summary: SPEP - FY21-22

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
St. Johns Youth Academy
Sequel Youth and Family Services
(Contract Provider)
4500 Avenue D
St. Augustine, Florida 32085
Primary Service: Skillstreaming the Adolescent
SPEP Review Period: 2/1/2021-1/31/2022
SPEP Review Conducted: 3/17/2022
Florida Department of Juvenile Justice
Report Date: 4/12/22
Introduction
The Standardized Program Evaluation Protocol (SPEP) is data-driven rating system for
evaluating program effectiveness. The SPEP was developed by relying on hundreds of studies
that have examined key characteristics of programs that demonstrated their ability to reduce
recidivism. To determine a SPEP score, the program’s services are compared to characteristics
of effective programs in the research of a similar type.
The SPEP score is composed of four principle characteristics that have been shown to predict
reductions in youth recidivism; service type, quality of service, dosage (amount of service), and
youth level of risk.
• Service Type: service type points are awarded based on the group category that the
service falls within
• Quality of Service: quality points are awarded by determining the extent to which the
program is delivered in what research suggests is a high-quality manner
• Amount of Service: or “dosage” refers to the amount and duration of services that were
received
• Risk Level: refers to the level of criminogenic risk for youth involved in the intervention.
The final output of the SPEP review is the Program Optimization Percentage (POP). This rate is
derived from the Basic Score and Program Optimization Score. The POP rate is a percentage
score that indicates how the service rates in effectiveness when compared to the potential
effectiveness if optimized to match the most effective services in the research. This means the
POP rate represents how close the program’s Primary Service is to its potential for that Primary
Service Type. For example, a POP rate of 55% would indicate that the program’s Primary
Service is operating at 55% of its potential effectiveness for recidivism reduction based on the
SPEP research.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 2
Basic Score: 20 Points
1. Primary Service and Supplemental Service Types POS: 20 Points
POP: 100%
There are five Primary Service Types that have been classified into Groups with a maximum
number of points possible for rating purposes. Some Primary Service Types may also have
qualifying Supplemental Service Types that could earn a program an additional 5 points.
The Primary Service for this program is Skillstreaming the Adolescent.
The program was awarded 15 points because the Primary Service is identified as a Group 3
Service. The specific Sub-Component Service Type identified is Social Skills Training. The
Primary Service was identified as this type of service as it focuses on developing social skills
required for an individual to interact in a positive way with others.
An additional 5 points was awarded based on a Qualifying Supplemental Service. The Qualifying
Supplemental Service was identified as None (automatic 5 points added to score), which was not
demonstrated to have been implemented.
The Primary and Supplemental Service Raw Score is equal to the sum of the Primary Service
points plus the Qualifying Supplemental Service points.
Note: Quality information is evaluated during quarterly and annual reviews.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 3
Basic Score: 10 Points
2. Overall Quality of Service Delivery Score POS: 20 Points
POP: 50%
The Quality of Service Delivery Score is the sum of the scores for the seven treatment quality
indicators. The Program Optimization Percentage Rating determines the Overall Quality of
Service Level:
Indicator Sum Score 0-3 = Low; Sum Score 4-7 = Medium; Sum Score 8-10 = High.
Sum of all Indicator Scores (a – g below): 6 Points
Overall Quality of Service Delivery Level:
Low (Raw Score = 5)
Medium (Raw Score = 10)
High (Raw Score = 20 Points)
Basic Score: 0 Point(s)
a. Facilitator Training
Maximum Possible Score: 1 Point
All facilitator(s) of the Primary Service must have received formal training specific to the
intervention or model/protocol.
The program utilized Skillstreaming the Adolescent as a primary service for the annual review
period of February 1, 2021 through January 31, 2022. A review of documentation showed
fourteen (14) staff were trained in the primary service- one recreation therapist, the former clinical
director, the current clinical director, the former assistant clinical director, and ten therapists. The
program did not provide proof of training for the former assistant clinical director. The program has
a written training protocol for the Skillstreaming service. The training is a four-hour in-service
training conducted by the clinical director or regional clinical director. The training is broken down
into three parts. The first part is the introduction to Skillstreaming and is one hour in length. The
second section is the review of materials and is two hours in length. The third section is the
observation by the clinical director of the trained staff conducting a group session. The
documentation showed all fourteen trained staff conducted groups during the annual review
period. The former clinical director and regional clinical director conducted all the monthly internal
fidelity monitoring. A trained staff member can conduct the monthly fidelity monitoring.
The program can earn 1 point if all facilitators receive formal training prior to delivering services to
youth.
At the time of the review, the program did not meet criteria to earn a score of 1.
Basic Score: 2 Point(s)
b. Treatment Manual/Protocol
Maximum Possible Score: 2 Points
There is a specific written manual/protocol detailing delivery of the Primary Service.
The program utilized the Skillstreaming the Adolescent 3rd edition. The manual introduces
Skillstreaming, contains scripts for the facilitators to follow as well as specific instructions for each
skill taught, example role plays, and student exercises. There are no separate student manuals.
The facilitator makes copies of the skill cards for each skill and hands out those copies to the
youth in the group. There are fifty skills taught to the youth. Skillstreaming is an open group with
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 4
groups being run year-round. The program maintains the attendance sheets and monthly internal
fidelity checks in the SPEP binder titled Skillstreaming. The program states all youth receive the
primary service. The current clinical director states the program decides which youth receives the
intervention first by determining if the youth has previously completed the required dosage of
services. If the youth has not, the youth is automatically included in the next incoming cohort. If
the youth has completed the required dosage, but continues to struggle with personal
accountability for their actions, they can be re-admitted in the next incoming cohort.
The primary service is a closed group with groups held on Tuesdays and Thursdays.
Basic Score: 1 Point(s)
c. Observed Adherence to the Manual/Protocol
Maximum Possible Score: 1 Point
Upon observation of the Primary Service by the Quality Improvement reviewer, the facilitator of
that service adhered to the written protocol/manual.
A session of Skillstreaming the Adolescent was observed on 2/24/2022. The group began at
2:45p. The facilitator began with group check in and then went over the group rules. The facilitator
then reviewed the skill from the last group. The facilitator asked the youth to read one step each
and to explain what they think the skill step means. The facilitator assigned the youth to role play.
The skill steps were written on chart paper. The facilitator passed out handouts and went over the
homework with the youth. The facilitator demonstrated knowledge of the material and ensured the
youth understood the concepts of the skill learned. The group ended at 3:23p.
The technical assistance specialist informed the therapist that the group should run for a full hour.
The facilitator stated she had to go out to get the youth from recreation outside before the start of
the group.
Basic Score: 1 Point(s)
d. Facilitator Turnover
Maximum Possible Score: 2 Points
Measures the extent to which facilitators of the specific intervention/service have changed as
well as gaps in service of that Primary Service.
The documentation reviewed for the annual review period of February 1, 2021 through January
31, 2022 shows the program experienced turnover for facilitators of Skillstreaming the Adolescent.
The assistant clinical director, clinical director, and nine therapists left the program during the
annual review period. There were no gaps in service, but the turnover did affect the primary
service. There were youth in the program who were not receiving the primary service but were
instead receiving a Skillstreaming-adjacent service. The clinical director documented the
Skillstreaming-adjacent service on the attendance sheets and did not enter this data into the
Evidence-Based Services Module (EBS). The primary service is an open group run year-round.
The facility administrator stated the process in the event of facilitator turnover is the program
plans to implement a co-facilitator guideline in which there are two facilitators running each group
so, in the event one of the facilitators is out for any reason, the group can continue.
The current clinical director stated turnover is also handled by scheduling incoming therapists to
participate in Skillstreaming training. Until that time, therapists who are not trained engage youth
in a Skillstreaming related (adjacent) life skills group which focuses on similar life skills. "Related
to Skillstreaming" is also documented on the sign in sheets.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 5
The program can earn 2 points if facilitator turnover does not impact groups.
At the time of the review, the program did not meet criteria to earn a score of 2.
Basic Score: 1 Point(s)
e. Internal Fidelity Monitoring
Maximum Possible Score: 2 Points
The program has a process to monitor the delivery of the intervention to examine how closely
actual implementation matches the model protocol.
The documentation reviewed for the annual review period of February 1, 2021 through January
31, 2022 shows the program completed twenty internal fidelity monitorings for facilitators of
Skillstreaming the Adolescent. The program is missing a monthly fidelity monitoring for the month
of February 2021 for two therapists; March 2021 for one therapist; April 2021 for one therapist, the
assistant clinical director, and the clinical director; June 2021 for the assistant clinical director; and
October 2021 for one therapists. The program did not complete any fidelity monitoring for the
months of November 2021, December 2021, and January 2022. The former clinical director and
the regional clinical director conducted all monthly fidelity monitoring for the annual review period.
The facility administrator stated the program conducts internal fidelity monitoring on a monthly
basis. Facilitators trained must be monitored monthly by another trained and experienced
facilitator.
The current clinical director stated the fidelity monitorings missed for the months of November
2021, December 2021, and January 2022 were due to facilitator turnover and availability of
trained therapists to conduct the fidelity monitoring.
The program can earn 2 points if if fidelity monitoring is completed every month for each
facilitator.
At the time of the review, the program did not meet criteria to earn a score of 2.
Basic Score: 1 Point
f. Corrective Action based on Fidelity Monitoring
Maximum Possible Score: 1 Point
The program has a process by which corrective action is applied and demonstrated based on
the fidelity monitoring of the delinquency intervention/therapeutic service.
The documentation reviewed for the annual review period of February 1, 2021 through January
31, 2022 shows the program did not identify any corrective actions on the monthly internal fidelity
monitorings. The facility administrator stated the program’s in-house corrective action process is,
when corrective action is needed, the facilitator to meet with the clinical director to review findings
from the completed fidelity monitoring to address concerns and provide support. The facilitator will
be re-assessed at the next month’s fidelity monitoring.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 6
g. Evaluation of Facilitator Skill Delivering the Basic Score: 0 Point
Intervention Maximum Possible Score: 1 Point
Performance evaluations of the facilitators of the specific intervention/service include
evaluation of skill in delivering the intervention/service.
A review of documentation for the annual review period shows the program has not completed
annual evaluations for the trained facilitators. The program provided annual evaluations
conducted during the previous annual review period. The clinical director stated eight of the
therapists left prior to their annual evaluations. Two therapists needed updated annual evaluations
completed. The clinical director stated those evaluations would be completed within sixty days.
The evaluation has an area titled facilitator skill delivering evidence-based practices. The annual
evaluations provided were for six therapists. Those prior evaluations had remarks which
discussed the facilitator’s skill in delivering Skillstreaming the Adolescent.
The program can earn 1 point if each facilitator’s performance evaluation includes discussion of
their skill in delivering this primary service.
At the time of the review, the program did not meet criteria to earn a score of 1.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 7
3. Amount of Service - Duration
Basic Score: 4 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 40%
Research indicates the target duration of 16 weeks for this type of service. Of the 56 youth in the
sample, 57% (32 of 56) reached at least the indicated target duration. Further explanation is
detailed in the Summary and Recommendations below.
Note: Dosage information (duration) is calculated from the Juvenile Justice Information System
(JJIS) Evidence-Based Services module. Duration is included for the youth in the SPEP sample.
4. Amount of Service – Contact Hours
Basic Score: 8 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 80%
Research indicates a target of 24 contact hours for this type of service. Of the 56 youth in the
sample, 95% (53 of 56) reached the indicated target contact hours. Further explanation is detailed
in the Summary and Recommendations below.
Note: Dosage information (contact hours) is calculated from the Juvenile Justice Information
System (JJIS) Evidence-Based Services module. Contact hours are included for the youth in the
SPEP sample.
5. Risk Level of Youth Served:
Basic Score: 23 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 92%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 89%
Moderate to High Score: 10 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 83%
Table 1
Moderate = 1 youth
Moderate-High = 21 youth
High = 28 youth
Total Youth in Sample = 56 youth
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 8
Percentage of Youth with High-Risk Level to Reoffend: 50%
High Score: 13 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 100%
Table 2
High = 28 youth
Total Youth in Sample = 56 youth
The risk level score is compiled by calculating the total percent of the SPEP sample that score
Moderate to High-Risk to reoffend and also the total percent of the SPEP sample that score High-
Risk to reoffend.
Of the SPEP sample, 89% (50 of 56) youth scored Moderate to High-Risk to reoffend, for a score
of 10 points.
Of the SPEP sample, 50% (28 of 56) youth scored High-Risk to reoffend, for a score of 13 points.
Note: The latest Community Assessment Tool (CAT) prior to the placement date was used in the
derivation of the risk level score. This CAT provides the best indication of the risk to re-offend
level of the youth when the youth was first placed in the program.
Summary and Recommendations
Program Program
Category Basic Score Optimization Optimization
Score Percentage
Primary and Supplemental Service Type 20 20 100%
Quality of Service Delivery 10 20 50%
Amount of Service: Duration 4 10 40%
Amount of Service: Contact Hours 8 10 80%
Risk Level of Youth Served 23 25 92%
Totals 65 85 76%
This SPEP report evaluates Skillstreaming the Adolescent, an intervention delivered at St. Johns
Youth Academy.
56 youth completed the program during the review period. Of those youth, 56 were included in the
sample.
The program scored Medium for Quality of Service Delivery.
The program earned 4 points for Amount of Service: Duration. Of the 56 total youth sampled, only
32 included dosage with end dates in the EBS Module. Of those youth with correct dosage, 32
received at least the recommended weeks of service. Youth in the sample completed between 18
and 98 weeks of service, with an average of 37 weeks.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 9
The program earned 8 points for Amount of Service: Contact Hours. Of the 56 total youth
sampled, all 56 included dosage in the EBS Module. Of those youth, 53 received at least the
recommended hours of service. Youth in the sample completed between 6 and 88 hours of
service, with an average of 40 hours.
The program was awarded 23 available points for Risk Level of Youth Served. This is calculated
using data from the Community Assessment Tool (CAT). This score reflects youths' most recent
CAT score prior to placement at the program. The program itself has no control over youths' CAT
risk level because the scored assessment was administered prior to the youths' admission.
RECOMMENDATION(S):
St. Johns Youth Academy can optimize their SPEP Quality of Service Delivery score by ensuring
all facilitators receive formal training prior to delivering services to youth, facilitator turnover does
not impact groups, fidelity monitoring is completed every month for each facilitator, and each
facilitator’s performance evaluation includes discussion of their skill in delivering this primary
service.
St. Johns Youth Academy can optimize their SPEP Amount of Service score by ensuring that
dosage for all youth is recorded accurately in EBS and by ensuring that youth receive the full
targeted dosage of service.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 10

file_name: FY2021-22 SJYA Skillstreaming.pdf


state: FL

facility_name: ACTS THERAPEUTIC GROUP HOME

summary: Initial Licensure — 4 deficiencies

raw_content:
Inspection: Initial Licensure
Survey Date: 11/14/2022
Track ID: 9F5H
Deficiencies: 4

  [C0027] OPERATING STDS - FACILITY ACTIVITIES SPACE(5)(a)2. Grounds shall have space for children's activities, which shall be designed based on the type of activities offered and age appropriateness. The grounds shall be maintained in a safe and reasonably attractive manner and kept free of standing water, debris, garbage, trash and other hazardous conditions.  (Correction: 01/22/2024)
  [C0038] OPERATING STDS - FACILITY STUDY AREAS(5)(b)5. Study areas shall have tables, chairs, appropriate lighting and bookshelves suitable for children's use.  (Correction: 01/22/2024)
  [C0043] OPERATING STDS - FACILITY BATHROOMS(5)(b)10. Bathrooms shall be provided and shall be separated from halls, corridors and other rooms by floor to ceiling walls. Children shall not have to go through another child's bedroom to get to a bathroom. Each bathroom shall have:
a. At least one toilet, washbasin, and tub or shower easily accessible to the bedroom area for each six children;
b. When multiple toilets are located in a single room, they shall be separated by individual toilet stalls to provide individual privacy;
c. Bathrooms with non-slip surfaces in showers or tubs;
d. Toilet paper and holders, individual hand towels or disposable paper towels and soap dispensers;
e. Distortion-free mirrors at a height convenient for use by children;
f. A place for toiletry storage; and
g. In a facility that houses children with physical handicaps that limit mobility, all toilet and bathing areas shall meet the requirements of the Florida Building Code for accessibility.  (Correction: 01/22/2024)
  [C0044] OPERATING STDS - FACILITY BEDROOMS(5)(b)11. Bedrooms.
a. Children shall not share sleeping areas with adolescents, and children or adolescents shall not share sleeping areas with adults.
b. Separate sleeping areas shall be provided for boys and girls.
c. The provider shall not permit children with physical handicaps that limit mobility to sleep above the first floor.
d. Bedrooms shall have at least 50 square feet of usable floor space per resident.
e. Bedrooms with multiple occupancy shall be limited to a maximum of 4 occupants.
f. Bedrooms for children shall be separated from halls, corridors, and other rooms by floor to ceiling walls.
g. Children's bedrooms shall be ventilated, well-lighted and located convenient to a bathroom and shall have at least one operable exterior window.
h. Each bedroom shall be furnished with the following equipment for each child: personal storage space, such as a dresser; space for hanging clothes; a bed and mattress in good repair, which is at least 36 inches wide and 72 inches long, bedding suited to the seasons and a pillow.
i. Clean sheets, pillow cases, and blankets shall be provided for each child upon arrival. Sheets and pillowcases shall be laundered at least weekly unless greater frequency is indicated. A bedspread must be provided. Blankets or quilts must be available for use during cold weather. Bedspreads and blankets or quilts must be laundered at least quarterly, or more often, as needed.
j. Sleeping areas shall be assigned based on children's individual needs for group support, privacy or independence and shall be appropriate to their ages, developmental levels and clinical needs.
k. Children shall be allowed to keep and display personal belongings and to add personal touches to the decoration of their rooms. The provider shall have and follow written procedures specifying what types of decoration are acceptable.  (Correction: 01/22/2024)

source: AHCA

report_type: Initial Licensure

inspection_type: Initial Licensure


facility_name: APALACHICOLA FOREST YOUTH CAMP

summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 01/04/2013
Track ID: 5WIE
Deficiencies: 1

  [None] NoneNone  (Correction: None)

report_type: Complaint

inspection_type: Complaint

requirement_description: NoneNone


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 02/11/2013
Track ID: VBVK
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: VBVK


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 02/26/2024
Track ID: NCK5
Deficiencies: 1

  [None] NoneNone  (Correction: None)


facility_name: BAYCARE BEHAVIORAL HEALTH

summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 01/06/2020
Track ID: 7TX1
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 2 deficiencies

raw_content:
Inspection: Complaint
Survey Date: 03/09/2015
Track ID: AAF4
Deficiencies: 2

  [C0115] STAFFING - PERSONNEL PROCEDURESPersonnel procedures. The provider shall have written personnel procedures that, at a minimum, address the following items:

The recruitment, retention, training and effective performance of qualified staff;

The types and numbers of clinical, managerial and direct care staff needed to provide children with care and treatment in a safe and therapeutic environment;

The requirement of the provider, as a mandated reporter, to report all suspected cases of child abuse, neglect and exploitation involving any employee, volunteer, or student to the Abuse Registry and the department, in accordance with Chapter 39 and Section 394.459, F.S.

Chapter 65E-9.007(1)(a), (b), and (c), F.A.C.  (Correction: 04/15/2015)
  [C0257] MEDICATION ADMINISTRATION - STORAGE OF MEDSAll drugs, including nonprescription drugs, shall be stored under double lock (e.g., a locked cabinet within a locked room or in a locked container within a locked cabinet).

External and internal medications and ophthalmic preparations shall be stored separately from each other.

Each child ' s medications shall be stored separately from each other.

Poisons and other toxic chemicals shall not be stored in a medication storage area.

No medication shall be repackaged by facility staff.

Chapter 65E-9.014(13)(a), (b), (c), (d), and (e), F.A.C.  (Correction: 04/15/2015)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 03/27/2019
Track ID: NRNE
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: NRNE


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 04/15/2015
Track ID: AAF4
Deficiencies: 1

  [C0246] MEDICATION ADMINISTRATIONThere shall be no pro re nata (PRN) orders for psychotropic medications.

Chapter 65E-9.014(7), F.A.C.  (Correction: 06/04/2015)


summary: Standard — 1 deficiency

raw_content:
Inspection: Standard
Survey Date: 07/11/2023
Track ID: ZOX3
Deficiencies: 1

  [None] NoneNone  (Correction: None)

report_type: Standard

inspection_type: Standard


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 08/06/2012
Track ID: K6IL
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Standard — 1 deficiency

raw_content:
Inspection: Standard
Survey Date: 08/16/2016
Track ID: 2PX5
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/11/2013
Track ID: OPWL
Deficiencies: 1

  [C0011] OPERATING STANDARDS - WRITTEN PROCEDURESWritten procedures. The provider shall establish and implement written procedures that ensure compliance with all provisions of this rule.

Ch 65E-9.005(2), F.A.C.  (Correction: 11/11/2013)

track_id: OPWL


facility_name: BROOKSVILLE YOUTH ACADEMY

summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 01/16/2024
Track ID: JGEK
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: JGEK


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 02/27/2025
Track ID: O0HR
Deficiencies: 1

  [C0017] OPERATING STDS - ORGANIZATION PERSONNEL P&P(3)(h) Personnel policies, procedures and records.
1. Personnel policies and practices shall be designed, established, followed and maintained to promote the objectives of the provider's program and to ensure there are sufficient staff to support a high quality of care and treatment.  (Correction: 04/18/2025)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 04/03/2024
Track ID: G0JD
Deficiencies: 1

  [C0184] CHILDREN'S RIGHTS - ABUSE/NEGLECT PROCEDURE(3) Child abuse and neglect.
(c) The provider shall establish and implement a written procedure for the immediate protection of the alleged victim or any other potential victim and prevention of a recurrence of the alleged incident pending investigation by the department or law enforcement.  (Correction: 05/07/2024)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 05/16/2024
Track ID: K51N
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/06/2025
Track ID: I5BZ
Deficiencies: 1

  [C0184] CHILDREN'S RIGHTS - ABUSE/NEGLECT PROCEDURE(3) Child abuse and neglect.
(c) The provider shall establish and implement a written procedure for the immediate protection of the alleged victim or any other potential victim and prevention of a recurrence of the alleged incident pending investigation by the department or law enforcement.  (Correction: 11/17/2025)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/21/2025
Track ID: PNO2
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/28/2024
Track ID: TCCJ
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: TCCJ


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 11/06/2024
Track ID: BKXY
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: BKXY


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 11/07/2023
Track ID: M6UT
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 11/24/2025
Track ID: 9OL6
Deficiencies: 1

  [None] NoneNone  (Correction: None)


facility_name: CITRUS HEALTH NETWORK

summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 04/05/2022
Track ID: M70L
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 2 deficiencies

raw_content:
Inspection: Complaint
Survey Date: 04/05/2024
Track ID: NOS0
Deficiencies: 2

  [C0134] STAFF ORIENTATION & TRAINING - INSERVICE 40HR(5) Staff orientation and training.
(e) The provider shall implement a minimum of 40 hours of in-service training annually for all staff and volunteers who work directly with children. Continuing education for professional licenses and certifications may count towards training hours if the training covers the appropriate areas. This training shall cover all policies and procedures relevant to each position and shall, at a minimum, include each of the following:

1. Administrative:
a. Administrative policies and procedures and overall program goals;
b. Federal and state laws and rules governing the program;
c. Identification and reporting of child abuse and neglect;
d. Protection of children's rights; and
e. Confidentiality.

2. Safety:
a. Disaster preparedness and evacuation procedures;
b. Fire safety;
c. Emergency procedures;
d. Violence prevention and suicide precautions; and
e. First aid and CPR, with competency demonstrated annually.

3. Child development:
a. Child supervision skills;
b. Children's physical and emotional needs;
c. Developmental stages of childhood and adolescence;
d. Family relationships and the impact of separation;
e. Substance abuse recognition and prevention; and
f. Principles and practices of child care.

4. Treatment services:
a. Individualized treatment that is culturally competent;
b. Treatment that addresses issues the child may have involving sexual or physical abuse, abandonment, domestic violence, separation, divorce, or adoption;
c. Behavior management techniques include, but are not limited to: preventing problem behavior, defining and teaching expectations, teaching and encouraging the child's long-term use of new skills as alternative behaviors, contingency management, teaching and promoting choice making and self-management skills, time-out, point systems or level systems, de-escalation procedures, and crisis prevention and intervention;
d. Treatment plan development and implementation;
e. Treatment that supports the child's permanency goals; and
f. The provider shall ensure ongoing training and be able to produce documentation of such training on the use of restraint and seclusion, physical escort, time-out, de-escalation procedures and crisis prevention and intervention.

(I) Before staff may participate in any use of restraint or seclusion, staff shall be competency trained to minimize the use of restraint and seclusion, to use alternative, non-physical, non-intrusive behavioral intervention techniques to handle agitated or potentially violent children, and to use restraints and seclusion safely.
(II) Staff shall complete a training course in the safe and appropriate use of seclusion and restraint and in the use of alternative non-intrusive behavior management techniques. The training course shall be provided by individuals qualified by education, training, and experience to provide such training. Competencies shall be demonstrated on a semiannual basis. Training requirements for all staff who participate in the use of restraint and seclusion shall include:

(A) An understanding of the underlying causes, e.g., medical, behavioral and environmental, of consequential behaviors exhibited by the children being served;
(B) How staff behaviors can affect the behaviors of others, especially children with a history of trauma;
(C) The use of non-physical interventions, such as de-escalation, mediation, active listening, self-protection and other techniques, such as time-out for the purpose of preventing potential and intervening in emergency safety situations;
(D) Recognizing signs of respiratory and cardiac distress in children;
(E) Recognizing signs of depression and potential suicidal behaviors;
(F) Certification in the use of cardiopulmonary resuscitation (CPR). Competency based re-certification in CPR is required annually;
(G) How to monitor children in restraint or seclusion; and
(H) The safe use of approved restraint techniques, including physi  (Correction: 05/21/2024)
  [C0217] POST RESTRAINT/SECLUSION - DEBRIEF WITH CHILD(10) Post-restraint or seclusion practices.
(a) After the use of restraint or seclusion, staff involved in an emergency safety intervention and the child shall have a face-to-face discussion, which is also known as a debriefing. Whenever possible, subject to staff scheduling, this discussion shall include all staff involved in the intervention. The child's parent or guardian shall be invited to participate in the discussion. The provider shall conduct the discussion in a language that is understood by the child and the child's parent or guardian. The discussion shall provide both the child and staff the opportunity to discuss the circumstances resulting in the use of restraint or seclusion and strategies to be used by the staff, the child, or others to prevent the need for the future use of restraint or seclusion. The discussion must occur within 24 hours of the emergency intervention, subject to the following exceptions:
1. Allowances may be made to accommodate the schedules of the parent(s) or legal guardian(s) of the child when they request an opportunity to participate in the debriefing and when staff deem their participation appropriate.
2. Allowances may be made to accommodate shift changes, vacation schedules, illnesses, and all applicable federal, state, and local labor laws and regulations.  (Correction: 05/21/2024)


summary: Standard — 3 deficiencies

raw_content:
Inspection: Standard
Survey Date: 04/05/2024
Track ID: QNUR
Deficiencies: 3

  [N0188] POST INTERVENTION DEBRIEFINGS  (Correction: 05/21/2024)
  [N0189] POST INTERVENTION DEBRIEFINGS  (Correction: 05/21/2024)
  [N0216] EDUCATION AND TRAINING  (Correction: 05/21/2024)

track_id: QNUR

requirement_description: POST INTERVENTION DEBRIEFINGS

requirement_description: EDUCATION AND TRAINING


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 05/21/2024
Track ID: 9ZU1
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 06/29/2022
Track ID: UE9Y
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: 2 — 1 deficiency

raw_content:
Inspection: 2
Survey Date: 1
Track ID: 3
Deficiencies: 1

  [4] 5  (Correction: 6)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/22/2025
Track ID: N0F4
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 12/17/2024
Track ID: ZAQY
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: ZAQY


summary: 1 — 1 deficiency

raw_content:
Inspection: 1
Survey Date: 12345678910
Track ID: 2
Deficiencies: 1

  [3] 4  (Correction: 5)


facility_name: CLEMENTINE PALMETTO BAY

summary: Initial Licensure — 1 deficiency

raw_content:
Inspection: Initial Licensure
Survey Date: 01/10/2023
Track ID: 3BT6
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 2 deficiencies

raw_content:
Inspection: Complaint
Survey Date: 04/03/2023
Track ID: P8VP
Deficiencies: 2

  [C0077] PROGRAM STDS - TREATMENT AND SERVICES(3) Treatment and services.
(a) Treatment shall be individualized, child and family centered, culturally competent, and based on the child's assessed strengths, needs, and presenting problems that precipitated admission to the program.
(b) Treatment services shall be provided as part of an individualized written treatment, plan that complies with Rule 65E-9.009, F.A.C., of this chapter.
(c) Treatment modalities and services shall be in accordance with the child's psychiatric, behavioral, emotional and social needs and be incorporated into their individualized treatment plan and discharge plan.
(d) The provider shall ensure that all staff caring for or providing treatment or services for the child:
1. Have current information about the child's treatment plan and goals, including the child's permanency goals if admitted pursuant to Section 39.407, F.S.; and
2. Direct all aspects of the child's treatment, services and daily activities toward meeting the child's specific treatment goals.
(e) The provider shall ensure that all staff providing a treatment modality to the child are qualified to provide that treatment modality.
(f) Discussions are held on an on-going basis with the individuals involved in implementing treatment.
(g) Treatment shall not be aversive, coercive, or experimental.
(h) Treatment provided, including behavior analysis services, shall be consistent with nationally recognized standards.
(i) When multiple modalities of treatment are provided, such as psychotherapy, behavior management, and medication, the treatment shall be coordinated among the treatment professionals.
(j) Treatment progress shall be monitored on a continuous basis and the treatment adjusted as needed to meet the child's individual treatment goals.  (Correction: 06/02/2023)
  [C0180] CHILDREN'S RIGHTS(1) The provider shall protect children's rights under the federal and state constitutions and as specified in Sections 394.459 and 394.4615, F.S. The provider shall also ensure that:
(a) Physical punishment and treatment modalities that place the child at risk of physical injury or pain or death, including electroconvulsive or other convulsive therapy, "cocoon therapy," or other hazardous procedures shall never be used.
(b) Children shall not be subjected to cruel, severe, unusual or unnecessary punishment or assigned excessive exercise or work duties, nor shall they be subjected to physical or mental abuse or corporal punishment.
(c) The simultaneous use of seclusion and mechanical restraint is prohibited.
(d) Children shall not be subjected to hazing, verbal abuse, coercion or remarks that ridicule them, their families or others.
(e) Children shall not be denied food, water, clothing, or medical care.
(f) Children shall not be exploited or required to make public statements to acknowledge gratitude to the provider program or perform at public gatherings.
(g) Identifiable pictures of children shall not be used without prior written consent of the parent or guardian. The signed consent form for any such usage shall be event-specific, indicate how the pictures will be used, and placed in the child's clinical record.  (Correction: 06/02/2023)


facility_name: DANIEL MEMORIAL

summary: Complaint — 2 deficiencies

raw_content:
Inspection: Complaint
Survey Date: 01/19/2023
Track ID: 5XUR
Deficiencies: 2

  [C0095] PROGRAM STD - CLOTHING & PERSONAL NEEDS(11) Clothing and personal needs.
(a) The provider shall complete a written inventory of personal belongings of each child upon admission and account for all personal belongings upon discharge. This written inventory shall be maintained in the child's case file and a copy given to the parent or guardian at admission and discharge.
(b) The provider shall ensure each child has individual personal hygiene and grooming items readily available and has training in personal care, hygiene, and grooming appropriate to the child's age, gender, race, culture and development.
(c) The provider shall involve the child in the selection, care and maintenance of personal clothing as appropriate to the child's age and ability. Clothing shall be maintained in good repair, sized to fit the child and suited to the climate and season.
(d) The provider shall allow a child to possess personal belongings. The provider may limit or supervise the use of these items while the child is in care.
(e) When needed, protection from the weather or insects shall be provided, such as rain gear and insect repellent.
(f) The provider shall return all of the child's personal clothing and belongings to the parent or guardian when the child is discharged from the facility.  (Correction: 03/01/2023)
  [C0194] RESTRAINT/SECLUSION - SAFE/PROPORTIONATE(1) General requirements.
(e) Restraint or seclusion shall be used in a manner that is safe and proportionate to the severity of the behavior and the child's chronological and developmental age; size; gender; physical, medical and psychiatric condition, including current medications; and personal history, including history of physical or sexual abuse.  (Correction: 03/01/2023)


summary: Standard — 4 deficiencies

raw_content:
Inspection: Standard
Survey Date: 09/11/2024
Track ID: 2TM8
Deficiencies: 4

  [C0160] LENGTH OF STAY(1) The provider shall involve the child and the child's parent or guardian to the fullest extent possible at all stages of treatment planning and discharge planning toward the goal of reintegrating the child into the community.
(2) The child's discharge plan shall be reviewed and, if necessary, revised during each review of the treatment plan.
(3) The provider shall design individualized services and treatment for the child to address the child's presenting problems on admission with a goal of discharge to the community or to a step-down program within 120 days of admission for residential treatment centers and 365 days for therapeutic group homes.  (Correction: 10/11/2024)
  [C0198] RESTRAINT/SECLUSION - OVERSIGHT(1) General requirements.
(i) The provider's medical or clinical director shall be responsible for providing oversight of ongoing monitoring, quality improvement and staff training in the use of restraint and seclusion and in the use of less intrusive, alternative interventions.  (Correction: 10/11/2024)
  [C0202] RESTRAINT/SECLUSION - VERBAL ORDER(3) Authorization of restraint or seclusion.
(c) If the ordering physician is not available on-site to order the use of restraint or seclusion, a verbal telephone order shall be obtained by, at a minimum, a registered nurse or other licensed staff, such as a licensed practical nurse (LPN), at the time of restraint or seclusion is initiated or immediately after it ends. At the time the order is received, the registered nurse or other licensed staff, such as an LPN, shall consult with the ordering physician about the child's physical and psychological condition. The order and consultation shall be documented in the child's case file.  If an emergency exists where restraint or seclusion is needed but the physician is not present or available by telephone, a psychiatric nurse, advanced nurse practitioner, physician assistant, or registered nurse may apply the restraint or place the child in seclusion, with follow up information provided to the physician as soon as is reasonably possible.  (Correction: 10/11/2024)
  [C0204] RESTRAINT/SECLUSION - PHYSICIAN AVAILABLE(3) Authorization of restraint or seclusion.
(e) The ordering physician shall be available to staff for consultation, at least by telephone, throughout the period of the intervention.  (Correction: 10/11/2024)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 09/11/2024
Track ID: 5WBM
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Standard — 1 deficiency

raw_content:
Inspection: Standard
Survey Date: 09/11/2024
Track ID: NS74
Deficiencies: 1

  [N0143] ORDERS FOR USE OF RESTRAINT OR SECLUSION  (Correction: 10/11/2024)


summary: 2 — 1 deficiency


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/17/2019
Track ID: YDJN
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: YDJN


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/20/2023
Track ID: XDCI
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: XDCI


summary: 1 — 1 deficiency

raw_content:
Inspection: 1
Survey Date: 1234567
Track ID: 2
Deficiencies: 1

  [3] 4  (Correction: 5)


facility_name: DEVEREUX FOUNDATION, THE

summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 01/10/2017
Track ID: UOLB
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: UOLB


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 04/12/2016
Track ID: 9QW8
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 06/26/2018
Track ID: T2DI
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 07/21/2017
Track ID: WQKX
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: WQKX


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 08/24/2017
Track ID: S6VV
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 11/07/2018
Track ID: HRIM
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: HRIM


summary: Complaint — 2 deficiencies

raw_content:
Inspection: Complaint
Survey Date: 12/09/2015
Track ID: MRNZ
Deficiencies: 2

  [C0077] PROGRAM STANDARDS - TREATMENT AND SERVICESTreatment and services.

Treatment shall be individualized, child and family centered, culturally competent, based on the child ' s assessed strengths, needs, and presenting problems that precipitated admission to the program.

Treatment services shall be provided as part of an individualized written services plan that complies with Rule 65E-9.009, F.A.C., of this rule.

Treatment modalities and services shall be in accordance with the child ' s psychiatric, behavioral, emotional and social needs and be incorporated into their individualized treatment plan and discharge plan.

The provider shall ensure that all staff caring for or providing treatment or services for the child:
1. Have current information about the child ' s treatment plan and goals, including the child ' s permanency goals if admitted pursuant to Section 39.407, F.S.; and
2. Direct all aspects of the child ' s treatment, services and daily activities toward meeting the child ' s specific treatment goals.

The provider shall ensure that all staff providing a treatment modality to the child are qualified to provide that treatment modality.

Discussions are held on an on-going basis with the individuals involved in implementing treatment.

Treatment shall not be aversive, coercive, or experimental.

Treatment provided, including behavior analysis services, shall be consistent with nationally recognized standards.

When multiple modalities of treatment are provided, such as psychotherapy, behavior management, and medication, the treatment shall be coordinated among the treatment professionals.

Treatment progress shall be monitored on a continuous basis and the treatment adjusted as needed to meet the child ' s individual treatment goals.

Chapter 65E-9.006(3)(a), (b), (c), (d), (e), (f), (g), (h), (i), and (j), F.A.C.  (Correction: 02/10/2016)
  [C0121] STAFFING - STAFF COMPOSITIONDirect care staff.

At a minimum, two (2) direct care staff shall be awake and on duty at all times. In addition, the following direct care staff-to-child ratios shall be provided and maintained:

1. During hours when children are present in the facility and normally awake, the direct care staff to child ratio shall be no less than 1:4; and

2. During hours when the children are normally asleep, the direct care staff to child ratio shall be no less than 1:6; and

3. While residents are away from the facility, the staffing ratio for those residents shall be no less than 1:4. The need for more intensive staffing will be determined by the child's physician.

4. Direct care staff shall not divide time on their shift between programs located in other areas of the facility or other buildings.

5. While transporting residents of residential treatment centers other than group homes, the driver shall not be counted as the direct care staff providing care, assistance or supervision of the child.

Chapter 65E-9.007(3)(e), F.A.C.  (Correction: 02/10/2016)

track_id: MRNZ


summary: Complaint — 2 deficiencies

raw_content:
Inspection: Complaint
Survey Date: 12/19/2017
Track ID: VH5Z
Deficiencies: 2

  [CZ813] RESULTS OF SCREENING & NOTIFICATION IN FILE59A-35.090(3) Results of Screening and Notification.
(c) The eligibility results of employee screening and the signed Attestation referenced in subsection 59A-35.090(2), F.A.C., must be in the employee's personnel file, maintained by the provider.  (Correction: 01/19/2018)
  [CZ814] BACKGROUND SCREENING CLEARINGHOUSE435.12(2) Care Provider Background Screening Clearinghouse.-
(b) Until such time as the fingerprints are enrolled in the national retained print arrest notification program at the Federal Bureau of Investigation, an employee with a break in service of more than 90 days from a position that requires screening by a specified agency must submit to a national screening if the person returns to a position that requires screening by a specified agency.
(c) An employer of persons subject to screening by a specified agency must register with the clearinghouse and maintain the employment status of all employees within the clearinghouse. Initial employment status and any changes in status must be reported within 10 business days.
(d) An employer must register with and initiate all criminal history checks through the clearinghouse before referring an employee or potential employee for electronic fingerprint submission to the Department of Law Enforcement. The registration must include the employee's full first name, middle initial, and last name; social security number; date of birth; mailing address; sex; and race. Individuals, persons, applicants, and controlling interests that cannot legally obtain a social security number must provide an individual taxpayer identification number.  (Correction: 01/12/2018)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 01/16/2024
Track ID: 3HQN
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 01/19/2023
Track ID: FI4Y
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 02/23/2021
Track ID: P939
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 06/26/2020
Track ID: 8D23
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 07/24/2025
Track ID: FNID
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: FNID


summary: Standard — 1 deficiency

raw_content:
Inspection: Standard
Survey Date: 08/24/2023
Track ID: HF09
Deficiencies: 1

  [N0207] FACILITY REPORTINGReporting of serious occurrences.
The facility must report each serious occurrence to both the State Medicaid agency and, unless prohibited by State law, the State designated Protection and Advocacy system.
Serious occurrences that must be reported include;
-	a resident's death;
-	a serious injury to a resident as defined in section §483.352 of this part; and
-	a resident's suicide attempt.
(1)  Staff must report any serious occurrence involving a resident to both the State Medicaid agency and the State designated Protection and Advocacy system by no later than close of business the next business day after a serious occurrence. The report must include
-	 the name of the resident involved in the serious occurrence,
-	a description of the occurrence and,
-	the name, street address, and telephone number of the facility.  (Correction: 12/06/2023)


summary: 2 — 1 deficiency

raw_content:
Inspection: 2
Survey Date: 1
Track ID: 3
Deficiencies: 1

  [4] 5  (Correction: 6)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/08/2025
Track ID: 2N8L
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/15/2024
Track ID: PIBR
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: PIBR


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/24/2024
Track ID: CMUP
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: CMUP


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 12/27/2023
Track ID: JOED
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: JOED


summary: 1 — 1 deficiency

raw_content:
Inspection: 1
Survey Date: 12345678910
Track ID: 2
Deficiencies: 1

  [3] 4  (Correction: 5)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 03/05/2026
Track ID: P3HO
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Initial Licensure — 1 deficiency

raw_content:
Inspection: Initial Licensure
Survey Date: 08/26/2025
Track ID: WMSH
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: WMSH


facility_name: DISCOVERY PRACTICE MANAGEMENT

summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 03/20/2025
Track ID: EBZC
Deficiencies: 1

  [C0121] STAFF COMPOSITION - DIRECT CARE STAFF(3) Staff composition. The provider shall have the following staffing, any of which may be part-time, if the required equivalent full-time coverage is provided, except for those positions with a required specified staffing ratio:
(e) Direct care staff. At a minimum, two (2) direct care staff shall be awake and on duty at all times. In addition, the following direct care staff-to-child ratios shall be provided and maintained:
1. During hours when children are present in the facility and normally awake, the direct care staff to child ratio shall be no less than 1:4; and
2. During hours when the children are normally asleep, the direct care staff to child ratio shall be no less than 1:6; and
3. While residents are away from the facility, the staffing ratio for those residents shall be no less than 1:4. The need for more intensive staffing will be determined by the child's physician; and
4. Direct care staff shall not divide time on their shift between programs located in other areas of the facility or other buildings; and
5. While transporting residents of residential treatment centers other than group homes, the driver shall not be counted as the direct care staff providing care, assistance or supervision of the child. For therapeutic group home residents, prior to a single staff person transporting one or more children in a motor vehicle, children must be assessed to ensure the safety of the children and staff.  (Correction: 08/01/2025)

track_id: EBZC


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 04/06/2026
Track ID: H42H
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 2 deficiencies

raw_content:
Inspection: Complaint
Survey Date: 05/15/2025
Track ID: ZLLQ
Deficiencies: 2

  [C0031] OPERATING STDS - FACILITY BUILDINGS/FURNITURE(5)(a)6. The interior and exterior of buildings and the furniture and furnishings shall be safe, comfortable, reasonably attractive, in good repair and shall function for the purpose for which such building and furniture has been designed.  (Correction: 06/02/2025)
  [C0047] OPERATING STDS-HLTH/SANITATION/SAFETY INSPECT(6) Health, sanitation and safety.
(a) Before a license is issued, and annually thereafter, the facility shall be inspected by the local office of the Department of Health to review compliance with state and local ordinances and health codes. Current written approvals or certificates of health and sanitary conditions and inspection reports shall be on file in the facility.  (Correction: 06/02/2025)

track_id: ZLLQ


summary: Complaint — 5 deficiencies

raw_content:
Inspection: Complaint
Survey Date: 10/20/2025
Track ID: QEGG
Deficiencies: 5

  [C0024] OPERATING STANDARDS - ORGANIZATIONIncident notification.

1. The provider shall comply with the department's and the agency's procedures for reporting incidents that pose risk of serious psychological and physical harm to children being served.

2. The provider shall develop and implement on an ongoing basis a written procedure for incident notification, reflecting the requirements of the department ' s operating procedure CFOP 215-6, which is incorporated by reference.

Ch 65E-9.005(3)(l), F.A.C.  (Correction: 12/30/2025)
  [C0121] STAFFING - STAFF COMPOSITIONDirect care staff.

At a minimum, two (2) direct care staff shall be awake and on duty at all times. In addition, the following direct care staff-to-child ratios shall be provided and maintained:

1. During hours when children are present in the facility and normally awake, the direct care staff to child ratio shall be no less than 1:4; and

2. During hours when the children are normally asleep, the direct care staff to child ratio shall be no less than 1:6; and

3. While residents are away from the facility, the staffing ratio for those residents shall be no less than 1:4. The need for more intensive staffing will be determined by the child's physician.

4. Direct care staff shall not divide time on their shift between programs located in other areas of the facility or other buildings.

5. While transporting residents of residential treatment centers other than group homes, the driver shall not be counted as the direct care staff providing care, assistance or supervision of the child.

Chapter 65E-9.007(3)(e), F.A.C.  (Correction: 12/30/2025)
  [ZZ000] INITIAL COMMENTS  (Correction: 12/30/2025)
  [ZZ824] RIGHT OF INSPECTION; INSPECTION REPORTS408.811 Right of inspection; copies; inspection reports; plan for correction of deficiencies.-
(1) An authorized officer or employee of the agency may make or cause to be made any inspection or investigation deemed necessary by the agency to determine the state of compliance with this part, authorizing statutes, and applicable rules. The right of inspection extends to any business that the agency has reason to believe is being operated as a provider without a license, but inspection of any business suspected of being operated without the appropriate license may not be made without the permission of the owner or person in charge unless a warrant is first obtained from a circuit court. Any application for a license issued under this part, authorizing statutes, or applicable rules constitutes permission for an appropriate inspection to verify the information submitted on or in connection with the application.
(a) All inspections shall be unannounced, except as specified in s. 408.806.
(b) Inspections for relicensure shall be conducted biennially unless otherwise specified by this section, authorizing statutes, or applicable rules.
(c) The agency may exempt a low-risk provider from a licensure inspection if the provider or a controlling interest has an excellent regulatory history with regard to deficiencies, sanctions, complaints, or other regulatory actions as defined in agency rule. The agency must conduct unannounced licensure inspections on at least 10 percent of the exempt low-risk providers to verify regulatory compliance.
(d) The agency may adopt rules to waive any inspection, including a relicensure inspection, or grant an extended time period between relicensure inspections based upon:
1. An excellent regulatory history with regard to deficiencies, sanctions, complaints, or other regulatory measures.
2. Outcome measures that demonstrate quality performance.
3. Successful participation in a recognized, quality program.
4. Accreditation status.
5. Other measures reflective of quality and safety.
6. The length of time between inspections.
The agency shall continue to conduct unannounced licensure inspections on at least 10 percent of providers that qualify for an exemption or extended period between relicensure inspections. The agency may conduct an inspection of any provider at any time to verify regulatory compliance.
(2) Inspections conducted in conjunction with certification, comparable licensure requirements, or a recognized or approved accreditation organization may be accepted in lieu of a complete licensure inspection. However, a licensure inspection may also be conducted to review any licensure requirements that are not also requirements for certification.
(3) The agency shall have access to and the licensee shall provide, or if requested send, copies of all provider records required during an inspection or other review at no cost to the agency, including records requested during an offsite review.
(4) A deficiency must be corrected within 30 calendar days after the provider is notified of inspection results unless an alternative timeframe is required or approved by the agency.
(5) The agency may require an applicant or licensee to submit a plan of correction for deficiencies. If required, the plan of correction must be filed with the agency within 10 calendar days after notification unless an alternative timeframe is required.
(6)(a) Each licensee shall maintain as public information, available upon request, records of all inspection reports pertaining to that provider that have been filed by the agency unless those reports are exempt from or contain information that is exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution or is otherwise made confidential by law. Copies of such reports shall be retained in the records of the provider for at least 3 years following the date the reports are filed and issued, regardless of a change of ownership.
(b) A licensee shall, upon the requ  (Correction: 12/30/2025)
  [ZZ830] EMERGENCY MANAGEMENT PLANNING408.821 Emergency management planning; emergency operations; inactive license.-
(1) A licensee required by authorizing statutes and agency rule to have a comprehensive emergency management plan must designate a safety liaison to serve as the primary contact for emergency operations. Such licensee shall submit its comprehensive emergency management plan to the local emergency management agency, county health department, or Department of Health as follows:
(a) Submit the plan within 30 days after initial licensure and change of ownership, and notify the agency within 30 days after submission of the plan.
(b) Submit the plan annually and within 30 days after any significant modification, as defined by agency rule, to a previously approved plan.
(c) Submit necessary plan revisions within 30 days after notification that plan revisions are required.
(d) Notify the agency within 30 days after approval of its plan by the local emergency management agency, county health department, or Department of Health.
(2) An entity subject to this part may temporarily exceed its licensed capacity to act as a receiving provider in accordance with an approved comprehensive emergency management plan for up to 15 days. While in an overcapacity status, each provider must furnish or arrange for appropriate care and services to all clients. In addition, the agency may approve requests for overcapacity in excess of 15 days, which approvals may be based upon satisfactory justification and need as provided by the receiving and sending providers.
(3)(a) An inactive license may be issued to a licensee subject to this section when the provider is located in a geographic area in which a state of emergency was declared by the Governor if the provider:
1. Suffered damage to its operation during the state of emergency.
2. Is currently licensed.
3. Does not have a provisional license.
4. Will be temporarily unable to provide services but is reasonably expected to resume services within 12 months.
(b) An inactive license may be issued for a period not to exceed 12 months but may be renewed by the agency for up to 12 additional months upon demonstration to the agency of progress toward reopening. A request by a licensee for an inactive license or to extend the previously approved inactive period must be submitted in writing to the agency, accompanied by written justification for the inactive license, which states the beginning and ending dates of inactivity and includes a plan for the transfer of any clients to other providers and appropriate licensure fees. Upon agency approval, the licensee shall notify clients of any necessary discharge or transfer as required by authorizing statutes or applicable rules. The beginning of the inactive licensure period shall be the date the provider ceases operations. The end of the inactive period shall become the license expiration date, and all licensure fees must be current, must be paid in full, and may be prorated. Reactivation of an inactive license requires the prior approval by the agency of a renewal application, including payment of licensure fees and agency inspections indicating compliance with all requirements of this part and applicable rules and statutes.

(4) . . . Licensees providing residential or inpatient services must utilize an online database approved by the agency to report information to the agency regarding the provider's emergency status, planning, or operations.  (Correction: 12/30/2025)

track_id: QEGG

requirement_description: INITIAL COMMENTS


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 12/09/2024
Track ID: 9VNS
Deficiencies: 1

  [C0119] STAFF COMPOSITION - R.N.(3) Staff composition. The provider shall have the following staffing, any of which may be part-time, if the required equivalent full-time coverage is provided, except for those positions with a required specified staffing ratio:
(c) Registered nurse.
1. A registered nurse shall supervise the nursing staff during the times that the children are present in the facility and normally awake, the nursing staff to child ratio shall be no less than 1:30, and during normal sleeping hours, the nursing staff to child ratio shall be no less than 1:40.
2. For therapeutic group homes that do not use restraint or seclusion in their program, the provider is not required to have a registered nurse or other nursing staff on duty, but shall have definitive written agreements for obtaining necessary nursing services.  (Correction: 03/07/2025)


summary: Standard — 1 deficiency

raw_content:
Inspection: Standard
Survey Date: 05/21/2018
Track ID: 0ZYK
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 09/11/2018
Track ID: WSKT
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: WSKT


summary: Initial Licensure — 1 deficiency

raw_content:
Inspection: Initial Licensure
Survey Date: 12/29/2015
Track ID: HQVY
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: HQVY


facility_name: FAMILY FIRST ADOLESCENT SERVICES

summary: Initial Licensure — 1 deficiency

raw_content:
Inspection: Initial Licensure
Survey Date: 01/13/2022
Track ID: BZ80
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Initial Licensure — 1 deficiency

raw_content:
Inspection: Initial Licensure
Survey Date: 01/22/2024
Track ID: GO8Z
Deficiencies: 1

  [None] NoneNone  (Correction: None)


facility_name: FLORIDA PALMS ACADEMY

summary: Standard — 1 deficiency

raw_content:
Inspection: Standard
Survey Date: 03/13/2024
Track ID: VKCL
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: VKCL


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 04/28/2025
Track ID: QSBL
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: QSBL


summary: Complaint — 5 deficiencies

raw_content:
Inspection: Complaint
Survey Date: 05/08/2019
Track ID: 6C2N
Deficiencies: 5

  [N0100] USE OF RESTRAINT AND SECLUSIONSubpart G: Condition of Participation for the Use of Restraint and Seclusion in Psychiatric Residential Treatment Facilities Providing Inpatient Psychiatric Services for Individuals Under Age Twenty One.  (Correction: 06/19/2019)
  [N0140] ORDERS FOR USE OF RESTRAINT OR SECLUSIONOrders for restraint or seclusion must be by a physician, or other licensed practitioner permitted by the State and the facility to order restraint or seclusion and trained in the use of emergency safety interventions. Federal regulations at 42 CFR 441.151 require that inpatient psychiatric services for beneficiaries under age 21 are provided under the direction of a physician.  (Correction: 06/19/2019)
  [N0145] ORDERS FOR USE OF RESTRAINT OR SECLUSIONWithin 1 hour of the initiation of the emergency safety intervention a physician, or other licensed practitioner trained in the use of emergency safety interventions and permitted by the state and the facility to assess the physical and psychological wellbeing of residents, must conduct a face-to-face assessment of the physical and psychological wellbeing of the resident, including but not limited to-

    (1) The resident's physical and psychological status;

    (2) The resident's behavior;

    (3) The appropriateness of the intervention measures; and

    (4) Any complications resulting from the intervention.  (Correction: 06/19/2019)
  [N0149] ORDERS FOR USE OF RESTRAINT OR SECLUSIONStaff must document the intervention in the resident's record. That documentation must be completed by the end of the shift in which the intervention occurs. If the intervention does not end during the shift in which it began, documentation must be completed during the shift in which it ends.  Documentation must include all of the following:  (Correction: 06/19/2019)
  [N0151] ORDERS FOR USE OF RESTRAINT OR SECLUSION[Documentation must include] the time the emergency safety intervention actually began and ended.  (Correction: 06/19/2019)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 08/27/2019
Track ID: OS8P
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: 2 — 1 deficiency

raw_content:
Inspection: 2
Survey Date: 1
Track ID: 3
Deficiencies: 1

  [4] 5  (Correction: 6)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/22/2019
Track ID: 31RE
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/22/2019
Track ID: NNTJ
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: NNTJ


summary: 1 — 1 deficiency

raw_content:
Inspection: 1
Survey Date: 1234567
Track ID: 2
Deficiencies: 1

  [3] 4  (Correction: 5)


facility_name: FLORIDA UNITED METHODIST CHILDREN'S HOME

summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 03/31/2026
Track ID: GQ2T
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 04/16/2019
Track ID: VYVF
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: VYVF


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 06/02/2015
Track ID: FUJD
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: FUJD


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 06/30/2016
Track ID: 06NH
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 08/11/2015
Track ID: 3U6U
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 08/25/2022
Track ID: S1QO
Deficiencies: 1

  [CZ816] BACKGROUND SCREENING-COMPLIANCE ATTESTATION408.809 Background screening; prohibited offenses.-
(2) Every 5 years following his or her licensure, employment, or entry into a contract in a capacity that under subsection (1) would require level 2 background screening under chapter 435, each such person must submit to level 2 background rescreening as a condition of retaining such license or continuing in such employment or contractual status. For any such rescreening, the agency shall request the Department of Law Enforcement to forward the person's fingerprints to the Federal Bureau of Investigation for a national criminal history record check unless the person's fingerprints are enrolled in the Federal Bureau of Investigation's national retained print arrest notification program. If the fingerprints of such a person are not retained by the Department of Law Enforcement under s. 943.05(2)(g) and (h), the person must submit fingerprints electronically to the Department of Law Enforcement for state processing, and the Department of Law Enforcement shall forward the fingerprints to the Federal Bureau of Investigation for a national criminal history record check. The fingerprints shall be retained by the Department of Law Enforcement under s. 943.05(2)(g) and (h) and enrolled in the national retained print arrest notification program when the Department of Law Enforcement begins participation in the program. The cost of the state and national criminal history records checks required by level 2 screening may be borne by the licensee or the person fingerprinted. The agency may accept as satisfying the requirements of this section proof of compliance with level 2 screening standards submitted within the previous 5 years to meet any provider or professional licensure requirements of the Department of Financial Services for an applicant for a certificate of authority or provisional certificate of authority to operate a continuing care retirement community under chapter 651, provided that:
(a) The screening standards and disqualifying offenses for the prior screening are equivalent to those specified in s. 435.04 and this section;
(b) The person subject to screening has not had a break in service from a position that requires level 2 screening for more than 90 days; and
(c) Such proof is accompanied, under penalty of perjury, by an attestation of compliance with chapter 435 and this section using forms provided by the agency.

435.05 Requirements for covered employees and employers.-Except as otherwise provided by law, the following requirements apply to covered employees and employers:
(2) Every employee must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer.

59A-35.090 Background Screening.
(2) Processing Screening Requests, Required Documents and Fees.
(d) An Attestation of Compliance with Background Screening Requirements, AHCA Form 3100-0008, January 2017, herein incorporated by reference, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-09106, and available from the Agency for Health Care Administration at: http://ahca.myflorida.com/MCHQ/Central_Services/Background_Screening/Regulations_Forms.shtml. This form must be completed by the individual and retained by the provider upon hire to attest that they meet the requirements for qualifying for employment, they have not been unemployed for more than 90 days from a position that requires Level 2 screening, and they agree to inform the employer immediately if arrested for any disqualifying offense.
(e) An administrator or chief financial officer must be screened and qualified prior to appointment to the position.
(3) Results of Screening and Notification.
(a) Final results of background screening requests will be provided through the Agency's secure website that may be accessed by all health care prov  (Correction: 10/10/2022)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/05/2016
Track ID: UYSZ
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: UYSZ


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/16/2024
Track ID: XJ1K
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 12/11/2014
Track ID: C789
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 12/19/2024
Track ID: E31S
Deficiencies: 1

  [None] NoneNone  (Correction: None)


facility_name: GALEN HOPE HOLDINGS, LLC

summary: Initial Licensure — 1 deficiency

raw_content:
Inspection: Initial Licensure
Survey Date: 01/13/2026
Track ID: CXTE
Deficiencies: 1

  [ZZ000] INITIAL COMMENTS  (Correction: )

track_id: CXTE


summary: Initial Licensure — 9 deficiencies

raw_content:
Inspection: Initial Licensure
Survey Date: 11/19/2025
Track ID: CXTE
Deficiencies: 9

  [C0018] OPERATING STDS - ORGANIZATION EMPLOY. SCREEN(3)(h) Personnel policies, procedures and records.
2. All paid personnel and volunteers shall be screened prior to employment, which shall include employment history checks, checks of references, local criminal records checks through local law enforcement agencies, fingerprinting, statewide criminal records checks through the Florida Department of Law Enforcement, and federal criminal records checks through the Federal Bureau of Investigation.  (Correction: 01/13/2026)
  [C0026] OPERATING STDS - FACILITY HANDICAP ACCESSIBLE(5)(a)1. If the facility accepts children with physical handicaps, the facility shall be handicap accessible.  (Correction: 01/13/2026)
  [C0042] OPERATING STDS - FACILITY CLOCKS/CALENDARS(5)(b)9. Clocks and calendars shall be provided.  (Correction: 01/13/2026)
  [C0046] OPERATING STDS - FACILITY VENTILATION/LIGHTS(5)(b)13. Ventilation and lighting.
a. The facility shall provide outside ventilation by means of windows, louvers, air conditioners, or mechanical ventilation in rooms used by children. Windows and doors used for outside ventilation shall be operable and shall have screens in good repair.
b. All areas of the facility occupied by children shall be temperature-controlled in a manner conducive to comfort, safety and privacy. Unless otherwise mandated by federal or state authorities, a temperature of 72 to 82 degrees Fahrenheit during waking hours and 68 to 82 degrees Fahrenheit during sleeping hours shall be maintained in all areas used by children. Cooling devices shall be placed or adjusted in a manner that minimizes drafts. Table fans and floor fans shall have protective covers.
c. The facility shall provide sufficient lighting for the comfort and safety of children, including in classrooms, study areas, bathrooms and food service areas.
d. All incandescent bulbs and fluorescent light tubes shall be protected with covers or shields.
e. Hallways to bedrooms and bathrooms shall be illuminated at night.
f. The facility shall provide egress lighting that will operate if there is a power failure.  (Correction: 01/13/2026)
  [C0050] OPERATING STDS-HLTH/SANITATION/SAFETY PHONES(6) Health, sanitation and safety.
(d) The facility shall have telephones, centrally located and readily available for staff and children's use in each living unit of the facility. Emergency numbers such as the fire department, police, hospital, physician, poison control center, ambulance and Florida Abuse Hotline shall be posted by each telephone. There shall be at least one cellular telephone available for use at all times in the event of power and telephone line outages.  (Correction: 01/13/2026)
  [C0089] HLTH/MED/EMERMED/PSYCH SRVS EMERGENCIES(7) Health, medical, and emergency medical and psychiatric services.
(j) All staff shall have training in the handling of emergency medical situations.
(k) Emergency medical services shall be available within 45 minutes, 24 hours a day, seven days a week.
(l) The program physician's name and telephone number shall be clearly posted in areas accessible by staff and others within the facility.
(m) There shall be a first aid kit available to staff for each unit or building for facilities with multiple units or buildings and one per facility for single unit or building facilities. Contents of the first-aid kits shall be selected by the medical staff.
(n) The provider shall have a written agreement with a licensed hospital verifying that routine and emergency hospitalization will be available.  (Correction: 01/13/2026)
  [C0091] PROGRAM STD - MED ADMIN LOCKED STORAGE(8) Administration of medication.
(b) All medicines and drugs shall be kept in a double locked location. Prescription medications shall be prescribed only by a duly licensed physician or an ARNP or physician's assistant working under the direction of a licensed physician.  (Correction: 01/13/2026)
  [C0224] TIME OUT - PURPOSE(11) Time-out.
(a) Time-out shall be used only for the purpose of providing a child with the opportunity to regain self-control and not as a consequence or punishment.  (Correction: 01/13/2026)
  [ZZ813] RESULTS OF SCREENING & NOTIFICATION IN FILE59A-35.090 Background Screening.
(3) Results of Screening and Notification.
(c) The eligibility results of employee screening and the signed Attestation referenced in subsection 59A-35.090(2), F.A.C., must be in the employee's personnel file, maintained by the provider.  (Correction: 01/13/2026)


facility_name: HOMESAFE

summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 03/07/2019
Track ID: N26J
Deficiencies: 1

  [C0256] MEDICATION SELF ADMIN-TRAINING CONTENT/SKILLS(12) Self administration of medication.
(d) The course shall consist of at least the following topics:
1. Basic knowledge and skills necessary for providing supervision for self-administration of medication;
2. Understanding a prescription label;
3. Procedures for recording/charting medications in the medication log;
4. Interpretation of common abbreviations used in administration and charting of medications;
5. Observation and reporting of side effects, adverse effects and outcomes of psychotropic medication treatment; and
6. Recognizing, documenting and reporting of medication errors.

(e) Upon completion of the course, the trainee shall be able to demonstrate the ability to:
1. Measure liquid medications, break scored tablets, and crush tablets in accordance with prescription directions;
2. Recognize the need to obtain clarification of an "as needed" prescription order;
3. Recognize a medication order which requires judgment or discretion, and advise the child, child's health care provider or facility employer of the inability to assist in the administration of such orders;
4. Complete a medication observation record;
5. Retrieve and store medication; and
6. Recognize the general signs of adverse reactions to medications and report such reactions.  (Correction: 06/21/2019)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 03/25/2016
Track ID: OAXM
Deficiencies: 1

  [C0184] RIGHTS OF CHILDREN - CHILD ABUSE & NEGLECTThe provider shall establish and implement a written procedure for the immediate protection of the alleged victim and prevention of a recurrence of the alleged incident pending investigation by the department or law enforcement.

Chapter 65E-9.012(3)(c), F.A.C.  (Correction: 05/20/2016)

track_id: OAXM


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 04/15/2016
Track ID: RGN7
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 06/02/2017
Track ID: S8UF
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 06/21/2017
Track ID: GUED
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: GUED


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 07/02/2018
Track ID: RMPP
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: RMPP


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 07/06/2015
Track ID: 0MXE
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 08/10/2016
Track ID: 96QV
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/27/2025
Track ID: 3R3L
Deficiencies: 1

  [C0011] OPERATING STDS - WRITTEN PROCEDURES(2) Written procedures. The provider shall establish and implement written procedures that ensure compliance with all provisions of this rule.  (Correction: 11/03/2025)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 12/28/2018
Track ID: 63LO
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 01/07/2020
Track ID: KNM1
Deficiencies: 1

  [C0132] STAFF ORIENTATION & TRAINING - NEW EMPLOYEES(5) Staff orientation and training.
(c) The provider shall conduct orientation for each new employee during the first 2 months of employment. The orientation shall include specific job responsibilities, policies and procedures, care and supervision of children, and competency-based first aid and CPR.  (Correction: 05/22/2020)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 01/13/2023
Track ID: CNES
Deficiencies: 1

  [C0012] OPERATING STDS - ORGANIZATION PROGRAM(3) Organization.
(a) Program. The provider shall have a written description of its philosophy, purpose, objectives, treatment program, services and methods of service delivery. This document shall be available to the agency, the department, referral sources, the parent(s), guardian or foster parent(s) and the public upon request. The program description shall include:
1. A description of the population of children served, including age and gender, types of disorders, and financial requirements;
2. The intake and admission process;
3. The types of treatment the provider can offer, based on a child's individual needs;
4. Methods for involving the parent or guardian in assessment, treatment, discharge, and follow-up care plans; and
5. An organizational chart describing each unit or division and its services, goals, procedures, staffing patterns and relationship to other services and divisions and how these contribute to the goals of the program.  (Correction: 02/15/2023)

track_id: CNES


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 01/28/2021
Track ID: NE0K
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 03/06/2019
Track ID: 0EH9
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 06/24/2022
Track ID: P143
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 07/08/2021
Track ID: 4V3N
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 08/09/2023
Track ID: 7YNN
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 09/12/2022
Track ID: 91YQ
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 10/05/2018
Track ID: SJPS
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: SJPS


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 12/21/2021
Track ID: 8CBZ
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 01/10/2023
Track ID: P84F
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 02/04/2020
Track ID: UJQR
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: UJQR


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 04/09/2018
Track ID: V93Z
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 04/18/2017
Track ID: GUK5
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 06/24/2022
Track ID: FQH8
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 07/18/2017
Track ID: B2LV
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 08/19/2021
Track ID: E9TE
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 08/27/2019
Track ID: XC7U
Deficiencies: 1

  [C0184] CHILDREN'S RIGHTS - ABUSE/NEGLECT PROCEDURE(3) Child abuse and neglect.
(c) The provider shall establish and implement a written procedure for the immediate protection of the alleged victim or any other potential victim and prevention of a recurrence of the alleged incident pending investigation by the department or law enforcement.  (Correction: 02/04/2020)


summary: — 1 deficiency

raw_content:
Inspection:
Survey Date: 12/11/2020
Track ID: 8P2L
Deficiencies: 1

  [C0048] OPERATING STDS-HLTH/SANITATION/SAFETY PROCEDU(6) Health, sanitation and safety.
(b) The provider shall have and follow written health, sanitation and safety procedures.  (Correction: 08/19/2021)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 12/20/2021
Track ID: 2RBP
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 6 deficiencies

raw_content:
Inspection: Complaint
Survey Date: 02/20/2025
Track ID: CKS0
Deficiencies: 6

  [C0011] OPERATING STDS - WRITTEN PROCEDURES(2) Written procedures. The provider shall establish and implement written procedures that ensure compliance with all provisions of this rule.  (Correction: 04/08/2025)
  [C0031] OPERATING STDS - FACILITY BUILDINGS/FURNITURE(5)(a)6. The interior and exterior of buildings and the furniture and furnishings shall be safe, comfortable, reasonably attractive, in good repair and shall function for the purpose for which such building and furniture has been designed.  (Correction: 04/08/2025)
  [C0077] PROGRAM STDS - TREATMENT AND SERVICES(3) Treatment and services.
(a) Treatment shall be individualized, child and family centered, culturally competent, and based on the child's assessed strengths, needs, and presenting problems that precipitated admission to the program.
(b) Treatment services shall be provided as part of an individualized written treatment, plan that complies with Rule 65E-9.009, F.A.C., of this chapter.
(c) Treatment modalities and services shall be in accordance with the child's psychiatric, behavioral, emotional and social needs and be incorporated into their individualized treatment plan and discharge plan.
(d) The provider shall ensure that all staff caring for or providing treatment or services for the child:
1. Have current information about the child's treatment plan and goals, including the child's permanency goals if admitted pursuant to Section 39.407, F.S.; and
2. Direct all aspects of the child's treatment, services and daily activities toward meeting the child's specific treatment goals.
(e) The provider shall ensure that all staff providing a treatment modality to the child are qualified to provide that treatment modality.
(f) Discussions are held on an on-going basis with the individuals involved in implementing treatment.
(g) Treatment shall not be aversive, coercive, or experimental.
(h) Treatment provided, including behavior analysis services, shall be consistent with nationally recognized standards.
(i) When multiple modalities of treatment are provided, such as psychotherapy, behavior management, and medication, the treatment shall be coordinated among the treatment professionals.
(j) Treatment progress shall be monitored on a continuous basis and the treatment adjusted as needed to meet the child's individual treatment goals.  (Correction: 04/08/2025)
  [C0082] HLTH/MED/EMERMED/PSYCH SRVS STAFF ON DUTY(7) Health, medical, and emergency medical and psychiatric services.
(c) The provider shall have a staff member on duty at all times, when children are present in the facility, who is trained and currently certified to administer first aid and CPR.  (Correction: 04/08/2025)
  [C0116] STAFF - COMMUNICATION(2) Staff communication. The provider's personnel procedures shall ensure and require the inter-communication among staff of information regarding children necessary to the performance of each staff responsibility, including between working shifts, staff changes and consultations with professional staff. Where one staff member or one program group relies upon information provided through this required free interchange of information, these interactions shall be documented in writing and maintained in the respective children's case files.  (Correction: 04/08/2025)
  [C0134] STAFF ORIENTATION & TRAINING - INSERVICE 40HR(5) Staff orientation and training.
(e) The provider shall implement a minimum of 40 hours of in-service training annually for all staff and volunteers who work directly with children. Continuing education for professional licenses and certifications may count towards training hours if the training covers the appropriate areas. This training shall cover all policies and procedures relevant to each position and shall, at a minimum, include each of the following:

1. Administrative:
a. Administrative policies and procedures and overall program goals;
b. Federal and state laws and rules governing the program;
c. Identification and reporting of child abuse and neglect;
d. Protection of children's rights; and
e. Confidentiality.

2. Safety:
a. Disaster preparedness and evacuation procedures;
b. Fire safety;
c. Emergency procedures;
d. Violence prevention and suicide precautions; and
e. First aid and CPR, with competency demonstrated annually.

3. Child development:
a. Child supervision skills;
b. Children's physical and emotional needs;
c. Developmental stages of childhood and adolescence;
d. Family relationships and the impact of separation;
e. Substance abuse recognition and prevention; and
f. Principles and practices of child care.

4. Treatment services:
a. Individualized treatment that is culturally competent;
b. Treatment that addresses issues the child may have involving sexual or physical abuse, abandonment, domestic violence, separation, divorce, or adoption;
c. Behavior management techniques include, but are not limited to: preventing problem behavior, defining and teaching expectations, teaching and encouraging the child's long-term use of new skills as alternative behaviors, contingency management, teaching and promoting choice making and self-management skills, time-out, point systems or level systems, de-escalation procedures, and crisis prevention and intervention;
d. Treatment plan development and implementation;
e. Treatment that supports the child's permanency goals; and
f. The provider shall ensure ongoing training and be able to produce documentation of such training on the use of restraint and seclusion, physical escort, time-out, de-escalation procedures and crisis prevention and intervention.

(I) Before staff may participate in any use of restraint or seclusion, staff shall be competency trained to minimize the use of restraint and seclusion, to use alternative, non-physical, non-intrusive behavioral intervention techniques to handle agitated or potentially violent children, and to use restraints and seclusion safely.
(II) Staff shall complete a training course in the safe and appropriate use of seclusion and restraint and in the use of alternative non-intrusive behavior management techniques. The training course shall be provided by individuals qualified by education, training, and experience to provide such training. Competencies shall be demonstrated on a semiannual basis. Training requirements for all staff who participate in the use of restraint and seclusion shall include:

(A) An understanding of the underlying causes, e.g., medical, behavioral and environmental, of consequential behaviors exhibited by the children being served;
(B) How staff behaviors can affect the behaviors of others, especially children with a history of trauma;
(C) The use of non-physical interventions, such as de-escalation, mediation, active listening, self-protection and other techniques, such as time-out for the purpose of preventing potential and intervening in emergency safety situations;
(D) Recognizing signs of respiratory and cardiac distress in children;
(E) Recognizing signs of depression and potential suicidal behaviors;
(F) Certification in the use of cardiopulmonary resuscitation (CPR). Competency based re-certification in CPR is required annually;
(G) How to monitor children in restraint or seclusion; and
(H) The safe use of approved restraint techniques, including physi  (Correction: 04/08/2025)


summary: Monitor — 1 deficiency

raw_content:
Inspection: Monitor
Survey Date: 02/24/2025
Track ID: UYZC
Deficiencies: 1

  [None] NoneNone  (Correction: None)

report_type: Monitor

track_id: UYZC

inspection_type: Monitor


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 09/12/2022
Track ID: SWY3
Deficiencies: 1

  [None] NoneNone  (Correction: None)


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 11/03/2021
Track ID: CRQC
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: CRQC


summary: Complaint — 1 deficiency

raw_content:
Inspection: Complaint
Survey Date: 12/21/2021
Track ID: QGPY
Deficiencies: 1

  [None] NoneNone  (Correction: None)

track_id: QGPY