
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 maintains a policy and procedures to ensure the designated health authority
(DHA) is notified when a youth admitted requires emergency care or routine notification in
accordance with the Department’s requirements. Five youth Individual Healthcare Records
(IHCRs) were reviewed. None of the five youth IHCRs reviewed were applicable for youth with a
known or suspected chronic condition during admission or a youth identified as in-need of
emergency care upon admission. Two of the five youth were taking psychotropic medications
upon admission and the psychiatrist was notified. It should be noted, the DHA and psychiatrist
were notified for all five youth admissions.
The nursing interview indicated a registered nurse notifies the DHA immediately upon a youth
being admitted with a serious or chronic condition, which is documented on the intake note and
the DHA appointment list.
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 maintains a policy and procedures to ensure the standard Department’s Health-
Related History (HRH) form is used for all youth admitted into their physical custody. A review of
five youth Individual Healthcare Records indicated all youth had a HRH form completed within
seven calendar days of admission. The HRH was completed prior to the Comprehensive
Physical Assessment, as evidenced by signature and date, and the physician reviewed each
HRH.
The nursing interview indicated a registered nurse is responsible for completing the HRH
immediately upon each youth admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the standardized Comprehensive Physical
Assessment (CPA) form is used for all youth admitted into the program. A review of five youth
Individual Healthcare Records (IHCRs) indicated all youth received a new physical assessment
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completed on the Department’s CPA form within seven calendar days of admission, conducted
by a medical doctor. Each CPA contained the Medical Grade, and all sections were marked with
an “O” or an “X”. All five youth refused part of the exam, which was noted on the CPA as “youth
refused”, as well as each youth signing a refusal form reflecting the refused portion of the CPA
and matched the date of the exam. In all five IHCRs the Department’s Problem List was
updated as required and each contained at least one verified Tuberculosis Skin Test (TST)
conducted within the last year, and the results of the TST were documented on the CPA and
Infectious and Communicable Disease forms, and they matched.
The nursing interview indicated the designated health authority completes a CPA within seven
days of each youth admission and yearly thereafter. A tuberculosis screening is conducted
yearly.
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 reflecting human immunodeficiency virus (HIV) test
results are only disclosed to the youth, the youth’s legally authorized representative, health care
providers during the course of consultation, diagnosis, or treatment of the individual, the
Department of Health for purposes of reporting and control of spread of disease, health facility
staff committees conducting program monitoring, evaluation, and service reviews, medical
personnel who have been subject to a significant exposure, and health care facility personnel or
agents for the healthcare provider who have a need to know in the course of patient care
activities or administrative operations.
A review of five youth Individual Healthcare Records (IHCRs) indicated all youth were clinically
screened and evaluated for sexually transmitted infections (STI) on the day of admission. All
five required further evaluation and a referral was made to the designated health authority
(DHA), which was documented on the STI screening tool. Four youth had testing ordered by the
DHA. Two of the four applicable youth received testing and the screening results, clinical
evaluations, and diagnosis were documented on the Infectious and Communicable Diseases
(ICD) form and were filed in the lab section of each IHCR. The remaining two youth refused
testing and a refusal form was maintained in each IHCR. None of the five youth were out of the
Department’s physical custody and/or symptoms were present requiring a re-screening. All five
IHCRs contained evidence each youth was offered counseling, testing, and if indicated,
treatment/referral for HIV. Two of the five youth received HIV testing and consent was obtained
from both. The remaining three youth did not provide consent for HIV testing. In the two
applicable IHCRs the HIV results were filed confidentially in a sealed envelope marked
“Confidential” and pre/post-test counseling was documented on the Individual Health Education
Record. The program’s registered nurse conducts the HIV testing, and the DHA conducts the
pre/post-test counseling. Three of the five reviewed youth were applicable for either STI or HIV
testing. In the three applicable records, each youth’s confidentiality was protected by not
including youth’s HIV status and any other STI diagnosis on the program’s internal alert system.
All five youth interviews indicated they can ask for HIV testing, if needed.
The nursing interview indicated all sexually active youth are screened and evaluated for STls
upon admission, and if requested, are immediately tested. If the STI screening indicates a need
for further evaluation by standing order the youth is tested upon admission. STI results are filed
in the lab section of the IHCR, and testing is documented on the ICD and STI screening forms.
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HIV test results are kept in a sealed envelope marked “Confidential” in the lab section of the
youth’s IHCR. The DHA provides HIV pre/post-test counseling, which is documented on the
Individual Health Education Record in the youth’s IHCR, and if additional counseling is needed,
the youth is referred to the health department.
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 their complaints treated appropriately through the program’s sick call system.
The program has a policy and procedures stating when there is no licensed nurse on-site the
shift supervisor will review all sick call requests as soon as possible, and within two hours after
the request is submitted.
A review of five youth Individual Healthcare Records (IHCRs) indicated one of the five youth
was applicable for presenting with similar sick call complaints three or more times within a two-
week period and a referral was made to the designated health authority (DHA). All five youth
submitted Sick Call Request forms and a registered nurse (RN) completed the forms in
subjective, objective, assessment, and plan format, and they were filed in each youth’s IHCR in
reverse chronological order. None of the youth were in restricted housing. Each sick call event
and date was documented on the Sick Call Index. In one of five youth IHCRs, three of the
youth’s nine sick call events were missing from the Sick Call Referral Log. In the remaining four
youth IHCRs, all sick call events were documented on the Sick Call Referral Log. A review of
the daily schedule, posted schedule, and nurse interview confirmed sick call is conducted twice
daily, as contractually required. The sick call hours are posted on the clinic door, sick call forms
are available in the multi-purpose room, and only licensed nurses conducted sick call. The
program has an exam table and equipment to utilize for sick call. During the annual compliance
review week, the annual compliance review team was unable to observe a sick call, since there
was no sick call event while the team was on-site.
All five youth interviews indicated when they make a sick call request, they are seen within one
day by the nurse.
The nursing interview indicated a youth must complete a sick call form and place it in the sick
call box to request a sick call. The sick call box is located in the multi-purpose room and is
checked twice daily. Sick call is conducted in the clinic by a RN, unless the DHA is on-site. If a
youth presents with the same complaint three or more times within a two-week period, the youth
must be referred to the DHA. The program does not utilize restricted housing.
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4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures regarding episodic and emergency care. The policy
includes nurses monitoring the first-aid kits weekly to prevent expiration or deterioration and to
replenish the contents, as well as the use, access and inventory of Narcan.
Five youth Individual Healthcare Records (ICHRs) were reviewed and in one the youth required
on-site first-aid or episodic care. The remaining four youth were not applicable, and the program
indicated they had no other applicable youth. The one applicable youth received episodic care
by licensed healthcare staff documented in elements, subjective, objective, assessment, and
plan (SOAP) format.
The program has nine first-aid kits which are located in the laundry room, kitchen, education
portable north, education portable south, classroom one, classroom two, master control, and the
remaining two are for the vans which are kept in master control. A review of three first-aid kits
indicated they were fully stocked with designated health authority (DHA) approved contents. A
review of first-aid kit checks for the annual compliance review period indicated they were
conducted as required. The program had two automated external defibrillators (AED) with the
procedures attached to the AED box and located in the clinic and master control. Both AEDs
were purchased in July 2024 and the batteries and pads expire November 2027. Observation of
both AEDs indicated they were in working order and the green light was on. Review of weekly
AED checks for the annual compliance review period indicated they were conducted by the
nurses as required. The program has the emergency numbers posted in the clinic,
administrative offices, and master control inaccessible to youth and accessible to all staff.
Supervisory staff were appropriately trained on the administration of the epinephrine auto-
injector. A review of five pre-service staff training records indicated all five received episodic,
first-aid, and emergency care training. A review of emergency medical drills for the annual
compliance review period indicated announced and unannounced drills were conducted at least
quarterly on each shift and simulated an episodic care event which called for immediate first-aid
and/or the administration of cardio-pulmonary resuscitation (CPR) techniques and the initiation
of the emergency procedures to follow when a life-threatening emergency does occur. A video
camera review of drills was not conducted due to no drill being completed in the time span the
video footage is saved. The program has not been open for one year; therefore, staff
participating in one drill including the use of CPR annually was not reviewed. During the annual
compliance review week, the annual compliance review team was unable to observe an
episodic care/first-aid event since there was no first-aid needed while the team was on-site. The
program maintains two doses each of Narcan in the medical cart and the emergency box, which
are inventoried perpetually and weekly. The nurses and supervisory staff have access to the
Narcan, and all have been trained. The program indicated they will be providing annual Narcan
training.
All five staff interviews indicated they could call 9-1-1 if a youth had a medical emergency.
All five youth interviews indicated they can see the doctor and/or the dentist if needed.
The nursing interview reiterated the location of the first-aid kits. Episodic care is provided by a
registered nurse (RN) utilizing a SOAP format note and maintaining it in the youth IHCR. If a
non-healthcare staff conducts first-aid, the Department form is used, and a RN will complete
follow-up within twenty-four hours. Youth who are sent off-site for emergency care are tracked
through a calendar and the episodic care log. The RN stated emergency medical drills are
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completed monthly and include CPR at least quarterly. The emergency numbers are posted in
medical, master control and administrative offices.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures ensuring the program provides for timely referrals
and coordination of medical services to off-site healthcare providers. Five youth Individual
Healthcare Records (IHCRs) were reviewed. Three of five IHCRs reviewed were applicable for
youth requiring off-site care. All off-site care events utilized the Summary of Off-Site Care
Consultation Report form, which was filed in each IHCR. Two of the three off-site care events
were emergency care and were documented on the Episodic Care Log. The remaining one
event was not episodic and was documented on the calendar. One of the three youth was
eighteen, and the remaining two youth had parental notification efforts documented in both
IHCRs. All three IHCRs maintained the discharge and additional applicable documents. In two
of three, the designated health authority (DHA) reviewed and signed/initialed all off-site care
findings, instructions, and information. In the remaining one record, the DHA had not been on-
site yet to conduct the review since the event happened. One of the three youth required a
follow-up appointment, which was tracked. The appointment was for a future date.
The nursing interview indicated youth who are sent off-site are tracked through a calendar and
the Episodic Care Log. When the hospital orders are received by a registered nurse the DHA is
contacted to continue the order, which is than faxed to the pharmacy and transcribed to the
Medication Administration Record. The medication pass list is also updated, the parent/guardian
telephonically informed, and a notification mailed. The DHA sees all youth who have gone off-
site for medical care the next time they are on-site, as well as reviewing the off-site orders and
signing off on them.
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 maintains a policy and procedures to ensure youth who have chronic conditions
receive regularly scheduled evaluations and necessary follow-up. Five Individual Healthcare
Records (IHCRs) were reviewed and one youth was identified on the Facility Entry Physical
Health Screening (FEPHS) form with a current chronic condition. The remaining four youth were
not applicable, and the program indicated they did not have any additional applicable youth. The
one applicable youth did not have a communicable disease, was not pregnant, was not taking
anti-tuberculosis medication, and did not require a periodic evaluation off-site. The youth was
taking prescribed medication on an on-going basis, was undergoing treatment for a physical
health condition, was classified with medical grade two to four, and was placed on the chronic
illness list. The youth was receiving periodic evaluations at least every ninety days and the
Department’s Problem List was updated as required.
The facility administrator interview indicated a daily meeting is conducted with the staff to
discuss all important medical issues. The designated health authority interview indicated
periodic evaluations for youth with chronic conditions are conducted every three months. When
a youth is identified as having a chronic condition, the condition is addressed, and an
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appointment is set for follow-up in ninety-day intervals until discharge. The nursing interview
indicated all youth with chronic conditions are seen at least every ninety days and it is monitored
by a nurse on the chronic clinic log.
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 maintains 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 a review of documentation of procedures and processes. A review of
five youth Individual Healthcare Records (IHCRs) indicated two youth were admitted with
medication which was noted on the Facility Entry Physical Health Screening (FEPHS) form and
progress notes. The remaining three did not have medication prescribed upon admission. Both
youth medications were verified prior to being admitted into the program utilizing the
Prescription Medication Verification Checklist form. The designated health authority (DHA) and
when applicable, the psychiatrist were contacted to obtain the order to resume the specified
medications. The remaining three youth had medications prescribed after they were admitted to
the program. All five youth medications had a current, valid order and were administered
pursuant to a current prescription, and when a current medication was continued, discontinued,
changed, or a new one ordered and the DHA placed an order on the Practitioner Order Form.
None of the youth were in restricted housing or received medication by a non-healthcare staff.
In four of five youth IHCRs, over-the-counter medications not listed on the Authority for
Evaluation and Treatment (AET) form were administered according to approved protocols or
practitioner orders. The remaining one youth did not receive those type of medications. All five
IHCRs contained pre-printed pharmacy Medication Administration Records (MAR) to document
all medication and treatment clearly indicating medication start and stop dates, as well as all
other required information. One of the five youth had one human error on one of the MARs, the
stop date had the wrong month. In all five IHCRs the staff and youth initialed each administered
medication entry and the nursing staff documented weekly side-effect monitoring on each MAR.
None of the MARs showed any undocumented explanations for a lapses or errors in medication
administration, none of the youth refused any medication, or received parenteral medication.
Two of the five youth were admitted with psychotropic medication and the DHA and psychiatrist
were notified of each youth’s admission. The psychiatrist conducted an initial diagnostic
psychiatric interview within fourteen days of admission and both youth received a medication
monitoring/review every thirty days as required.
The program did not have any standing orders, emergency treatment orders, or pro re nata
orders for psychotropic medications.
One medication administration process was observed during the annual compliance review
week. The staff escorted the youth to the clinic individually to see the nurse. It was the nurse’s
sole responsibility to conduct medication delivery and speaking to the youth regarding the
reason why he was in the clinic. The nurse prepared the prescription medication when the youth
was present, verified youth’s alert status, and the Six Rights of Medication
Delivery/Administration was verified. The nurse observed the youth and ensured he swallowed
the medication. The staff and youth initialed the MAR.
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Five youth were interviewed and three indicated the nurse provides medication. The remaining
two stated they do not receive medication. All three youth with medication stated they are called
to the medication cart, must provide their name, and date of birth, and get their mouth checked
after medication pass, and sign a form. Two of the three applicable youth also stated they get
water with the medication.
The nursing interview indicated all youth's medication is verified upon admission using the
Department form and all medications must have a pharmacy label intact with the youth's name
on it. The program utilizes pre-printed pharmacy MARs and non-healthcare staff are trained by
the health services administrator or registered nurse to be able to provide medication. The list of
approved non-healthcare staff is posted in the medical clinic.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program maintains a policy and procedures stating any medical equipment classified as
sharps, as well as stock medications, shall be secured and inventoried utilizing a routine
perpetual inventory descending count as each sharp is utilized and disposed of or when the
medication is administered. The program has a policy and procedures addressing the
destruction and disposal or return of expired or discontinued medications and reporting criteria
regarding inventory discrepancies.
A review of sharp and over-the-counter (OTC) stock medication inventories for the annual
compliance review period indicated they were conducted perpetually and weekly. Stock OTC
medications and sharps were maintained in a locked closet. All other medications are locked in
the medication cart. All controlled substances are kept in a locked box within the locked
medication cart. Observation of the medication cart indicated it was locked, well organized,
clean, youth specific medications kept divided from OTC medication, separating topicals,
liquids, and pills. The clinic had a medication only refrigerator, which was noted by a large sign
on the outside of the refrigerator. At the time of the annual compliance review, the program did
not have any refrigerated medication. Observation of the medication only refrigerator indicated
the nurses stored their food inside. The program was made aware, and the food was removed.
All medications are maintained inaccessible to youth. The program had only one controlled
substance on-site during the annual compliance review week. The controlled substance had a
shift-to-shift inventory count, as well as a perpetual count noted on the youth’s Individualized
Controlled Medication Inventory Record. A review of nine staff training records indicated
supervisory-level, non-healthcare staff were trained in the delivery and oversight of medication
self-administration by a registered nurse. Observation of a nurse conducting three OTC
medication counts, three sharp counts, and one controlled substance count indicated all
inventory and actual counts matched.
The nursing interview indicated two nurses must be present to dispose of medication. All
controlled medication disposal requires the pharmacy consultant and two nurses. The interview
verified all controlled substances/narcotics are kept in the medication cart and are double
locked.
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4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has infection control procedures in place including prevention, containment,
treatment, and reporting requirements related to infectious diseases in accordance with the
Occupational Safety and Health Administration (OSHA) federal regulations and the Center for
Disease Control and Prevention (CDC) guidelines. The infection control procedures were
reviewed by the facility administrator (FA) on August 16, 2024, and the designated health
authority (DHA) on August 1, 2024. The infection control procedures included common,
infectious diseases of childhood, self-limiting, episodic contagious illnesses, viral or bacterial
infectious diseases, tuberculosis, Hepatitis A, B, and C and human immunodeficiency virus
infectious diseases caused by bloodborne pathogens, other outbreaks or epidemics caused by
any other infectious agent, whether spread directly or indirectly, outbreaks of pediculosis and/or
scabies, Methicillin-Resistant Staphylococcus Aureus and other emerging antibiotic-resistant
micro-organisms, foodborne illnesses such as those caused by Escherichia Coli, and bio-
terrorist agents. The procedures also addressed chemical exposures in the workplace, Hepatitis
B immunizations availability for staff, and staff access to protective equipment. The program’s
process for needle stick post-exposure evaluation requires the post-exposure evaluation and
follow-up be made available immediately to staff and include documenting the routes of
exposure and how exposure occurred. The program did not have any instances in which the
local county health department, CDC, and/or the Department’s Central Communications Center
(CCC) had to be notified of an infectious disease. The FA/designee had not established a
separate file due to no facility/occupational exposure. The exposure control plan was written in
accordance with OSHA standards and was available to all staff in master control and the clinic.
The plan was reviewed and signed annually by the administration of the program and/or
designees on August 16, 2024.
The FA interview indicated the exposure control/infection control plans are kept in master
control and in the medical clinic. The nursing interview indicated the exposure control plan is
located in master control and medical. The health service administrator/registered nurse (RN)
conduct infection control and exposure control plan training for staff annually. The youth receive
infection control training annually and is conducted by a RN. Stock over-the-counter (OTC)
medication is locked in a storage closet and inventoried weekly and perpetually. OTC
medication in the locked medication cart is counted daily.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a policy and procedures stating how they will maintain active
supervision of youth at all times. Observations of staff during the annual compliance review
week found staff supervising youth appropriately during all observed activities. According to the
policy and procedures, staff-to-youth ratios are as follows: 1:8 during awake hours, 1:12 during
sleep hours, 1:12 at Pinellas Technical College, and 1:5 for off-site activities. Observed activities
made during the annual compliance review week, were supervision of youth during school
hours, in the multi-purpose room, mealtime, education, and youth movement through the facility.
The daily schedules were posted in the multi-purpose room, dormitory hall, and cafeteria. At no
time during the annual compliance review week were youth observed wandering freely about
the program. Interactions between staff and youth were observed to be positive. Observation of
youth rooms found windows to have no coverings. Video review indicated staff observe youth
while they are in their sleeping rooms. An informal interview with three staff indicated they knew
the count of the youth they were supervising.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program maintains a policy and procedures addressing the development, implementation,
and on-going maintenance of the behavior management system (BMS) by all appropriate
parties, to include education. The policy addresses staff feedback of the BMS by their
supervisor and administration. Feedback is provided on an on-going basis or as needed. There
is an agreement between the program and school to ensure staff and teachers monitor the BMS
during school. The facility administrator provided training to the education staff. A review of five
youth case management records indicated each youth participated in orientation upon arrival to
the program to include a review of the BMS. A review of three position descriptions found the
behavior management system to have been addressed with a blanket statement for staff to
follow all policies and procedures of the program, not a direct statement detailing the staff
responsibilities with the BMS. A review of five staff pre-service training records found four to
have received BMS training and one staff who was a re-hire who had already completed BMS
training. Observations, during the annual compliance week, found the BMS was posted in the
multi-purpose room and hallway of the program to include conduct and positive and negative
consequences. Each youth is provided a program handbook which describes the BMS. A review
of the youth handbook indicated the BMS is included and clearly written. The parent/guardian
handbook also includes a description of the BMS. The BMS was not updated during the annual
compliance review period. The program utilizes a level system, which is a coordinated system of
promoting safety, respect, fairness, youth rights, positive and negative consequences, non-
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punitive constructive disciplinary actions, opportunities for positive reinforcement, recognition of
accomplishment and positive behaviors at a four-to-one ratio, promoting socially acceptable
means for youth to meet their needs, a process for explaining to the youth the reasons for
sanctions being imposed, youth having the opportunity to explain their behavior, the impact their
behavior may have on others, reparations for harm caused to others, and alternate behaviors. A
review of the BMS confirmed it is not used to increase a youth’s length of stay, deny basic rights
or services, promote the use of group punishment, allow youth to punish other youth, or include
disciplinary confinement. The program can use, peaceful conflict resolution or the disciplinary
board to ensure separation of the youth from the population is minimized. Observations of staff
and youth interactions during the annual compliance review week verified staff were adhering to
the BMS by utilizing a ratio of four-to-one positive to negative consequences when redirecting
the youth as indicated in the program’s policy. Staff use point cards to monitor how well the
youth are progressing in the program. Staff review the point cards with the youth prior to the end
of their shift or when the youth receive a loss of points. The youth and staff sign the point card
once reviewed. Youth earn points daily for complying with the program rules. At the end of the
week, the points are totaled, and the youth are rewarded based on the number of points earned.
Rewards include point store, food items from local restaurants, outings, hygiene items, extra
phone calls, movie night and use of the game room. Each youth enters the program on an
orientation level prior to starting the BMS and progresses their way up the levels. Special
conditions in the contract require the program to have seven levels included in the BMS and
once the youth reach level four or higher, they are allowed to access the commissary. A review
of the point cards and BMS confirmed this practice. The BMS includes the following
contractually required levels: orientation, eagle, panther, bear, falcon, lion, and transition. Five
staff were interviewed, and all stated youth earn points to advance through the level system,
Each staff was able to explain the incentive process and stated basic rights of the youth cannot
be taken away as a consequence. Each interviewed staff member was able to explain how
youth are informed of their consequences and are able to explain their actions. Five youth were
interviewed, and each stated the consequences of negative behavior which included write ups,
level freezes, level drop, and earning zero points which effects the daily and weekly incentives.
Each youth was able to articulate the rewards used in the program and all stated youth can earn
incentives, canteen, snacks, and meals. Four of five youth indicated staff are consistent with the
BMS, and one stated the program does not have incentives and they are infrequently given. All
interviewed youth were able to explain the difference between each level and how to move from
level to level, and no youth can punish another youth. The facility administrator interview
confirmed he was able to explain the BMS, how rewards and consequences are implemented,
staff implementation, and consistency are monitored.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
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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 to 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. The program has forty-six cameras. All cameras
were operational at the time of the annual compliance review. The video coverage is stored for
thirty days. The program’s practice is to conduct checks of youth in their rooms every eight to
ten minutes. Ten-minute check sheets were reviewed from October 2024 to February 2025
finding no more than ten minutes passed without the staff actively observing each youth. Staff
completing the checks initialed the check sheet. Video review of thirty-minutes on thirteen
different days and shifts found no more than ten minutes passed without staff actively observing
youth with one exception. On February 15, 2025, staff completed a check at 1:42 a.m. and then
another check was not completed until 2:09 a.m.; however, staff entered the checks as being
completed on the ten-minute check form. This was found by the facility administrator (FA) during
the annual compliance review week and the FA reported the findings to the Department’s
Central Communications Center. Five staff were interviewed and four indicated room checks are
completed every eight minutes. The remaining staff member stated room checks are completed
every seven to ten minutes. The FA was interviewed and confirmed the program has forty-six
cameras which are all operational and hold thirty days of video recording.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program maintains a policy and procedures which addresses population census, counts,
and tracking of youth. The program’s policy indicates headcounts will occur and shall be
documented at the beginning of each shift. The program has adapted to counts being
completed formally and informally a minimum of every hour and every movement. Observations
throughout the annual compliance review week found staff conducting counts throughout their
shifts. The program utilizes the master control logbook to document youth counts and
movements. Logbooks were reviewed from October 2024 to February 2025. The logbook is
utilized to maintain a chronological record of events as they occur. The program headcounts are
conducted by the shift supervisor at the beginning of each shift to verify accuracy and document
count in the program’s logbook. Counts are conducted at beginning of shift, after each outdoor
activity, and during emergency situations. The logbook also tracks youth intakes, releases, head
counts, total daily census counts, transfers and movements outside of the facility. Staff were
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aware of all youth whereabouts and were able to provide the proper counts to the annual
compliance review team members. Five staff were interviewed, and each were aware of count
procedures, as required by program policy, including what to do in the case of an unsuccessful
count.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a policy and procedures addressing logbook entries. The program does
not use shift reports. The program maintains a chronological record of events, incidents, and
activities in a logbook as required by policy. Logbooks utilized by the program during the last
five months since the program start-up monitoring was completed in October 2024 were
reviewed. Each reviewed logbook is bound with numbered pages and entries were made in ink
with no white-outs or logbook entries being removed or missing, name, date and times of
program events to include staff and youth involved, and any internal incidents reported to the
Florida Abuse Hotline or the Department’s Central Communications Center were included.
Logbook entries included emergency situation, 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 security checks and other security checks
conducted by direct care staff, transports away from the facility, including the names of the staff,
youth involved, and the destination, requests by law enforcement to access any youth, removal
of any youth from the mainstream population, admission and releases, including the name,
date, and time of anticipated arrival or departure and mode of transportation. The program did
not have any escapes or escape attempts during the annual compliance review period requiring
documentation in the logbook. On-coming staff members participate in a shift briefing and sign
the logbook acknowledging they are aware of all information from the last two shifts and alert
changes. Each reviewed logbook entry was legible and included the time and date of the entry,
printed name and the signature of the staff member making the entry.
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 policy and procedures to address key control. Policy and procedures
addressed distribution, tracking, storage, inventory of keys, missing or lost keys, and
replacement of damaged keys. A review of the inventory matched the key rings in use.
Observations during the annual compliance review week found the staff personal keys are kept
in a secure lock box within the administrative office, which is not accessible to youth, staff
receive their assigned program keys at shift change by the shift supervisor and staff sign for the
keys. Each set of keys has an assigned key hook. Keys are assigned to staff according to their
department. Restricted keys, temporary keys, and visitor keys are all kept separate from each
other. Staff who are designated to be assigned permanent keys sign a Permanent Key
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Assignment Agreement prior to taken possession of permanent keys. There were no reports of
a broken or damaged key. There were no incidents of lost keys, which was verified by the
review of internal incident reports and the Department’s Central Communications Center
reports. A random check of three staff key rings confirmed the keys matched the inventory,
except for nursing keys which had two additional keys added which were not on the key ring
inventory. These keys were added to the key ring following new locks being installed in medical
during the annual compliance review week. The physical plant manager added these keys to
the inventory immediately. The physical plant manager is responsible for replacing broken or
damaged keys. Informal interviews with staff confirmed staff’s knowledge of the key rings and
assigned keys. All observations during the annual compliance review week found personal keys
were secured and staff were aware of program keys in their possession. Key control logs
documented the issuance and return of keys on a consistent basis. Staff who were designated
to be assigned permanent keys signed the Permanent Key Assignment Agreement, which is
maintained in the facility administrator’s office All five interviewed staff confirmed they had
knowledge of and implementation of key control policies and procedures. An informal interview
with the shift supervisor indicated assigned keys are only assigned by the FA, restricted keys
are kept apart from non-restricted keys, and only assigned staff can access restricted keys. The
shift supervisor tracks keys as they are signed out and back in by staff prior to receiving their
personal 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
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, youth, and incoming
and outgoing mail, which is clearly explained in the program’s policy and procedures and youth
handbook. The policy also states any staff who is found in possession of contraband in the
program will be subject to disciplinary action up to, and including, dismissal, as well as
procedures regarding notification of law enforcement for items considered illegal as defined in
Florida Statutes. The program disposes of found contraband by turning it over to the local
sheriff’s office and notifying the Department’s Central Communications Center (CCC). A review
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of eleven CCC reports found eight reports were involving searched of youth following their
return from the technical school. Two of the eleven CCC’s were for contraband being introduced
into the facility, which was turned over to the local sheriff’s office upon discovery of the
contraband items. The remaining one contraband incident was for staff bringing in their personal
cellular phone. The staff member’s employment was immediately terminated. Documentation
confirmed the program followed all contraband procedures regarding the CCC contraband
incidents. The program’s policy and procedures and the youth handbook define items and
materials considered contraband when found in the possession of youth, provides youth with a
list of contraband, and informs youth of the consequences if found with contraband. The
prohibited list includes personal cellular telephones and/or equipment and/or electronic devices
capable of taking pictures and/or audio/video recordings, which are prohibited in the secure
area. The list also includes unauthorized articles of clothing and food, controlled substances,
prescriptions or non-prescription drugs and any firearm or explosive device. Program policy and
the youth handbook also explains the searching of the physical plant, facility grounds, youth and
staff, and incoming and outgoing mail. The program maintains room search forms which
document any contraband findings and documents these findings in the program logbook. A
review of contraband forms from October 2024 to February 2025 was completed. Contraband
was found two times inside the secured area of the program and documentation supported
these findings as well as disposition of the contraband. Items not considered illegal contraband
was documented on the contraband search form as well as the disposition of the item. Any item
not considered illegal contraband will be sent to the youth’s home or retained at the program
until the youth’s release. The contraband notice is posted, and states law enforcement will be
contacted for anyone bringing in contraband and a criminal report will be filed. This practice was
confirmed through an interview with facility administrator. A review of the visitor’s log and
outside contractors sign in form confirmed the inclusion of the contraband attestation statement.
Eleven personnel records were reviewed for new staff hired since the program start-up
monitoring, and all had signed copies of the contraband attestation. The facility administrator
was interviewed and stated in the event illegal contraband items are discovered, the facility will
immediately contact local law enforcement and the CCC. All instances of contraband items and
the disposal of contraband items will be documented appropriately after being discarded or
turned over to local law enforcement or investigating agency. Five staff were interviewed and all
confirmed searches are conducted daily and each staff could articulate the search process.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a policy and procedures addressing searches and full body visual
searches. The program conducts searches as a method to prevent the introduction of
contraband and unauthorized items into the facility. The policy indicates full body visual
searches of youth are conducted after off-site transports. Searches are completed after
visitation, before and after every movement, before moving youth from an outside area into the
building, and prior to moving youth from the building to an outside area. The annual compliance
review team was able to observe an off-site transport and new admission during the week of the
annual compliance review. The review team observed a properly conducted search and full
visual searches before and after the transport. The review team also observed several youth
searches during the week of the annual compliance review week including transition to school,
to group, to recreation, and back to the dormitory. No youth were observed to be using any
tools, except for a mop and a broom. Search procedures and expectations were properly
explained to all youth before searches were conducted. Searches were conducted by staff of
the same gender as the youth, while a second staff member assisted with supervision.
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Searches were thorough and done in a manner which did not degrade the youth. All searches
were documented in the program’s logbook. The annual compliance review team was
electronically searched, and frisk searched every day of the annual compliance review week. A
video review of five staff searches was conducted and found all staff entering the facility were
electronically searched as well as frisk searched. Five staff were interviewed, and all staff stated
searches are completed at every movement, two staff stated after outings youth receive a full
visual body search, and one staff stated a youth is searched if suspected of having contraband.
Five youth were interviewed, and all stated they are searched when returning from an off-
campus activity, and four stated they are searched after an outdoor activity, visitation, and
meals. Two youth stated they are searched when items are missing at the program.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a policy and procedures addressing vehicles and maintenance. The
program utilizes two vans for youth transports. The two vans passed inspections this annual
compliance review period. The program is not a high/secure program; therefore, a safety screen
is not required. A member of the annual compliance review team observed both vehicles, and
all required equipment was identified, which included a seat belt cutter, window punch, and fire
extinguisher. In order to preserve the items inside of the first-aid kit, the kits are not stored in the
vehicles. Staff check out a travel bag which includes a first-aid kit, seat belt cutter, wire cutter,
knife for life, and youth information binder prior to a transport and returns the travel bag to the
program upon return. All seatbelts in the vans were in proper working condition. A random
check of ten personal vehicles and both vans was conducted during the annual compliance
review week, and all were found to be locked. A transport was observed during the annual
compliance review week and transport staff were found to abide by the transport policy and
procedures.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a policy and procedures addressing transportation of youth, outlining
staff to youth ratio during transports as one-to-five; however, if there are five or less youth, a
minimum of two staff are needed to perform all transports and one must be the same gender as
the youth. The program’s policy and procedures meet all requirements outlined by the
Department’s policy. The program’s transport vehicles were observed by the annual compliance
review team and both vehicles were found to be in working order. The program has an
approved transport list which is updated monthly to ensure staff driver’s licenses are valid. The
approved driver’s list is located in the administrative area. The annual compliance review team
observed the facility transporter conduct a routine check of the program’s transport vehicle prior
to being used. The vehicle was found locked and secured. The program is not a secure or high-
risk program, making the requirement for a safety screen, not applicable. The annual
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compliance review team was able to observe a transport and the staff to youth ratio was two-to-
one, a staff of the same gender was present, staff and youth wore their seat belts, and the youth
was not attached to the vehicle. Policy and procedures, observations, and interviews verified
staff will utilize a facility cellular telephone during transports. Five youth interviews indicated they
are never secured to the vehicle during transports and none of the interviewed youth had seen
contraband being placed in the vehicle. Five staff were interviewed and all stated youth must
wear seat belts, handcuffs and shackles during transport. All staff stated they bring a program
telephone with them during transports. Each staff stated they take a first-aid kit on transports,
suicide response kit, fire extinguisher, and the seat belt cutter. All staff stated they cannot use
personal vehicles to transport youth and the van is searched prior to, and after, a transport. In
the event of an accident or transport emergency, three staff stated they would pull off the road
to a safe location, ensure youth safety, assess the situation, notify the supervisor, and call 9-1-1
if necessary. One of the five staff stated they would call the facility administrator if an
emergency or accident occurred during a transport and the remaining staff was unsure of what
to do during an emergency or accident during transport.
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 which designates the facility administrator (FA) or the
unit manager as the person responsible for conducting the weekly safety and security audits.
The program’s Preventative Maintenance Checklist meets the requirements outlined in Florida
Administrative Code. The weekly safety audits are kept in a binder in the FA’s office. Findings
are discussed and a corrective action plan is implemented to fix any deficiency noted. During
the annual compliance review period, there were no inspections missing. The forms
documented safety and maintenance repairs needed and the date and time the repairs were
completed, or due to be completed. All forms were reviewed and signed by the FA. The forms
include checks of radios, cameras, keys, telephones, mechanical restraints, the generator,
flashlights, fire safety equipment, alarms, anchor points, youth rooms, recreation area, facility
grounds, correction action needed, and corrective action completed. A review of program
deficiencies related to safety and security during the annual compliance review period reflected
a minor deficiency closed in November 2024 for tool inventory/management. The interview with
the facility administrator confirmed the weekly safety audits are conducted in accordance with
program policy and procedures.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures to address tool inventory and management of
tools. The policy addresses the issuance, inventory, and control of equipment and tools. The
policy also states all class A tools are maintained in the maintenance office. Youth only have
access to class B tools which are brooms, mops and scrub brushes. Tools such as machetes,
bowie knives and other blade knives are prohibited by policy. The program has identified their
physical plant manager and facility administrator (FA) as the program’s tool control managers.
The policy classifies tools into two categories as class A tools and class B tools. Class A tools
are hazardous with sharp edges or points and with a high potential to be used as a weapon to
inflict serious bodily harm such as knives, hammers, screw drivers, and electric drills. Class B
tools do not have sharp edges or points such as brooms, mops, and scrub brushes. The
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physical plant manager or FA inventories all tools daily at the beginning of their shift and at the
end of their shift except on FA’s or physical plant manager’s assigned days off. The physical
plant manager completes a sign-in and out sheet when a tool is used. Class B tools are
inventoried monthly. Tools are inventoried prior to being issues for work and following work
activities. Staff must sign-in and out the class B tool being used. A review of the inventory and
verification of thirteen tools found the inventory to be accurate. At the time of the annual
compliance review, the program only had thirteen total tools. The plant manager stated there
were no dysfunctional tools which required disposal or replacement.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures addressing youth tool handling and supervision
and includes all required elements. Youth do not have access to class A tools, only class B tools
which consist of a broom, mop, and scrub brush and staff must sign them out from the secure
closet located on the dormitory. The program completes risk assessments prior to youth
handing tools. The program maintains a ratio of one staff to five youth for vocational training
which does include the use of tools while the youth attend a local technical school. Five youth
case management records were reviewed, and all records indicated youth have been trained on
the proper usage of class B tools during their orientation process. Youth signed an
acknowledgement of tool training during the orientation process for class B tools. The signed
acknowledgement form is filed in each youth’s record. Each youth receives a risk assessment
monthly. Youth do not participate in work projects During the annual compliance review week,
youth were observed to be cleaning their rooms and dormitory using class B tools only at a ratio
of three youth to two staff. There were no work projects to observe during the annual
compliance review week. Five youth were interviewed, and all five confirmed youth are only
allowed to use a scrub brush, mop, and a broom. Five staff were interviewed and all five staff
stated youth are allowed to use class B tools only. One of five staff also stated youth must
complete a risk assessment prior to handling tools.
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 maintains a policy and procedures which addresses outside contractors. The
physical plant manager is responsible for escorting any outside contractors around the facility
and ensuring tools are signed in and out. The program has established guidelines for outside
contractors which includes information regarding tool control and restrictions. The program has
a form to be signed by outside contractors which addresses how tools will be checked upon
arrival to and departure from the program, restrictions to youth work area access, immediate
reporting of missing tools, restriction of personal cellular telephones and/or equipment capable
of taking pictures and/or recording audio/video in secure areas, and the contraband attestation
statement. If any restricted items are required, the facility administrator must give permission.
The form also requires contractors to list each tool brought into the facility. This list is reviewed
by the physical plant manager or designee before the contractor has access to a secure area.
This list is again reviewed before the contractor exits the program. The contractor’s failure to
sign this form prohibits access to work within the program. Outside contractors are escorted and
supervised by the physical plant manager or designee any time they are within the facility. The
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review team was not able to observe this process during the annual compliance review week.
Three program invoices were reviewed to ensure outside contractor agreements were signed on
the date of service. All invoices and contractor agreements matched and there were no
discrepancies found.
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 maintains a policy and procedures to provide for the safety and security of both
staff and youth in the event of an emergency or disaster. All drills for the annual compliance
review period were reviewed. The documentation showed drills were consistent with the
Continuity of Operations Plan (COOP). All drills contained the type of drill, date, time,
participants, and a brief scenario, including findings and recommendations. Fire drills were
conducted monthly on each of the two shifts with no exceptions being noted. There were fifteen
fire drills required, and all fifteen drills were completed. Emergency drills were conducted semi-
annually as required with an escape drill occurring February 15, 2025, on both shifts and an
actual hurricane evacuation occurring October 7. 2024, which was documented as a drill for
both shifts. Evacuation and egress routes were posted throughout the facility, and all nine fire
extinguishers were inspected annually. The facility administrator reported the program shall
conduct practice events or drills at least semi-annually for the following emergency or disaster
situations: riots and other major disturbances, hurricane or other severe weather/evacuation
drills, hostage situations, escape drills, bomb threats, chemical spills, flooding, and terrorist
threats/acts; fire drills shall occur monthly. Five staff were interviewed and reported they all have
participated in drills to include fire, suicide, medical and COOP. Five youth were interviewed and
reported they have been instructed on what do in case of fire and have participated in a monthly
drill.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a policy and procedures addressing the Continuity of Operations Plan
(COOP). The program maintains a combined COOP and Emergency Disaster Preparedness
Plan. The policy states the COOP is located in the facility administrator’s (FA) office and
observations during the annual compliance review week confirmed this practice as well as
confirming it is readily available to staff. The plan addresses alternative housing plans approved
by the applicable Department regional director/designee. The COOP was last approved on July
24, 2024, and updated February 13, 2025, and submitted for approval. The COOP addresses
the following: fire prevention and evacuation, severe weather, disturbances or riots, bomb
threats, hostage situations, chemical spills, flooding, terrorist threats or acts, staff roles and
responsibilities, any equipment and supplies needed, information about youth which may be
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needed, alternative housing arrangements, provisions for continuity of care and custody of
youth, and provisions for public protection. The program has food and necessary supplies
readily available in case of emergency evacuation, which are maintained on-site in the kitchen
storeroom. Emergency equipment maintained at the program includes bedding, pillows, extra
clothing and undergarments, shoes, hygiene items, and copies of group materials. The program
maintains an administrative hard copy file on all youth in case of emergency, with all required
information which are in the case management office and FA’s office. Five youth emergency
files were reviewed which confirmed this practice. The FA interview confirmed the COOP is in
the FA’s office.
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 maintains a policy and procedures addressing storage and inventory of flammable,
poisonous, and toxic items and materials. The program’s policy and procedures also address
chemical spills and clean-up of chemical spills. This process is also captured in the Continuity of
Operations Plan. The program’s flammable, poisonous, and toxic materials are stored in a
flame-resistant cabinet located outside the facility in the maintenance shed inaccessible to
youth. The program maintains proper inventory of these items. The physical plant manager,
facility administrator (FA), and supervisors are the individuals authorized to handle flammable,
poisonous, and toxic items. A binder is stored with the chemicals containing the Safety Data
Sheets (SDS) for the items located in the cabinet as well as cleaning supplies. The cleaning
supplies are maintained in the locked maintenance office and can only be accessed by the
physical plant manager, supervisors, and FA. Staff sign these items in and out with each use.
The policy prohibits chemicals from being poured on the ground or being disposed of by any
method other than what is outlined by the biohazard guidelines. Disposal procedures are in
accordance with Occupational Safety and Health Administration standards. All flammable, toxic,
caustic, and poisonous items are disposed of by the physical plant manager or FA at the county
waste management site, if the chemical cannot be returned to the vendor. The program’s
physical plant manager was interviewed on the proper procedures of disposing chemicals and
stated all items for disposal are collected by the county waste disposal or returned to the
vendor. The physical plant manager further stated the program has not needed to dispose of
any chemicals and a review of the disposal log confirmed this. Kitchen staff dispose of kitchen
waste by use of the plumbing drains. Kitchen grease is disposed of monthly by a contracted
grease disposal company. A review of the five flammable, toxic, caustic, and poisonous items
being maintained on-site were confirmed by the inventory with no items missing and a SDS
included for each. An interview with the FA validated program’s practice.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
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removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedures addressing youth handling and supervision of
flammable, poisonous, and toxic materials. The policy prohibits youth using those items and
materials which are flammable, poisonous, and toxic. These materials are stored outside the
building in the maintenance room/office. Youth do not have access to these items and are
supervised by staff during daily cleaning. Video camera observations, during the annual
compliance review week, reflected youth participating in facility clean-up and found staff spray
the cleaning chemical and youth wipe the area. Five youth were interviewed and all youth
indicated they are prohibited from using chemicals/cleaning products at the program.
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 maintains a policy and procedures to allow visitation and communication for youth
while in the program. The visitation procedures and schedule are posted on the wall in the
lobby, the multipurpose room, and dormitory hallway. The visitation and communication
procedures are covered in the youth handbook and addressed on the orientation checklist. The
program utilizes staff translators or an online interpret site with live translators, if necessary.
Visitation documentation indicated visitation is being offered on Saturday or weekdays if
requested by the youth’s parent/guardian as required by policy and contract. The visitation,
telephone, and correspondence logs were reviewed. The logs showed youth have contact with
only approved persons. Incoming and outgoing mail is searched and recorded in the
correspondence logs, then given to the youth’s case manager who delivers the mail to the youth
and has them open the mail in front of them. There were no youth applicable for a history of
human trafficking; therefore, the program is not required to request clarification from youth’s
juvenile probation officer about any parent/guardian past or current human trafficking
investigation involvement. Five youth and staff interviews confirmed youth can make weekly
calls to their parent/guardian. The facility administrator stated they use an online language
interpreter site, if needed.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a policy and procedures stating recreation activities shall be provided for
a minimum of one hour a day. Policy states a schedule shall be made with a selection of
activities for the youth to choose from. The youth have a variety of recreation and leisure
activities which promote social and cognitive skill development, creativity, teamwork, healthy
competition, mental stimulation, and physical fitness. The program’s schedule has structured
indoor and outdoor recreation and leisure activities which includes large muscle activity for a
minimum of one hour each day. A review of the logbook during the annual compliance review
period indicated recreation was conducted as scheduled. The program’s contract requires a
recreation therapist. At the time of the annual compliance review, this position had been vacant
since October 2024. A review of five youth case management records confirmed each youth
record contained a wellness plan and was incorporated into their performance plan. Five youth
were interviewed, and all five stated the program allows them an opportunity to exercise, play
outside, read a book, play a board game, sports, or physical fitness activities for at least one
hour daily. Five staff were interviewed, and confirmed recreation was occurring and included
activities such as football, basketball, running, board games, and playing video games.
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.
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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.
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Standard 6: Safety and Security
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program has a policy and procedures ensuring the implementation of career and technical
education services. The contractually required career and technical education services are
Florida Ready to Work Soft Skills, Occupational Safety and Health Administration certification
(OSHA-10), and cardiopulmonary resuscitation (CPR)/first-aid. Additionally, the program is
contracted to work with Pinellas Technical College to enroll youth into at least one of their
technical courses. These technical courses include the following industry certifications from the
Master Credentials List: Autodesk Certified User-Auto Computer Aided Drawing, National
Center for Construction Education & Research (NCCER) Electrical, Heating Ventilation & Air
Conditioning Excellence Employment Ready, NCCER Plumbing, American Welding Society
Certified Welder, and Automotive Service Excellence Damage Analysis and Estimating.
The program’s career and technical education (CTE) coordinators, facilitate Florida Ready to
Work Soft Skills and OSHA10. Certification is not required to facilitate Florida Ready to Work
Soft Skills and OSHA10 as these are certified by each organization upon youth passing the
web-based modules and assessments. Code Blue CPR was contracted to provide the required
CPR/first-aid certification.
Fourteen youth completed the industry certifications for OSHA10 and first-aid/CPR. Three of the
fourteen youth have been released from the program, with eleven youth actively working
towards completing Florida Ready to Work Soft Skills and are on track to complete within the
contracted time frame. One youth has completed the required Soft Skills and is now working in
Digital Skills. Five youth case management records were reviewed. None of the youth were
applicable for Florida Ready to Work Soft Skills. Documentation confirmed all five youth are
completing OSHA-10 and CPR/first-aid.
Five youth were interviewed. All five confirmed they are being provided educational services. All
five youth stated they participate in CTE services. Three out of five youth stated they receive
micro credentialing and two out of five youth stated they receive Florida Ready to Work Soft
Skills. An interview with the facility administrator (FA) confirmed youth are receiving CTE
services through Florida Virtual School and Pinellas Technical College. FA stated program or
contracted provider provides youth with Florida Ready to Work, Career Safe, financial
management, interviewing skills, resume building, and cyber security and awareness.
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6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures which address educational access. A review of the
residential contract providers' program activity schedule confirmed it coincided with the
provider’s scheduled class times. A review of three randomly selected days of video camera
footage and logbook entries confirming youth were escorted to and from education classes, as
scheduled is not applicable due to annual compliance review team being unable to determine
the precise times students are dropped off and picked up from Pinellas Technical College,
where they attend post-secondary classes; however, logbook reviews indicated on one day the
transportation van departed on time, while on two other days, it left the program eight minutes
late to drop off the youth at Pinellas Technical College. A review of logbook entries for one day
each month of the annual compliance review period verified students arrived and departed the
program on time to attend Pinellas Technical College, except for one day of one month. Five
youth were interviewed. All five indicated there are not disruptions during school.
6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The contract provider has a policy and procedures to address educational access. A review of
the education schedule indicates, at a minimum: 250 days of education programming, a
minimum of twenty-five hours of educational access weekly, and twenty of the 250 days
allocated for teacher planning and/or training. The schedule was approved and submitted to the
Department. Youth receive credits for their educational and training experiences while in the
program. A review of three randomly selected days of video camera footage and logbook
entries indicated education classes were not facilitated as scheduled. Specifically, on one day
there was no teacher in the classroom until 10:00 a.m., ninety minutes past the scheduled 8:30
a.m. start time. Additionally, on another day school started eighteen minutes late. The lead
educator was interviewed, which confirmed the accuracy of provided educational schedule and
confirmed the educational instruction schedule was being adhered to.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The contract provider has policy and procedures to develop and implement a vocational
development program. The education contract provider is responsible for developing a career
education program appropriate for the educational abilities and goals of youth in the program
and appropriate for the length of stay and classification of youth in the program. The career
education program does include Type 1 services through life management skills and personal
finance and money management courses. The career education program also includes Type 2
services through career and technical education (CTE) course offerings which provide
exploration and knowledge of occupations within those specific careers. The career education
program includes Type 3 services through CTE course offerings which provide content and
competencies for those specific careers.
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Each CTE course offering by the education provider includes soft skills for those specific
careers. The education contract provider is also responsible for providing Career and
Professional Education (CAPE) courses leading to pre-apprentice certifications and industry
certification. Youth at this program are enrolled in Digital Information Technology and
Foundations of Programming which are courses which lead to the CAPE Industry Certification.
The lead educator was interviewed. The lead educator stated program provides CTE services,
not the educational contract provider.
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The contract provider has a policy and procedures for staff and youth to develop an Education
Transition Plan upon admission, which includes provisions for continuation of education and/or
employment. Three closed youth case management records were reviewed. None of the three
records were applicable for an education transition plan. Three additional records were
requested for a minimal sample of three records. The program only had two youth applicable for
requiring an Education Transition Plan. A review of both youth records found a a youth transition
plan developed collaboratively with the youth, program, education, and aftercare staff. Each
plan detailed specific plans for continued education or employment, a recommended post-
release educational placement based on the youth's individual needs and performance, and the
services and interventions provided to address their assessed educational needs and post-
release plans. There was no mention of Department personnel for youth in residential programs
within the plan. The parent/guardian section of the plan was not applicable as both youth are
eighteen years old, and the personnel from the post-release school district section was not
applicable because the youth are graduates and will not be returning to a post-release school
district. Additionally, the certified school counselor and specific monitoring responsibilities
sections were marked not applicable due to the lack of applicability for the population of this
program of students who are working on post-secondary education. Five youth were
interviewed. All five youth confirmed participation in the development of their education
transition plan. The lead educator was interviewed. The lead educator confirmed their role in
helping youth develop an Education Transition Plan within ten days of entry into the program, as
well as continuation of education or employment. The lead educator stated the Education
Transition Plan can include exceptional student education services, a Section 504 plan, English
Language Learner services, a Multi-Tiered System of Supports, general equivalency diploma,
and Florida Virtual School Home Education.
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The contract provider has a policy and procedures to ensure qualified instructional personnel
are provided to teach and provide exceptional education and related services to youth in the
program. A review of documentation confirmed instructors and Florida Virtual School flex
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teachers hold valid and active Florida educator's certificates with appropriate coverage as found
in the Course Code Directory; however, one instructor was found to be teaching out-of-field
courses without school board approval. One youth received instruction from this instructor and
their parent/guardian was not notified. All other teachers reviewed are teaching “in-field”.
Sections regarding certificates with alternative coverage and subject matter expertise were not
applicable.
6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
The education contract provider is responsible for referring all youth who receive their high
school diploma or equivalent to Florida Youth College so they can work with a Career Navigator
on postsecondary courses and/or enrollment in a state or technical college. Three closed youth
case management records were reviewed. All three reviewed youth were already referred to
Florida Youth College prior to being admitted to the program due to transferring from another
program.
Five youth were interviewed. Three of five interviewed stated they were participating in post-
secondary education. One youth stated he will begin post-secondary education in March 2025.
The remaining youth has not yet completed their high school diploma or equivalent. The three
youth who are participating in post-secondary education stated they are in classes for welding,
electrician services, and culinary arts.
The lead educator was interviewed. The lead educator confirmed youth are referred to the
Florida Youth College upon completion of their high school diploma or its equivalent.
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Each referral received by Florida Youth College (FYC) from the education contract provider is
assigned a Career Navigator. The Career Navigator then connects with youth through the
residential contract provider to schedule an orientation session. During orientation, the youth
and Career Navigator develop a career pathway plan to include postsecondary courses and/or
enrollment in a state or technical college. The Career Navigator continues to assist youth on
their career pathway plan and have incremental follow up sessions scheduled through the
residential contract provider.
Three closed youth case management records were reviewed. Each youth had an assigned
Career Navigator when upon entry to the program. The partnership between program and
Pinellas Technical College is new model within the Department. As a result, the process of how
Career Navigators with FYC and CTE Coordinators at program would assist youth has not yet
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clearly been established. Career Navigators did assist each youth with their application and
enrollment at Pinellas Technical College and monitored each youth’s progress at thirty, sixty,
and ninety-day follow ups. Career Navigators also assisted youth in creating a career plan
based on the youth’s interests and aptitude. After the ninety-day follow ups, the CTE
Coordinators assisted youth with the transfer to their home county college prior to their release;
therefore, none of the youth were applicable for 180 day follow-ups from Career Navigator staff.
An informal interview was conducted with the Florida Scholars Academy instructor. The
instructor stated youth are very excited about the option to go to Pinellas Technical College.
When asked which options are offered to youth during their time in FSA, instructor stated digital
literacy courses are provided to involve youth in technology as well as other courses in health
and nutrition. Instructor also stated they support youth’s academic and credentialing progress
through one-on-one, group, and intervention services.
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report_type: QI Residential

program_name_raw: Britt Technical Youth Academy

rule: Indicator 1.15

excerpt: Advisory Board

rating: Limited Compliance