summary: QI Residential - FY25-26

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Everglades Youth Academy – Maximum/High Risk
Youth Opportunity Investments, LLC
(Contract Provider)
5050 SE 168th Street
Okeechobee, Florida 34972
Review Date(s): September 29-October 3, 2025
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Danielle Penn, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Nicos Antonakos, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Belinda Alexander, Office of Education, Central Education Coordinator, (Standard 2, 2.18)
Serena Brown, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Christine Calvert-Joyner, Office of Accountability and Program Support, Regional Supervisor
(Standard 3)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Education and
Interviews)
Lidia Lanns Clarke, Office of Post Secondary & Workforce Education, Regional Workforce
Education Coordinator South (Standard 2, 2.19)
Rebecca Smith, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Sharon Wong, Office of Accountability and Program Support, Regional Monitor (Interviews)
Program Name: Everglades Youth Academy - Maximum/High Risk MQI Program Code: 1482
Provider Name: Youth Opportunity Investments, LLC. Contract Number: 10289
Location: Okeechobee County / Circuit 19 Number of Beds: 80
Review Date(s): September 29-October 3, 2025 Lead Reviewer Code: 218
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 71 (Revised August 2025)
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Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 71 (Revised August 2025)
In d ic a t o r R a t in g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t a n d M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 3
In c id e n t R e p o rtin g (C C C )* 1 .0 4
R ig h t In te ra c tio n s (R I) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 5
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 6
In -S e rv ic e T ra in in g 1 .0 7
G rie v a n c e P ro c e s s 1 .0 8
D e lin q u e n c y In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .0 9
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 0
R e s to ra tiv e J u s tic e P ro g ra m m in g 1 .1 1
In te rn a l A le rts S y s te m a n d A le rts (J J IS )* 1 .1 2
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 3
A d v is o ry B o a rd 1 .1 4
S ta ff P e rfo rm a n c e 1 .1 5
S p e c ia l C o n tra c t C o n d itio n s 1 .1 6
D a ta T re n d A n a ly s is 1 .1 7
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 71 (Revised August 2025)
In d ic a t o r R a t in g s
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n 2 .0 1
Y o u th O rie n ta tio n 2 .0 2
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r 2 .0 3
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s 2 .0 4
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t 2 .0 5
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s 2 .0 6
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y ) A s s e s s m e n ts a n d R e a s s e s s m e n ts 2 .0 7
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S ) 2 .0 8
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls , a n d T ra n s m itta l* 2 .0 9
P e rfo rm a n c e P la n R e v is io n s a n d In c o rp o ra tio n o f O th e r P la n s 2 .1 0
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls 2 .1 1
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s 2 .1 2
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s ) 2 .1 3
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T ) 2 .1 4
E x it P o rtfo lio 2 .1 5
E x it C o n fe re n c e 2 .1 6
Y o u th In p u t 2 .1 7
E d u c a tio n a l A c c e s s (R e s id e n tia l C o n tra c t P ro v id e r)* 2 .1 8
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s (R e s id e n tia l C o n tra c t P ro v id e 2 .1 9
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Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff* Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning* Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Suicide Prevention Plan* Satisfactory
3.10 Suicide Prevention Services* Satisfactory
3.11 Secure Observation* Satisfactory
3.12 Suicide Precaution Observation Logs* Satisfactory
3.13 Suicide Prevention Training* Satisfactory
3.14 Mental Health Crisis Intervention Services* Satisfactory
3.15 Crisis Assessments* Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services* Satisfactory
3.17 Baker and Marchman Acts* Satisfactory
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 71 (Revised August 2025)
Standard 4: Health Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 71 (Revised August 2025)
In d ic a t o r R a t in g s
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e * 4 .0 1
L ic e n s e d M e d ic a l S ta ff* 4 .0 2
F a c ility O p e ra tin g P ro c e d u re s 4 .0 3
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t 4 .0 4
P a re n ta l N o tific a tio n /C o n s e n t 4 .0 5
H e a lth c a re A d m is s io n S c re e n in g & R e s c re e n in g F o rm 4 .0 6
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n 4 .0 7
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e A d m is s io n N o tific a tio n 4 .0 8
H e a lth -R e la te d H is to ry 4 .0 9
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g 4 .1 0
S e x u a lly T ra n s m itte d In fe c tio n & H IV S c re e n in g 4 .1 1
S ic k C a ll P ro c e s s 4 .1 2
E p is o d ic /F irs t-A id /E m e rg e n c y C a re 4 .1 3
O ff-S ite C a re /R e fe rra ls 4 .1 4
C h ro n ic C o n d itio n s /P e rio d ic E v a lu a tio n s 4 .1 5
M e d ic a tio n M a n a g e m e n t 4 .1 6
P s y c h ia tric S e rv ic e s * 4 .1 7
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s 4 .1 8
In fe c tio n C o n tro l/E x p o s u re C o n tro l 4 .1 9
P re n a ta l C a re /E d u c a tio n 4 .2 0
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
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Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision* Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks* Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test* Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Satisfactory
5.24 Controlled Observation Satisfactory
5.25 Controlled Observation Safety Checks and Release Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 71 (Revised August 2025)
Program Overview
Everglades Youth Academy - Maximum/High-Risk program is an eighty-bed program, for
thirteen to twenty-one-year-old males located in Okeechobee, Florida. The program is operated
by Youth Opportunity Investments, LLC, through a contract with the Department. The program
provides Mental Health Overlay Services (MHOS). The program is co-located with Everglades
Youth Academy - Sex Offender Program under the same contract on the same campus. The
program fosters each youth by providing Skillstreaming the Adolescent, Moral Reconation
Therapy, Impact of Crime, Thinking for a Change, and Living in Balance curricula. Additional
treatment services include individual, family, recreational, and group therapy. The program’s
administration is comprised of one facility administrator (FA), four assistant facility
administrators (AFAs), one human resource manager, and one administrative assistant. Case
management services are to be provided by one director of case management, five case
managers, and two transition services managers. Medical services are accessible twenty-four
hours a day, seven days a week and are provided by a registered nurse (RN) serving as the
health services administrator, and four licensed practical nurses (LPNs), a contracted physician,
a contracted optometrist, a contracted dentist, and a contracted psychiatrist.
The program shares eight therapists a clinical director and an assistant clinical director under
contract 10289, as there are two programs shared under the same contract number. Mental
health staff at the program shall include one designated mental health clinician authority
(DMHCA), one licensed assistant clinical director, and eight non-licensed therapists.
Educational services are overseen by Florida Scholars Academy and provided by Florida Virtual
School, and Florida Youth College for career and technical education. The building is designed
with two wings, each containing three separate living units. The Everglades Youth Academy -
Maximum/High-Risk program occupies five living units. Each living unit has sixteen individual
sleeping rooms, a case management office, an open-concept day room, and an adjoining
classroom. The program has one main master control and two sub-control stations, seven
therapist offices, education offices, program administration offices, a maintenance office and
storage areas, one large recreation field, six small recreation courts, a kitchen, a medical clinic,
two medication pass rooms, and an automotive sally port. The program has 113 video security
cameras monitored by master control staff and all cameras were operational at the time of the
annual compliance review. The video surveillance system is capable of recording thirty days of
video footage. At the time of the annual compliance review, the program had fourteen vacancies
consisting of two case managers, one food service worker, one intake coordinator, two master
control technicians, three safety and security specialists, four therapists, and one transition
services manager.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 71 (Revised August 2025)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a written policy and procedures to ensure all newly hired staff and volunteers
receive an initial background screening. The program had thirty-one newly hired staff and no
volunteers since the last annual compliance review. A review of the staff records showed each
of the thirty-one received a background screening prior to contact with youth and confidential
records. The documentation revealed a criminal history report was reviewed and the Staff
Verification System (SVS) module was updated on behalf of each of the thirty-one staff
members. The newly hired staff were added to the Clearinghouse Roster. None of the records
reviewed were applicable for obtaining an exemption prior to working with youth or for a break in
services. The program uses a pre-employment assessment tool for all direct care staff. The
reviewed documentation revealed each of the newly hired staff received a passing score on the
pre-employment assessment tool prior to being hired. All staff hired since the last annual
compliance review had a signed contraband attestation. The program did not have any new
volunteers or interns eligible for a background screening during the annual compliance review
period. The Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to
the Department’s Background Screening Unit (BSU) on January 7, 2025, meeting the annual
requirement.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a written policy and procedures to ensure all staff and volunteers receive a
background rescreening every five years from their initial date of hire. The program’s
administrator tracks each staff’s hire date and volunteer start dates to determine when the five-
year rescreening should be submitted. The program had fifteen staff applicable for a five-year
rescreening since the last annual compliance review. Each staff’s rescreening was completed
and submitted to the Department’s Background Screening Unit prior to their anniversary date.
Each rescreening was completed at least ten business days prior to each staff’s five-year
anniversary. There were no volunteers or interns applicable for a five-year rescreening since the
last annual compliance review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 71 (Revised August 2025)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a written policy and procedures to ensure a safe and secure environment for
staff, youth, and others to feel safe and secure from any form of abuse or harassment. The
program’s policy is to promote an environment of physical, psychological, and emotional safety.
Child abuse is not tolerated within the program. Staff shall immediately report all allegations of
abuse, neglect, or sexual harassment. Any incident or suspected incident of retaliation against
youth or staff who reported an allegation of abuse must be reported immediately. Staff are
required to report any alleged neglect or violation of responsibilities which may have contributed
to an incident or retaliation. All staff, volunteers, interns, and contracted staff who have
knowledge, or reasonable cause to suspect a youth is being abused or neglected, shall report
the information to the Florida Abuse Hotline or the Department’s Central Communications
Center (CCC), if the youth is eighteen years of age or older. Once the call has been completed,
staff must notify the facility administrator (FA) or supervisor on duty as soon as possible. The FA
or supervisor shall then begin an immediate review. The program had a total of twelve CCC
allegations or incidents related to physical, psychological, and/or emotional abuse during the
annual review period. There were no human trafficking victims, child sexual exploitation, or labor
trafficking incidents reported by the program. A review of five staff records for involved staff
indicated staff signed the code of conduct documentation in the staff handbook. A tour of the
program confirmed the Florida Abuse Hotline and the Department’s CCC telephone numbers
were posted throughout the program. The program’s steps for reporting abuse include the
program conducting pre-service and in-service annual training with staff to review incident
reporting. The Florida Abuse Hotline and CCC reports are reviewed during monthly staff
meetings and staff are educated as needed during monthly coaching sessions. All incidents are
reported to the CCC within two hours of the program becoming aware. Youth and staff have
unlimited access to the Florida Abuse Hotline and the CCC. The program completed the
Trauma Responsive and Caring Environment (TRACE) self-assessment on April 22, 2025. A
review of all incidents since the last annual compliance review found there were twelve incidents
which involved complaints related to physical, psychological, or emotional abuse, and each
were closed as substantiated. A review of documentation revealed management took immediate
action regarding the staff involved in each incident by initiating an investigation for all cases.
The FA was interviewed and stated staff are always expected to maintain ethical and
professional behavior. Expectations are for staff to interact with youth in a manner promoting
their emotional and physical safety. Additionally, any employee who deviates from these rules
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 71 (Revised August 2025)
and standards will be subject to corrective action, up to, and including termination of
employment. This includes the expectation for staff to interact with youth in a manner promoting
their emotional and physical safety while incorporating trauma responsive practices. The FA
reported all staff complete TRACE training during pre-service orientation training and annually.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a written policy and procedures in reference to the reporting of incidents in
accordance with Florida Administrative Code. The program had sixty-seven reportable incidents
since the last annual compliance review. A review of ten incidents found all were reported to the
Department’s Central Communications Center (CCC) within two hours of the incident or staff
becoming aware of the incident. All ten incidents were documented in the program’s logbook. A
review of the program’s internal incident reports found there were no additional incidents which
should have been reported to the CCC and were not. The program has experienced a decrease
in the number of reportable incidents to the CCC since the last annual compliance review. An
informal interview with the program’s facility administrator (FA) confirmed the program has a
policy in reference to the CCC and ensures all matters which require reporting are verbally
reported within the two-hour timeframe, when the program becomes aware of the incident. In
addition, several of the program’s CCC incidents were related to Florida Scholars Academy
events.
1.05 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program has a written policy and procedures in reference to the utilization of physical
intervention techniques in accordance with Florida Administrative Code. The program had
eighty Right Interactions (RI) incidents since the last annual compliance review. There was
documentation to support a monthly summary of RI Reports was submitted to the Department
each month since the last annual compliance review. A review of ten RI Reports found all
involved staff completed appropriate statements prior to the end of their shift. The RI Reports
were reviewed and processed within seventy-two hours by all required parties. Documentation
supported copies of the RI Reports were reviewed and placed in the program’s RI binder within
forty-eight hours of each reviewed incident. The program’s RI training plan was updated on
December 10, 2024, and the program’s RI training plan was approved by the Department’s
Office of Talent, Leadership, and Culture on December 11, 2024. The program experienced a
decrease in the number of RI Reports compared to the last annual compliance review period.
The program’s RI rate during the annual compliance review period was 2.70, which was above
the statewide Residential RI rate of 2.57. Five staff were interviewed, and all were aware of the
program’s RI practices. An interview with the facility administrator (FA) revealed the staff
complete an RI Report and submit the report to the FA for review. RI incidents are tracked using
the incident report trackers and monthly RI Reports. Video is reviewed to ensure the use of
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force aligned according to the RI matrix. Deviations from the matrix result in a staff coaching
note or retraining. Once a month, the RI incident tracker is reviewed with the program and
corporate staff to determine if there is a rise in incidents. If so, corrective action plans are
developed to prevent further incidents. All reports are filed in accordance with Florida
Administrative Code. None of the reviewed incidents were applicable for the use of mechanical
restraints, an incident resulting in injury, or for a youth alleging abuse.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has a written policy and procedures which state the residential contracted provider
staff will satisfy pre-service/certification requirements as outlined by Florida Administrative Code
within 180 days of hire. The program’s policy requires all full time and part time staff and
volunteers to receive a minimum of 120 hours of pre-service training during their first 180 days
of employment. Volunteers receive training appropriate to their assignments. All supervisors, the
facility administrator (FA), the assistant facility administrator (AFA), and any other staff in
management positions shall complete sixteen additional hours of supervisor specific pre-service
training within ninety-days of employment. Only supervisors and direct care staff are counted in
youth-to-staff ratio. An informal interview with the FA reported case managers, therapists,
the AFA, maintenance staff, kitchen staff, and operations managers can supervise youth;
however, maintenance staff and kitchen staff are not considered to be direct care staff and are
not counted in the staff-to-youth ratio. All training instructors were qualified to deliver trainings.
The program submitted a pre-service training plan and calendar, which was approved by the
FA, assistant secretary for the Office of Residential Services, and the director of the
Department’s Office of Talent, Leadership, and Culture. Seven reviewed staff training records
provided evidence of each staff completing their required training within 180 days of hire. A
review of the staff records showed all seven were direct care staff. Each direct care staff training
record confirmed the staff completed the required training to have contact with youth and
confidential youth records. Each direct care staff met the required training requirements to
include abuse recognition, reporting, and prevention, cardiopulmonary resuscitation (CPR)
certification, first-aid certification, automated external defibrillator (AED), emergency
procedures, program operating procedures, Prison Rape Elimination Act (PREA),
professionalism, interpersonal communication, ethics including standards of conduct, Right
Interactions model training, and suicide awareness and prevention training. Additional trainings
completed within the 180 days of hire, after having contact with youth, were active shooter
preparedness, adolescent development and behavior, balanced approach to rehabilitative
justice, the Department’s Central Communications Center incident reporting, civil rights,
communication, confidentiality/Health Insurance Portability and Accountability Act (HIPAA),
Department of Juvenile Justice (DJJ) legacy/history, equal employment opportunity, gang
awareness, human trafficking, infection control, information security awareness, the
Department’s Juvenile Justice Information System (JJIS), mental health and substance abuse,
Motivational Interviewing, quality report writing, safety, security, and supervision of youth, sexual
harassment, effective and respectful treatment of youth, and trauma responsive practices. All
seven staff completed training in the grievance process, infection control, the Exposure Control
Plan, behavior management system, the intent and safe use of tools as required by the
program’s manual, and specialized services training. Additionally, training included Mental
Health Overlay Services, Substance Abuse Treatment Services, and Juvenile Sex Offender
training. A review of three applicable pre-service supervisory training records confirmed the
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required sixteen hours of supervisory training were completed. Documentation for three staff
within their first 180 days of hire confirmed completion of all mandatory training.
1.07 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a written policy and procedures in reference to in-service training for all staff.
Seven staff training records were reviewed for in-service training. All seven reviewed staff
training records indicated each staff exceeded the twenty-four hours of annual in-service
training requirements. The seven staff had current certifications in Right Interactions (RI). Each
staff member had certifications in first-aid, automated external defibrillator (AED), and
cardiopulmonary resuscitation (CPR). Each of the two applicable staff completed the eight hours
of management/supervisory training in the areas of coaching, leadership, and personal
accountability. Additional trainings such as active shooter preparedness, human trafficking
intervention, information security awareness, mental health and substance abuse, and Prison
Rape Elimination Act (PREA) were completed by the staff. The staff all received
professionalism, interpersonal communication and ethics training, in addition to sexual
harassment, suicide awareness and prevention, trauma responsive practices, emergency
response, bloodborne pathogens, the Exposure Control Plan, Mental Health Overlay Services,
and Juvenile Sex Offender training. The program’s emergency drills are conducted quarterly on
each shift. The program has a training calendar which is updated whenever changes occur. All
trainings were conducted by qualified trainers and were documented in the Department's
Learning Management System (SkillPro). The program has a written in-service training plan
which was approved and signed by the facility administrator (FA), the assistant secretary for the
Office of Residential Services, and the director of the Department’s Office of Talent, Leadership,
and Culture.
1.08 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a written policy and procedures regarding their grievance process. Based on
the program’s policy, procedures are in place to confirm each youth’s right to grieve and to
ensure all youth are treated fairly, respectfully, without discrimination, and their rights are
protected. The program’s grievance procedures include informal, formal, and appeal phases
with a time frame of two days to provide feedback to the youth and to correct the grieved
situation or condition. Youth are provided with the opportunity to file an alternate informal
request by using a Request to Speak form as their first option to voice an objection and
informally resolve a complaint. The grievance and Request to Speak forms were available to the
youth and present on each living unit as observed during the program tour. Reviewed
documentation found there were five grievances and several Request to Speak forms submitted
by youth since the last annual compliance review. A review of the formal grievances revealed
the youth’s grievances were resolved at the formal phase and within the required timeframes.
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Seven staff records were reviewed for in-service and pre-service training. Each staff received
the required training on the program’s grievance process and procedures. Five youth and five
staff were interviewed during the annual compliance review. All youth and staff were able to
explain the grievance process. An interview was completed with the facility administrator (FA).
According to the FA, all grievances received will be reviewed in the daily management meeting
and will be assigned to an appropriate staff member for investigation. The assigned grievances
will be reviewed and investigated by the assigned staff member within two days of the
assignment and if the grievance is not resolved, a supervisory level staff will investigate the
grievance and respond within two days. The person investigating the grievance will never be the
subject of the youth's grievance. If the FA is the subject of the grievance, the FA's supervisor
will determine the most appropriate steps towards resolution of the grievance. Efforts will be
made to conclude the grievance process within five working days. If resolution cannot be
obtained within the timeframe, documentation of the reason will be included within the response.
1.09 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff who’s regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.10 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a written policy and procedures in place to address life skills training for youth.
The life and social skills training is provided utilizing the Skillstreaming the Adolescent and
Living in Balance (LIB) curricula. The groups specifically address communication, interpersonal
relationships and interactions, non-violent conflict resolution, anger management, and critical
thinking. A review of the program’s activity schedule confirmed each group is provided to the
youth once to twice a week by the therapists. All staff conducting groups received formal and
on-the-job training from a certified trainer to deliver the curriculum. Skillstreaming the
Adolescent groups incorporate hygiene and health skills. A review of seven youth case
management records and group sign-in sheets indicated services were delivered as required.
Five youth were interviewed and reported they participate in life skills groups while at the
program. All five-youth reported they were able to demonstrate the skills during role playing
activities in groups. An informal interview with the clinical director indicated youth can practice
skills in groups, role play activities, learn how to handle situations in a positive way, and how to
interact better with staff and other youth daily while at the program. An interview with the facility
administrator (FA) indicated all youth participate in daily mental health groups and life and social
skills groups.
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1.11 Rehabilitative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s rehabilitative justice programming includes Impact of Crime (IOC) groups, which
is a primary service. Youth participate in reparation activities at the program. The program offers
rehabilitative justice and community service opportunities for all youth, which allow youth to
complete community service through canteen points, assisting in the kitchen, participating in
community service projects, through faith-based activities, assisting maintenance staff with
cleaning of the program’s recreation yard, assembling hygiene packages/kits for the local
homeless and domestic violence shelters, and listening to guest speakers as part of their
rehabilitative justice activities. Youth have participated in activities which included animal
husbandry through raising chickens and donating the eggs to the local domestic abuse shelter,
assisting maintenance staff, making posters and cards, food collection and can drives, and
participation in the greenhouse projects. At the time of the annual compliance review, the animal
husbandry project was under repair and there were no chickens present due to an incident with
raccoons. The groups and activities are designed to assist youth in accepting responsibilities for
harm they have caused by their past criminal actions, challenging them to recognize and modify
their irresponsible thinking such as denying, minimizing, rationalizing, and blaming victims, and
expose youth to victims’ perspectives through victim speakers. The interviewed facility
administrator (FA) reported rehabilitative justice programming included working on the
vegetable garden and chicken coop, through the donation of food and holiday gifts, through
program renovation projects, and youth support initiatives. An interview with the designated
mental health clinician authority explained rehabilitative justice is provided throughout the week
through different group projects or activities at the program. The program did not have youth
participating in rehabilitative justice activities during the week of the annual compliance review;
therefore, an observation was not able to be completed. Five youth were interviewed, and
reported they participate in rehabilitative justice groups/activities while at the program.
1.12 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a written policy and procedures to address youth alerts. The program enters
alerts into the Department’s Juvenile Justice Information System (JJIS) for youth requiring an
alert which may not have been entered prior to the youth’s admission. The program has an alert
board in the main conference room, which identifies each youth’s special alerts, escape risk,
mental health alerts, and/or gang affiliation. The reviewed documentation revealed the
program’s internal alert report is reviewed daily during shift briefings by the program’s
supervisory staff. Observations verified the kitchen staff had access to each youth’s diet and
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allergy alerts. Seven youth records were reviewed for case management, medical, mental
health, and substance abuse alerts. All applicable alerts were accurately entered into JJIS. All
internal and JJIS alerts were downgraded or discontinued by medical staff, the director of case
management, and/or licensed mental health staff. Five staff were interviewed, and each
reported they are informed of youth alerts by reviewing the program’s alert board, during shift
meetings, and by reviewing the medical binder. An interview with the facility administrator (FA)
indicated all internal alerts are entered into JJIS, updated, and provided to the shift supervisor
daily. The program’s FA revealed youth alerts are reviewed daily during morning management
meetings and any changes in medical alerts are emailed to all staff. The nursing interview
indicated the nurses are responsible for updating the medical alert system.
1.13 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program has a written policy and procedures to ensure the management of all records are
consistent across operations and programs, the company philosophy, goals, objectives, and the
legal and contractual requirements. A review of seven youth healthcare, mental health and
substance abuse, and case management records showed each was marked “Confidential” and
each record documented the youth’s name, Department identification number (DJJID), the
youth’s date of birth, youth’s county of residence, date of admission, and committing offenses.
Observations during the annual compliance review week found all Individual Healthcare
Records, mental health and substance abuse records, and case management records were
secured in a locked room, which was not accessible to youth.
1.14 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a written policy and procedures regarding an advisory board. The program
has a community advisory board which meets on a quarterly basis. The reviewed
documentation supported the program’s community advisory board meets at least quarterly.
The reviewed meeting minutes, sign-in sheets, and agendas documented the meetings
occurred on February 28, May 20, and September 29, 2025. The meeting on September 29,
2025, was held in person and the documentation showed the remaining two community
advisory board meetings were held virtually, with a standing conference call in number. The
advisory board members consisted of a member from the law enforcement community, a
judiciary community member, interested community partners, a community business member, a
school board member, a victim advocate, a parent/guardian whose child was previously
involved in the juvenile justice system, and a faith-based community member. A review of
community advisory board agendas and meeting minutes documented the program provides the
board members with information regarding program updates, community updates, and
community service activities. An interview with the facility administrator (FA) reported the
program’s meetings are held quarterly. The program’s FA reported invitations are sent to
community members by mail and email with a calendar invite and a follow-up call for
confirmation is made if a response is not received from the invites. There is an established
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recruitment effort to increase attendance. A community advisory board member was interviewed
by telephone during the annual compliance review. The board member is an active member of
the community and has been a member of the advisory board for several years.
1.15 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a written policy and procedures regarding performance evaluations. The
program completes ninety-day performance evaluations for newly hired staff and annual
evaluations for all staff thereafter. The administrative staff reported they provide coaching
sessions as needed. The program maintains a detailed position description for all staff and a
written agreement outlining duties for all contracted staff. Seven staff personnel records were
reviewed, and the performance evaluations were specific to each staff’s job description. All
seven reviewed performance evaluations found each staff’s evaluation was based on the
performance standards for their position. The evaluations rated the staff’s quality of work,
modeling of appropriate behavior, positive reinforcement in a four-to-one ratio, and each
evaluation included ratings on the staff’s job-specific responsibilities. Five staff were interviewed
regarding their performance evaluations. All five reported they had received a ninety-day
performance evaluation. The facility administrator (FA)was interviewed and reported staff are
evaluated after their first ninety days and annually thereafter, on their job performance. A morale
committee was developed to increase staff morale. Events such as spirit week and staff
appreciation week were implemented to increase staff retention. Referral bonuses, retention
bonuses, and stipends were implemented to lower staff turnover. Additionally, virtual job fairs
were conducted to have a larger outreach to surrounding communities
1.16 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program is required to implement all items and services either negotiated or outlined in the
contract which are considered special contract conditions or listed within the scope of services
attachment. These may be referenced as the Memorandum of Negotiation (MON), summary of
negotiated points, special conditions, or simply listed in contract. The program tracks
measurable contract conditions through outcome measures entered in the Department’s
Juvenile Justice Information System (JJIS), which are administratively monitored by the
assigned contract manager. The program’s contract contains site-specific requirements to
include diverse media, faith-based opportunities, rehabilitative justice and community service
offerings, parenting education, motivation, achievements, and reward activities. A review of
documentation, on-site observations, and an interview with the facility administrator (FA)
validated the program was providing special contract conditions, as required. The program has
a partnership with a community prison ministry representative who leads religious activities for
youth desiring to participate. The program offers rehabilitative justice and community service
opportunities for all youth in which the youth are allowed to complete community service through
canteen points, assisting in the kitchen, assisting maintenance, assisting with the animal
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husbandry program, making posters and cards, food collection and can drives, and participation
with the greenhouse. The program has an animal husbandry program, however, there are no
chickens currently on-site. The chicken coop at the program is currently under repair. The
program’s greenhouse has been updated and repaired since the last annual compliance review.
The program provides education and support for youth who are expecting a child during the
transition phase. The program’s registered nurse provides instruction on developmental
milestones, shaken baby syndrome, car seats, and water safety to the confirmed fathers. The
youth coordinate with their therapists regarding specific family therapy and expectant fathers are
provided additional materials such as books, brochures, and mentoring opportunities during
their stay and special visitations are coordinated, when appropriate. An informal interview with
the program’s compliance manager confirmed the program had a total of eight applicable youth
who received parental resources and education. Observations in the youth’s living units showed
books and other publications were provided. The educational and fictional reading materials for
youth to sign out and specific requests are accommodated as appropriate. Materials are
screened and vetted through the lead teacher for appropriateness and media donations are
encouraged by parents/guardians and community stakeholders. On-site observations and
informal interviews confirmed the youth have access to a variety of reading materials in addition
to tablet access. The program participates with drives for the donation of clothing, shoes,
hygiene items, food, and engage in holiday celebrations with the youth. The youth with
community service requirements coordinate with their assigned case manager to ensure
performance planning reflects the need, and all eligible youth completed all their community
service hours while at the program. The community service hours are tracked on logs and
provided to the assigned juvenile probation officer. The program utilizes trained volunteers,
mentors, and other members from the community to provide positive modeling and experiences
for the youth and has a partnership with the community and local church volunteers, nonprofit
agencies, to include a domestic violence shelter, professional athletes, the local sheriff’s office,
and staff mentors to speak and model experiences with youth. The on-site observations
reflected the youth were wearing their assigned uniforms and were observed to be appropriately
dressed. The program participates in additional activities with community partnered programs.
Some of the program’s activities include sport competitions, training camps, and other
achievement celebrations. Incentives and celebrations for positive behavior and youth success
include honor roll, graduations, student of the month, classroom of the week, daily, weekly, and
monthly incentives, a football team, inter-program sports tournaments, movie nights, music
studio access, canteen, gym access, quarterly dinners with administration, academic
competitions, cook-off competitions, student council, carnival/field days, family days, holiday
celebrations, and pizza parties. The program has implemented an on-site barbershop in which
the youth provided an opportunity to showcase their creativity by participating in the incentivized
barbershop program. The barbershop opened on September 17, 2025. An interview was
completed with the FA and confirmed the program offers greenhouse activities, cleanup details,
and maintenance and food service assistance opportunities. Incentive celebrations are held in
addition to the daily and weekly incentives for academic and behavioral achievements.
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1.17 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a written policy and procedures which addresses data trend analysis
components. The program’s administration and management policy addresses research efforts
to enhance operations and contribute to the base knowledge of juvenile justice. The program’s
quality assurance and program planning policy detailed a formal process for monitoring and
evaluating quality, compliance, fidelity, appropriateness, safety, and effectiveness of all program
services utilizing a framework for measurement and evaluation of outcomes and process
measures. The program conducts weekly security audits, and the report identifies any
deficiencies and potential issues within the program and anticipated resolution dates. A review
of the weekly security audits confirmed the audits were conducted and completed on a weekly
basis as required. An interview with the program’s compliance manager explained the
program’s efforts to collect and analyze data. Additionally, the program participates in monthly
compliance reviews to discuss accomplishments, the facility administrator’s (FA’s) plan of
action, any corrective actions put in place, monthly staff and youth survey responses relating to
perceptions of program safety, living environment, treatment environment, whether youth
community meetings are occurring, and monthly incidents. The program conducts interviews
with families and youth on a quarterly basis, tracks outcome measures, monitors incident
reports, conducts internal fidelity monitoring, tracks evidence-based services, incidents, and
quality improvement audits. The program discusses scores, results, and findings in the morning
management meetings, monthly management meetings, community advisory board meetings,
and during the program’s all-staff meetings.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a written policy and procedures regarding initial contacts with the
parent/guardian and court notification. A review of seven youth case management records
indicated the program notified each parent/guardian by telephone within twenty-four hours of
admission and in writing within forty-eight hours. All seven reviewed records included
documentation the juvenile probation officer (JPO), court, and applicable post residential
services counselor were notified of the youth’s admission in writing within five working days.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a written policy and procedures regarding youth orientation. A review of seven
youth case management records indicated the program provided each youth an orientation on
the day of admission. Each reviewed case management record documented a signed receipt
acknowledging the youth received an orientation packet including a copy of the youth handbook.
The program’s orientation included services available, daily schedule, expectations and
responsibilities of the youth, written information on the program’s behavior management system
including rules governing conduct and positive and negative consequences for behavior,
information on how to access medical and mental health services, access to the Florida Abuse
Hotline or the Department’s Central Communications Center (CCC) if the youth is over eighteen
years of age, the program’s zero-tolerance policy regarding sexual misconduct including how to
report incidents or suspicions of sexual misconduct, special accommodations, the right to be
free from sexual misconduct, the right to be free from retaliation for reporting such misconduct,
the agency’s sexual misconduct response policies and procedures, items considered to be
contraband including illegal prohibited items, and possession which may result in the youth
being prosecuted. Additionally, the youth orientation included information on the performance
plan process, dress code and hygiene requirements, procedures regarding visitation, mail, and
use of the telephone, expectations for release from the program, including the youth’s
successful completion of individual performance plan goals, recommendation to the court for
release based on the youth’s performance in the program, the court’s decision to release,
community access, grievance procedures, emergency procedures, procedures for fire drills and
building evacuation, a program tour, a general layout of the program which focuses upon those
areas not accessible to youth, and assignment to a living unit and room, treatment team, and a
staff advisor or youth group. Information is conveyed verbally to youth with limited reading skills
or who are visually impaired, deaf, or otherwise disabled. Observations of a youth orientation
were not conducted due to the program not having an admission during the week of the annual
compliance review. An interview with five youth was conducted, and each youth stated they
received an orientation within twenty-four hours of their admission. Each youth confirmed
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orientation to the program included program rules, procedures, schedules, and other pertinent
information. Additionally, each youth reported they were provided a copy of the handbook.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a written policy and procedures which address obtaining written consent of
youth who are eighteen years of age or older. A review of seven youth case management
records showed two youth records were applicable for youth who were eighteen years of age or
older, and the program provided an additional youth for review. A review of each record found a
consent form signed by each youth prior to any release of information related to the youth’s
physical or mental health screenings, assessments, or treatment.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a written policy and procedures regarding the classification process for youth
upon admission to the program and the completion of reassessments as warranted. A review of
seven youth case management records confirmed each record contained an admission
classification form which included all required elements outlined by Florida Administrative Code.
The program’s classification form included physical characteristics of the youth, age and
maturity level, identified special needs, history of violence, gang affiliation, criminal behavior,
sexual aggression or vulnerability to victimization, youth’s perception of vulnerability, youth’s
history of potential or verified human trafficking, suicide risk, medical risk, escape risk, and
security risk. Seven youth case management records documented the date of the youth’s
classification, including all elements on the classification form, and confirmed they were
completed on the day of admission. A review of the Department’s Juvenile Justice Information
System (JJIS) alerts and the program’s internal alerts indicated four of the seven youth had a
security alert due to aggression. None of the seven youth reviewed were applicable for suicide
risk, medical risk, or escape risk. Each of the seven youth were classified for purposes of
assignment to a living area, sleeping room, and youth group or staff advisor. Five of the seven
youth with medical, mental health, substance abuse, security risk factors, and/or special needs
identified during or after the classification process were immediately entered into the program’s
internal alert system and JJIS, the remaining two youth were not applicable. Reclassifications
were conducted for each of the seven youth reviewed and revealed there was an increase in
each youth’s privileges or freedom of movement. Reviewed documentation confirmed the
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program’s policy and procedures clearly outlined the classification process and included a
classification system promoting safety and security, and effective delivery of treatment services,
based on the determination of each youth’s individual needs and risk factors, which addresses,
at a minimum, items outlined in Florida Administrative Code. The program’s policy regarding
reassessment ensures all program youth may be re-classified at intervals throughout their
length of stay. Staff shall reclassify youth when warranted based upon changes in the youth’s
supervision status, new or updated alerts, behavioral concerns, and relevant information
provided to the treatment team to ensure safety and security of the youth and program. An
interview with the facility administrator (FA) confirmed an initial intake screening process takes
place within twenty-four hours. An admission classification meeting is conducted to formally
review the youth's history, special needs, and risk factors to determine the appropriate levels of
supervision. Additionally, the alert status needs are identified for potential safety and security
risks impacting the living unit and room assignment. An admission classification meeting will be
held to include the youth, therapist, case manager, nurse, and living unit representative, at a
minimum. Each parent/guardian shall be invited to participate in the classification meeting, if
available.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a written policy and procedures regarding gang identification including
notification to law enforcement. A review of seven youth case management records found one
youth was applicable for notification to law enforcement of suspected gang association. Two
additional case management records were provided by the program. Each of the three
applicable records documented local law enforcement was notified of suspected gang activity
prior to the annual compliance review seven-day notification. Reviewed documentation
confirmed law enforcement from each youth’s home county was notified of the youth’s gang
affiliation. Reviewed documentation reflected all gang alerts were maintained in the
Department’s Juvenile Justice Information System (JJIS) and updated as required, upon
identification. Each of the three applicable records documented gang information was shared
with the educational staff at the program and the youth’s assigned juvenile probation officer
(JPO). None of the three applicable youth had a post-residential services counselor.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a written policy and procedures regarding a youth’s participation in gang
prevention and/or intervention activities. The program’s policy addresses providing youth with
an opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang. The
program utilizes the Yes, We Can, Youth Empowerment Solutions (YES) Leadership curriculum
and Gang Intervention Group as part of the gang prevention and intervention curricula. A review
of seven youth case management records was conducted. One youth was applicable for being
identified as a gang member or affiliate. The program was able to provide two additional
applicable youth records. Documentation supported all three-youth participated in gang
prevention and intervention strategies monthly. Each youth’s performance plan included goals
and objectives related to gang intervention strategies to be completed prior to release from the
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program. An additional gang intervention strategy used by the program included ARISE
Foundation’s Life Skills Gangs: 50+ Stories of Fractured Lives. A review of the program’s sign-in
sheets reflected the youths’ participation. An interview with the facility administrator (FA)
confirmed the program’s gang intervention and prevention strategies.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a written policy and procedures to ensure a Residential Assessment for Youth
(RAY) is completed for each youth within thirty days of admission. A review of seven youth case
management records confirmed six youth records contained a RAY which was completed within
thirty days of admission to the program. The remaining youth was transferred from another
program run by the same provider and therefore did not require a new RAY upon admission to
the program. Each initial RAY was maintained in the Department’s Juvenile Justice Information
System (JJIS). Seven youth case management records revealed each youth was applicable for
reassessments. Six youth records indicated RAY Reassessments were completed at least
every ninety-days, the remaining youth’s reassessment was completed three days late. Each
initial RAY and reassessments were maintained in the youth’s official case record. Each youth’s
case record documented the dates of the youth’s reassessment, and any other updates or
reassessments which were completed when deemed necessary by the intervention and
treatment team to effectively manage the youth’s case.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a written policy and procedures regarding the completion of the Youth Needs
Assessment Summary (YNAS). A review of seven youth case management records supported
six youth’s YNASs were completed within thirty days of the youth’s admission. The remaining
youth did not require an updated YNAS due to being transferred from another program run by
the same provider. Each youth’s YNAS was documented in the Department’s Juvenile Justice
Information System (JJIS).
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2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program has a written policy and procedures outlining performance plan development,
goals, and transmittal. A review of seven youth case management records confirmed six youth’s
Individualized Performance Plans (IPPs) were developed within thirty days of the youth’s
admission and developed after the completion of the initial Residential Assessment for Youth
(RAY) and the Youth Needs Assessment Summary (YNAS). The remaining youth did not
require new performance plan development due to being transferred from another program run
by the same provider. Each of the reviewed IPPs were developed and signed by the treatment
team leader, youth, administrative representatives, living unit representatives, treatment staff,
education staff, the Department of Children and Families (DCF) counselor, when applicable,
and all parties who had significant responsibility in goal completion. A review of documentation
showed each of the seven completed IPPs were mailed to each youth’s parent/guardian
requesting a signature. Each of the seven IPPs had the signature sheet of parties who had
significant responsibility in goal completion filed in the youth’s official case record. Each
reviewed IPP included the youth’s individualized goals based upon the prioritized needs
identified during the initial assessment, addressed the youth’s top three criminogenic needs,
specific delinquency interventions based on RAY results, and court-ordered sanctions. One of
the youth records was applicable and documented transition activities targeted for the last sixty-
days of the youth’s anticipated stay. Each IPP outlined program staff responsibilities and target
dates for goal completion. Each of the seven IPPs were sent to each youth’s committing court
judge, assigned juvenile probation officer (JPO), and parent/guardian. None of the seven youth
were involved with DCF. Five interviewed youth confirmed they participated in the development
of their performance plan, treatment goals, and received a copy of their performance plans.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a written policy and procedures in place ensuring revisions to a youth’s
performance plan. A review of seven youth case management records revealed all youth were
applicable for Individualized Performance Plan (IPP) revisions. Each of the revisions were
based on the Residential Assessment for Youth (RAY) Reassessment results, when acquired
information warranted updates, and based on the youth demonstrating progress toward
completing a goal. None of the seven records were applicable for youth demonstrating lack of
progress towards completing a goal. One youth was applicable and the IPP documented the
facilitation of transition activities during the last sixty days of the youth’s stay. Each of the seven
reviewed youth had additional plans, to include academic or treatment plans, included in their
performance plans. None of the seven youth were applicable for a case plan through the
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Department of Children and Families (DCF) and to have their performance plans coordinated
with the DCF plans.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety-day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program has a written policy and procedures ensuring the completion of Performance
Summaries and transmittals. A review of seven youth case management records revealed six
youth were applicable for initial Performance Summaries. The remaining youth did not require a
new performance plan due to being transferred from another program run by the same provider.
All seven-youth had Performance Summaries completed within ninety calendar days. One youth
was applicable for a Performance Summary completion prior to release, and a review of the
youth’s record indicated the summary was completed. All seven Performance Summaries
included all required elements to include the youth’s status on each performance goal, overall
treatment progress, academic status, credits earned in the program, performance and behavior
in school, youth’s behavior, level of motivation and readiness to change, interaction with peers,
interaction with staff, overall behavior adjustment to the program, and significant positive and
negative events. Each youth’s Performance Summary included documentation which was
signed confirming the youth read and was allowed to add comments to the Performance
Summary. Each youth was provided a copy of the signed summary, and the original summary
was filed in the youth’s case management record. Each Performance Summary was signed and
dated by the treatment team leader, staff preparing the summary, facility administrator (FA) or
designee, and the youth. Documentation showed each Performance Summary was sent to the
youth’s committing court, assigned juvenile probation officer (JPO), the youth’s parent/guardian,
and the Department of Children and Families (DCF), when applicable. Three closed case
management records were reviewed for release summaries. Each record included a copy of the
youth’s original summary, along with justification for release, sent with the Pre-Release
Notification (PRN) to the assigned JPO. Reviewed documentation showed the release summary
and PRN was sent within seventy-two hours prior to release. Signed copies were retained in
each of the three records. Once the PRN was approved, the program provided a written
notification to the youth’s parent/guardian regarding the planned release, and the program
completed a Residential Assessment for Youth (RAY) exit assessment. None of the three
records were applicable for the court objecting to the youth’s release. Reviewed documentation
and an interview with the program’s compliance manager verified victim notification was not
needed for the three closed case management records
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a written policy and procedures regarding parent/guardian involvement in
case management services. Documentation supported the program makes efforts to include the
parent/guardian in the assessment process, development of the youth’s performance plan,
progress reviews, formal treatment team meetings, and transition planning. If the
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parent/guardian is unable to attend the meetings in person, they are afforded the opportunity to
participate by telephone or conference call or can provide verbal or written input prior to the
meeting. A treatment team meeting was observed during the annual compliance review
confirming the parents/guardians of the youth participated in the meeting. A review of the
youth’s progress notes revealed the program reaches out to the parent/guardian to facilitate
involvement by telephone, by email, and/or a letter will be sent to the residence. An interview
was conducted with the facility administrator (FA), and it was indicated all parents/guardians are
provided a handbook upon admission. The youth’s parent/guardian is encouraged to participate
in monthly treatment team meetings and family sessions. Five youth were interviewed and all
stated their parent/guardian participated by telephone or in person.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a written policy and procedures regarding treatment team meetings. A review
of seven youth case management records determined formal treatment team meetings were
held every thirty days for each youth, and three youth records were applicable for informal
meetings which were held bi-weekly, as required. Four youth reviewed were not applicable for
informal treatment team meetings due to being committed to the maximum-risk level program.
Documentation for each of the formal and informal treatment team review meetings included the
youth’s name, date of review, required attendees, comments from treatment team members or
others, a brief synopsis of the youth’s progress, performance plan revisions, performance plan
goals, positive and negative behaviors, behaviors resulting in physical interventions, the youth’s
documented opportunity to demonstrate skills acquired in the program, treatment progress, and
Residential Assessment for Youth (RAY) Reassessment results. All seven records contained
formal treatment team documentation in the youth’s case management record. All required
parties were present either in person or by telephone during the formal and informal treatment
team meetings. A treatment team meeting was observed during the annual compliance review,
and all required participants were present during the treatment team. An interview with five
youth indicated their parent/guardian participate by telephone or in person and actively
contribute in the planning, and staff talk about their performance to include progress on
performance plan goals, positive and negative behavior, and treatment progress. All five youth
were able to articulate examples of showing learned skills during their treatment team to include
filling out forms and speaking verbally in front of the team.
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2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has a written policy and procedures addressing transition planning, conferences,
and Community Re-Entry Team (CRT) meetings. A review of three closed youth case
management records was conducted and the transition conference was held at least sixty days
prior to the youth’s targeted release date. Each record documented the youth, treatment team
leader, facility administrator (FA) or designee, and other team members attended the transition
conference. There was documentation provided to support the program invited and encouraged
the youth’s assigned juvenile probation officer (JPO), parent/guardian, education staff, and any
other additional pertinent parties to participate in the youth’s transition conference. None of the
three youth were determined to have a human trafficking history. Documents supported each
transition conference included a review of transition activities on the youth’s performance plan,
necessary performance plan revisions, additional transition activities as needed, target
completion dates, and persons responsible for transition activities. The treatment team leader
obtained attendees’ dated signatures, representing their acknowledgement of the transition
goals and accountability for completion. A copy of the plan was sent with a request for return
with signature to anyone not in attendance who had a responsibility for completion of transition
goals; however, none were returned. None of the forms were transmitted electronically.
Reviewed documentation found a CRT meeting was conducted prior to each youth’s release
and the youth and case manager participated. Documentation revealed there was evidence of
an invitation to participate in the CRT meeting for each of the three closed case management
records.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a written policy and procedures outlining the requirements of the exit portfolio.
A review of three closed youth case management record’s documentation showed each youth’s
exit portfolios were discussed during the transition conference. One of the three reviewed exit
portfolios contained a state-issued identification card and the other two did not. Documented
telephone contacts and notes demonstrated the program was actively working with the youth
and the family to obtain an identification card. One record contained a Social Security card and
birth certificate; the remaining youth’s portfolios did not contain a birth certificate or Social
Security card. An interview with the program’s compliance manager and reviewed
documentation showed telephone contacts and notes where the program was actively working
with the youth and the family to obtain the required documents. Each exit portfolio contained a
copy of the youth’s transition plan, a calendar of upcoming appointments, vocational certificates
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earned at the program, school transcripts, résumé, and a sample employment application.
Documentation supported each youth’s exit portfolio was verified during the exit conference,
and documentation indicated the exit portfolio was given to the youth upon release and
forwarded to the youth’s assigned juvenile probation officer (JPO). The program’s contract did
not include any additional requirements for the exit portfolio.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a written policy and procedures to ensure the completion of each youth’s exit
conference. Three closed youth case management records were reviewed and determined
there was documentation each youth’s exit conference was conducted after the program notified
the youth’s assigned juvenile probation officer (JPO) of the youth’s pending release, and at least
fourteen days prior to the youth’s release date. Reviewed documentation indicated the date of
the conference, signatures, and a summary of pending transition goals were included. The
youth’s date of admission and date of termination were documented in the case record and
correlated with the Department’s Juvenile Justice Information System (JJIS). Each record had
documentation reflecting the status of transition activities established at the transition
conference and the plans were finalized for the youth’s release. Documentation revealed
provisions for continuation of education and employment. The youth’s parent/guardian and
assigned JPO were aware of the vocational plan for the youth and there was documented
evidence the youth’s case manager and parent/guardian were aware of the plan, documents,
and post-release discharge plans. Two of the three exit conferences had documentation to
confirm the treatment team leader, parent/guardian, education representative, assigned JPO,
youth, and other pertinent parties participated, and there was documentation in each youth
record indicating the exit conference was held separately from the transition conference and
Community Re-Entry Team (CRT) meetings. The third record indicated the education
representative did not participate.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a written policy and procedures regarding written provisions for youth input.
The program has a formal process to promote constructive input by youth through giving them a
Request to Speak form, which will be filled out and submitted. This form is located on each
youth living unit. Additionally, the program provides town hall meetings twice a month and
student advisory board meetings, which are held monthly for each living unit. There was a
review of the program’s sign-in sheets, agendas, and meeting minutes to confirm the meetings
were being held as required. Advisory meetings were conducted once each month and the town
hall meetings were conducted twice each month. An interview with five youth indicated youth
may submit a grievance form about a concern or can request to speak to a supervisor, use town
hall meetings to express concerns, or contact the facility administrator (FA), if needed. An
interview with the FA indicated monthly surveys are completed by youth, bi-weekly town hall
meetings are conducted, and monthly student advisory council meetings are conducted to allow
youth input and for them to communicate their concerns.
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2.18 Educational Access (Residential Contract Provide) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures ensuring education access. The program
integrates education into the daily schedule. A review of three videos and three logbooks
reported youth arriving to and returning from class on time. In addition, randomly selected
logbook entries over the past year were reviewed and reported youth were moved accordingly
with little deviation. Five interviewed youth reported there were no interruptions during the
school day.
2.19 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program has written policies and procedures related to implementation of career and
technical education services. The provider’s contract states Florida Ready to Work Soft Skills
certification, Occupational Safety and Health Administration ten-hour (OSHA-10) certification,
and cardiopulmonary resuscitation (CPR) certifications are to be completed by each youth
within three months of program entry. Additionally, youth shall complete certification training
from the Master Credential List (MCL) prior to release. Career and technical education
certifications were received for 122 youth. Five youth earned certifications in culinary arts,
sixteen youth in digital and interactive media, twenty-four in OSHA, thirty-four in CPR,
seventeen in Florida Ready to Work Soft Skills, nine earned academic certifications, and twenty-
one earned food handler’s certifications. Services are provided Monday through Friday from
3:15 p.m. to 5:00 p.m. The provider’s contract states youth will have the opportunity to receive
training in culinary arts through the Florida Safe Staff Food Handler program certification and
earn career and technical industry certifications in telecommunication technologies, network
cabling, wireless systems, and grounding and bonding. These certifications are expected to be
initiated within the first three months of program entry. Youth in high and maximum-risk
programs are expected to obtain an industry certification from the MCL prior to release;
however, no evidence of earned industry certifications from the MCL or provider contract was
observed during the review. Six closed case management records were reviewed, documenting
none of the youth earned the Florida Ready to Work Soft Skills certification, three did not earn
the OSHA-10 certification, one did not earn a CPR certification, and three did not complete the
Florida Safe Staff Food Handler certification during the review period. The program reported
these issues were identified during an internal quarterly review and a corrective action plan has
been implemented, with full compliance expected by October 31, 2025. The interviewed facility
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administrator reported the program was providing career and technical education. Five
interviewed youth stated they were working with the Home Builder’s Institute or food service,
taking steps to enroll at a community college, studying for business, and obtaining their general
high school equivalency diploma (GED).
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program has a written policy and procedures regarding the designated mental health
clinician authority (DMHCA). The program’s DMHCA is a full-time staff who is on-site at least
forty hours each week and is responsible for the coordination and implementation of mental
health and substance abuse services in the program. The program’s DMHCA is a licensed
clinical social worker, whose license is free and clear in the State of Florida, which expires
March 31, 2027. There has only been one staff serving as the DMHCA since the last annual
compliance review. A review of the policies, job description, and an interview verified the
DMHCA is on-site Monday through Friday for at least forty hours each week. Additionally, the
DMHCA is on call twenty-four hours a day, seven days a week for emergency consultation. The
program’s assistant clinical director serves as the back-up to the DMHCA, which is a licensed
marriage and family therapist, with the State of Florida. The reviewed license was free and clear
and expires March 31, 2027. The DMHCA was interviewed and reported they provide clinical
supervision for non-licensed mental health professionals, oversee the weekly group schedule,
oversee the monthly fidelity monitoring calendar, and oversee clinical staff schedules to include
scheduled individual and family sessions. They reported communicating with the clinical staff
daily in addition to formal weekly supervision to ensure good morale and open dialog, fostering
the effective functioning of the clinical department.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. In addition to the
program’s designated mental health clinician authority (DMHCA), the program has a licensed
assistant clinical director and one licensed therapist. The assistant clinical director is a licensed
marriage and family therapist. The license was free and clear in the State of Florida with an
expiration date of March 31, 2027. The program’s additional licensed therapist was a licensed
mental health counselor. The reviewed license was free and clear in the State of Florida with an
expiration date of March 31, 2027. The program is licensed under Chapter 397 with the
Department of Children and Families to provide substance abuse treatment to adolescents. The
license expires April 1, 2026, and was displayed in the program’s lobby.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program had
three non-licensed therapists at the program and one non-licensed position was filled by a
licensed staff not requiring clinical supervision. The program’s designated mental health
clinician authority (DMHCA) shall ensure the non-licensed staff working under their supervision
are performing services they are qualified to provide, based on education, training and
experience. Reviewed documentation supported the DMHCA provided on-site face-to-face
clinical supervision to the three non-licensed staff since the last annual compliance review. The
supervision was documented on the program’s form and included all elements on the
Department’s Licensed Mental Health Professionals and Licensed/Certified Substance Abuse
Professionals Direct Supervision Log form. The program is licensed under Chapter 397 with the
Department of Children and Families to provide substance abuse treatment to adolescents. The
license expires April 1, 2026, and included the program’s physical address. One of the non-
licensed therapists held a master’s-level degree and two held a bachelor’s-level degree. Each
reviewed degree was from an accredited university or college in the field of counseling, social
work, psychology, or related human services field. Each non-licensed mental health clinical staff
who conducted Assessments of Suicide Risk completed twenty hours of training in assessing
suicide risk, mental health crisis intervention, and emergency mental health services. The
program had four therapist vacancies, which have been vacant since October 11, 2023, July 23,
2024, May 7, 2025, and August 1, 2025.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a written policy and procedures to establish a system to gather important
treatment and emergent information prior to each youth’s entry into the general population.
Seven mental health and substance abuse records were reviewed, and each contained a
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) completed on the date
of the youth’s admission. Each record documented the screener reviewed available information
to include the commitment packet, reports, and/or records for existing documentation of mental
health or substance abuse problems or history of human trafficking. Each MAYSI-2 was
completed in full by a trained screener in the Department’s Juvenile Justice Information System.
Six of the seven reviewed MAYSI-2s indicated the need for further assessment; however, it is
the program’s practice to refer all youth for additional assessment. Each referral documented
the notification to the designated mental health clinician authority (DMHCA). None of the youth
were applicable for being at-risk for suicide or identified as being in crisis. Each youth was
referred for a comprehensive assessment, and the reason for the referral was documented. The
reviewed policy and procedures indicated the facility administrator (FA) is responsible for the
implementation of a standard admission mental health and substance abuse screening process.
The policy addressed the administration of the MAYSI-2, staff training in administration, and a
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standardized referral process. The interviewed FA reported the program’s case manager or
designee will facilitate an admission classification meeting for all newly admitted youth
immediately following the initial intake screening process. Meeting outcomes will be
documented and a justification for room placement will be identified on the Admission
Classification form. The interviewed DMHCA reported during the intake process problem areas
are discussed with the youth and the parent/guardian.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a written policy and procedures to establish assessment and evaluation
processes to guide the development of the youth’s individualized treatment plan. It is the
program’s process to complete a new combined mental health and substance abuse evaluation
for all newly admitted youth. A review of seven mental health and substance abuse records
indicated each contained an evaluation completed within thirty calendar days of admission.
Each record contained documented consent for substance abuse services. Two evaluations
were completed by a non-licensed staff working under the direct supervision of a licensed
professional and were signed by the licensed staff within ten calendar days. Each new
evaluation documented the youth’s identifying information, reason for evaluation, relevant
background information including home environment and family functioning, history of physical
abuse, sexual abuse, neglect, witnessing violence and other forms of trauma, behavioral
functioning, physical health, mental health and substance abuse history, and education
functioning. Each assessment documented the completion of a Mental Status Examination,
interview procedures administered, discussion of findings, diagnostic impressions, patterns of
alcohol and drug abuse, impact of alcohol and drug abuse on major life areas, risk factors of
continued alcohol and other drug abuse, and recommendations. The interviewed designated
mental health clinician authority (DMHCA) reported the mental health staff gathers current
information from each youth during admission and then confirms each youth's report by
referring to collateral information obtained in the youth's records. This information is used to
complete the brief behavioral health status exam. Additionally, each youth receives a
comprehensive evaluation within twenty-one days of admission.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a written policy and procedures to establish individualized treatment planning
processes which guide service delivery. A review of seven mental health and substance abuse
records indicated each had an initial treatment plan created within seven days of the initiation of
treatment. Each plan was documented on the program’s form and included all elements on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. One of the initial
plans was applicable, and included psychiatric needs to include medication and frequency of
monitoring. Each of the seven plans were signed by the clinical staff completing the form, the
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youth, treatment team leader, program management, education staff, and other pertinent
parties. Each documented the participation by telephone, or the attempt to solicit telephone
participation from the parent/guardian and the assigned juvenile probation officer (JPO). Five of
the initial plans were completed by a non-licensed staff working under the direct supervision of
the licensed staff and were signed the same day by a licensed staff. Two plans were completed
by a licensed staff.
All seven youth were applicable for individualized treatment plans and plan reviews. Two
individualized plans were applicable and included psychiatric services, including psychiatric
medication and frequency monitoring. Individualized plans were completed on the program’s
form and included all elements of the Department’s form. The plans were applicable for fifty-two
reviews, which were all completed within thirty days as required. All seven individualized plans
and all plan reviews included signatures from the clinical staff completing the forms, the youth,
treatment team leader, program management, living unit representative, education staff, and
other applicable team members. Each documented the telephone participation or the solicitation
of telephone participation from the parent/guardian, and the assigned JPO. Four individualized
plans were completed by a non-licensed staff working under the direct supervision of a licensed
staff and were signed by licensed staff the same day, and three were completed by licensed
staff. When applicable, plans documented the signature and review of the individualized plan by
the psychiatrist. Each youth’s individualized plan contained goals and objectives which were
individualized, and each plan prescribed a minimum of two monthly individual sessions, one
monthly family session, and four weekly group sessions. The interviewed designated mental
health clinician authority (DMHCA) reported mental health professionals complete master
treatment plans within twenty-five days of admission and treatment plan reviews are created
monthly and reviewed by the DMHCA or designee. Updates are made using a treatment
addendum if treatment adjustments are needed.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
The program has a written policy and procedures to establish individualized treatment planning
processes which guide service delivery. Additionally, the program has a policy and procedures
to establish discharge and transition planning processes for mental health and substance abuse
treatment services. A review of seven mental health and substance abuse records showed each
youth was assigned to a treatment team upon arrival to the program. Reviewed treatment team
assignment forms and treatment team documents verified the youth, program administration, a
living unit representative, medical staff, and mental health staff attended treatment team
meetings. Additionally, treatment team plans and reviews documented the parent’s/guardian’s
telephone participation or attempts to solicit their telephone participation. All seven reviewed
records contained a properly executed Authority for Evaluation and Treatment (AET) and a
signed Youth Consent for Substance Abuse Treatment form. All mental health and substance
abuse treatment notes were documented on the program’s form and contained all elements in
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the Department’s Counseling/Therapy Progress Notes form. Mental health and substance
abuse therapy included individual counseling and psychosocial skills training for all seven
reviewed youth. Reviewed progress notes verified each youth received services as stipulated in
their individualized treatment plans.
Three mental health and substance abuse records were reviewed for discharge plans. Each
record contained a discharge plan completed on the Department’s Mental Health/Substance
Abuse Treatment Discharge Summary form. No youth were applicable for being released on
suicide precautions. Each discharge plan included future needed services. Reviewed
documentation supported the discharge plans were discussed with the youth’s parent/guardian
and assigned juvenile probation officer (JPO) during the exit conference and a copy of the plans
were provided to the youth, parent/guardian, and assigned JPO. The program’s practice is to
obtain the parent’s/guardian’s signature upon release, and to provide them with a copy at
release. Additionally, the discharge summary is sent by email and by mail to the assigned JPO
after release.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program’s specialized treatment service is Mental Health Overlay Services (MHOS). The
program has a written policy and procedures to establish service delivery protocols for the
delivery of MHOS. The program’s clinical groups include Moral Reconation Therapy (MRT) and
Skillstreaming the Adolescent. MRT is a primary service and is reviewed during the annual
fidelity monitoring. A review of Skillstreaming the Adolescent group sign-in sheets confirmed
groups were being provided as scheduled. The program provides Skillstreaming the Adolescent
groups two times each week, and MRT two times each week. A review of group video
recordings verified groups were conducted as documented. The program’s counselor to youth
ratio shall not exceed sixteen youth, and a review of caseload assignments showed caseloads
were between twelve and fourteen youth for the program’s four counselors. Youth plans and
progress notes verified the program was conducting individual therapy sessions at least every
two weeks, family sessions at least once each month, and the psychiatrist was on-site at least
every two weeks. The program subcontracts with a board-certified behavior analyst (BCBA) to
provide services as needed. The BCBA sign-in sheets supported services were provided as
needed each month since the last annual compliance review, with the exception of January,
where there were no BCBA sign-ins. There were no documented instances where services were
missed due to medical quarantine since the last annual compliance review. Five interviewed
youth reported they participate in group, family, and individual counseling at the program. Five
interviewed staff reported the mental health staff facilitate clinical groups. The interviewed
facility administrator confirmed the groups provided, and the interviewed designated mental
health clinician authority (DMHCA) reported the clinical staff provide individual, family, and
group therapy services to address the mental health and substance abuse needs of the youth.
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3.09 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a written Suicide Prevention Plan. The Suicide Prevention Plan describes the
essential components and provides guidelines for the identification, management and
assessment of a potential suicide risk or at-risk youth. Potential suicide risk or at-risk youth refer
to youth who have a history of or demonstrate behaviors which indicate they are thinking about
or contemplating suicide; however, are not acutely suicidal. The acutely suicidal youth who
attempt suicide or present an imminent threat of suicide must be treated as an emergency and
the program’s emergency plan shall be implemented. The written plan included identification
and assessment of youth at-risk for suicide, staff training, suicide precautions, levels of
supervision, referral, communication, notification, documentation, immediate staff response, and
a review process. The review process for suicide attempts and mortality review included
circumstances surrounding the event, program procedures relevant to the incident, relevant
training received by involved staff, pertinent mental health and medical services involving the
victim, possible precipitating factors, recommendations, if any, for changes in policy, training,
medical or mental health services, and/or operating procedures. The plan was reviewed
annually and was last signed on August 4, 2025, by the designated mental health clinician
authority(DMHCA) and the facility administrator.
3.10 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
The program has a written Suicide Prevention Plan which details the methods for identification,
assessment, and supervision of youth “at-risk” for suicide. The program’s practice is to screen
all newly admitted youth for suicide risk and to then complete an Assessment of Suicide Risk
(ASR) regardless of the screening results. Seven youth records were reviewed, and each had
an ASR completed on the day of admission. Each ASR was completed in full on the
Department’s form and resulted in the youth being transitioned to standard supervision status.
Each documented the notification to the parent/guardian, and the assigned juvenile probation
officer (JPO) regarding the youth’s potential risk. Each was completed by a non-licensed staff
working under the direct supervision of a licensed clinician or a licensed staff. Each ASR
completed by a non-licensed staff was signed the same day by a licensed staff. None of the
admission ASRs were applicable for needing a Follow-Up ASR. The program had three
additional precautionary observation events since the last annual compliance review. A review
of each of the three events indicated the youth were placed on suicide precautions after staff’s
behavior observations. Each ASR was completed in full by a licensed staff and the youth
remained on constant supervision in each instance. Each event documented the notification to
the parent/guardian and the assigned JPO of the youth’s status. Subsequent Follow-Up ASRs
were completed until the youth were deemed appropriate for close supervision. The youth’s step
downs to close supervision only occurred after a documented conference between the licensed
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clinical staff and the facility administrator (FA) or designee. The discontinuation of close
supervision in each of the three events was documented in accordance with the program’s
Suicide Prevention Plan. A suicide risk alert was appropriately placed and removed in the
Department’s Juvenile Justice Information System and the program’s logbook in each instance.
The Suicide Precautions-Observation Logs were completed in their entirety for the duration
each youth was on precautionary observation. The program did not have any youth on suicide
precautions in the past thirty days; therefore, a review of supervision through video was not able
to be completed. The interviewed designated mental health clinician authority reported youth
are assessed and placed on the program’s internal alert system for precautionary observation.
A new log is completed for each shift and staff are notified of supervision levels during each shift
briefing. All precautionary observation placements are documented in the program’s logbook,
the licensed staff confer with the FA regarding placement, and the parent/guardian and
assigned JPO are notified by telephone.
3.11 Secure Observation (Critical) Satisfactory Compliance
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program has a written Suicide Prevention Plan which details the methods for identification,
assessment, and supervision of youth at-risk for suicide. The plan states secure observation will
be used only as a last resort to ensure youth safety. The program had one youth applicable for
secure observation placement since the last annual compliance review. The reviewed
documentation supported the placement in secure observation was authorized in writing by the
designated mental health clinician authority (DMHCA) and the facility administrator (FA).
Documentation supported a staff of the same gender conducted a visual check of the youth and
a Health Status Checklist was completed. The youth was in controlled observation prior to being
placed on secure observation status, and the controlled observation checklist confirmed the
room was inspected prior to the youth’s placement in the room. The decision to place the youth
on secure observation status was made after the youth displayed at-risk behavior and the youth
was maintained on constant supervision while in the secure observation room. Suicide
Precautions-Observation Logs were maintained for the duration the youth was placed in secure
observation and within eight hours of placement an Assessment of Suicide Risk (ASR) was
completed by the licensed DMHCA. The youth was removed from secure observation after
seven hours, mental health staff documented supportive counseling services, and the youth’s
level was reduced only after a conference with the DMHCA and FA. The DMHCA and FA
concurred on the removal of secure observation status, and the communication was
documented on the ASR. The youth’s placement and removal from secure observation was
documented in the youth’s mental health record and the program’s logbook as required. The
program did not have any secure observation placements in the past thirty days; therefore, a
review of supervision by video was not able to be completed.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program has a written Suicide Prevention Plan which details the methods for identification,
assessment, and supervision of youth at-risk for suicide. There were three documented
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incidents requiring a youth to be placed on precautionary observation since the last annual
compliance review. A review of Suicide Precautions-Observation Logs for the three applicable
incidents were reviewed. Reviewed logs confirmed they were maintained for the duration youth
were on suicide precaution status and the supervision observations were documented in real
time, not exceeding thirty-minute intervals. Two logs were applicable for observed warning signs
and the logs documented the warning behavior, consultations, and reviews with a licensed
mental health staff. Each log was signed by mental health staff and supervisory staff as
required. Each log documented the youth supervision level instructions and safe housing
requirements.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a written Suicide Prevention Plan detailing the training requirements for staff.
All staff having direct contact with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk. All staff having direct contact with youth shall be trained in the
supervision procedures and documentation which must be completed on youth identified as at
risk. The program will offer a minimum of six hours of training annually on suicide prevention
and implementation of suicide precautions. A review of training records for seven in-service and
seven pre-service staff confirmed each had the required six hours of training in suicide
prevention and implementation of suicide precautions. The program has three suicide response
kits located in master control, sub master control east, and sub master control west. The kits are
co-located with first-aid kits and contain a rescue tool, wire cutters, and needle nose pliers. The
program conducts “mock” suicide drills no less than quarterly on each shift for all staff who
come into contact with youth. The program’s practice is to review drills during the monthly all
staff meetings allowing staff who were not present to have the opportunity to review each drill
scenario and procedures in an effort to understand the process and receive the necessary
training to respond to an incident of a suicide attempt or incident of serious self-inflicted injury.
The interviewed facility administrator reported drills occur monthly. Five interviewed staff
reported, if a youth reports suicidal thoughts, staff are responsible for searching the youth and
room for sharp objects, maintaining sight and sound supervision, and documenting the
supervision. Additionally, one staff reported they would talk to the youth about what is going on.
Each staff knew the location of the program’s suicide kits and reported drills occur monthly. A
video review of a “mock” suicide drill confirmed drills were simulated. Drills were documented as
occurring monthly alternating between the program’s two shifts and drills were in response to a
suicide attempt and/or incident of simulated self-inflicted injury. Program youth were not used in
drill simulations. Reviewed drills confirmed the program’s practice of completing monthly drills
alternating by shift. Each drill included details regarding staff and applicable emergency
contacts made, and life saving measures used.
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3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a written Crisis Intervention Plan to ensure the program differentiates between
youth in mental health crisis and those requiring suicide precautions or emergency treatment. A
review of the Crisis Intervention Plan showed it included details regarding a notification and alert
system, means of referral, including youth self-referral, communication, supervision,
documentation, and review.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a written Crisis Intervention Plan which details the procedures regarding the
completion of a Crisis Assessment and a follow-up Mental Status Examination. The program
had three incidents requiring the completion of a Crisis Assessment since the last annual
compliance review. Two of the three assessments were completed the day the youth was
determined to be in crisis, and the third assessment was completed within twenty-four hours.
Each of the three reviewed Crisis Assessments included the reason for the assessment, a
Mental Status Examination and interview, determination of danger to self and/or others,
including imminence of behavior, intent of behavior, clarity of danger, lethality of behavior, initial
clinical impressions, supervision recommendations, treatment recommendations,
recommendations for follow-up or further evaluation, and notification to the parent/guardian
regarding follow-up treatment. Each Crisis Assessment was completed by a licensed staff. Two
youth were applicable for being placed on mental health alert and the appropriate alerts were
made internally, documented in the logbook, and entered into the Department’s Juvenile Justice
Information System. The two-youth remained on alert status until a follow-up Crisis Assessment
and a Mental Status Examination were completed. Supervision observations for the two
applicable youth were documented on the Department’s Mental Health Alert Observation Log as
required. All Crisis Assessments were completed on-site. All three assessments were
completed for youth who were an alleged Prison Rape Elimination Act event victim and referrals
for an immediate Crisis Assessment were completed. Documentation supported each youth was
offered on-going mental health treatment services.
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3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a written Emergency Response Plan to outline the mental health and
substance abuse emergency procedures and to ensure youth who are believed to be an
imminent danger to themselves or others because of mental illness or substance abuse
impairment receive emergency mental health or substance abuse services. A review of the plan
confirmed the plan included processes for immediate staff response, notification,
communication, supervision, authorization to transport for emergency mental health or
substance abuse services, transportation for emergency Baker Act or Marchman Act,
documentation, training, and review.
3.17 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a written policy and procedures to establish a planning process designed to
identify areas affecting youth and incorporate trauma responsive practices. A review of seven
mental health and substance abuse records showed each record contained a Safety Plan
created on the date of admission. Each plan was jointly prepared with the youth,
parents/guardians, and the program’s clinical staff. Each Safety Plan incorporated applicable
recommendations from previous and current clinical assessments and incorporated trauma
responsive practices. Each plan was updated monthly as part of the monthly treatment plan
review process. None of the plans required updates outside of the routine reviews as a result of
a significant behavioral or mental health event. All seven Safety Plans included the youth’s
identified warning signs, baseline behaviors, crisis recognition, jointly developed coping
strategies, the youth’s preferred intervention strategies, and a debriefing process. The
interviewed designated mental health clinician authority reported Safety Plans are kept in the
clinical office and in east sub control and west sub control, accessible to all staff. Five
interviewed youth reported they contributed to the development and review of their Safety
Plans. The interviewed facility administrator reported Safety Plans are updated at a minimum of
every thirty days and as needed.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a written policy and procedures which requires a contracted health authority to
provide on-site medical services to youth in the program. The program maintains a contract with
a State of Florida board-certified licensed medical doctor (MD) who serves as the designated
health authority (DHA). The DHA had a clear and active license in the State of Florida, expiring
on January 31, 2026, with specialty training in pediatrics. A review of the Florida Department of
Health records supported the DHA had no current disciplinary cases and/or public complaints
on record. The program has an advanced practice registered nurse (APRN), who holds a clear
and active license in the State of Florida, which expires on July 31, 2026, with specialty training
in family health. The APRN has a Collaborative Practice Protocol (CPP) in place with the
physician signed by both parties on August 28, 2025. Reviewed documentation during the
annual compliance review period found the APRN had not been utilized for clinical duties. A
review of the sign-in and sign-out logs during the annual compliance review period confirmed
the DHA was on-site, at a minimum of once a week, with a week defined as the seven-day
period beginning on Sunday and ending on Saturday. The program has a back-up DHA who is a
licensed physician with a clear and active license in the State of Florida expiring on March 31,
2026. Reviewed documentation found the back-up DHA was utilized on two occasions during
the month of December 2024, when the DHA was not on-site. Reviewed documentation
confirmed the program received approval from the Department’s Office of Health Services for
tele-medicine/tele-health services. Reviewed documentation found the psychiatrist utilized tele-
health to provide mental health services. Tele-health was only utilized for youth who agreed to
participate in tele-health sessions. There were no instances of tele-health being used to perform
a Comprehensive Physical Assessment (CPA), and all medical services were provided in
person. The DHA reported their role in the program is to conduct CPAs, periodic evaluations
every ninety days for youth on medication or with chronic conditions, to evaluate and approve
nursing protocols, assess youth with a sickness, and provide oversight of medical staff. The
DHA confirmed being on-site once a week and being available by telephone twenty-four hours a
day. An interview with the APRN confirmed the program’s practice.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a written policy and procedures in place for licensed medical staff. The
program’s on-site nursing coverage is provided by one full-time registered nurse (RN), who
serves as the health services administrator (HSA) and is contractually required to be on-site
forty hours a week. In addition, there are four full-time licensed practical nurses (LPNs) on-site.
A review of nurse licensure credentials for nurses who provided services during the annual
compliance review period confirmed licenses were clear and active. Each held a current
certification in cardiopulmonary resuscitation (CPR) and first- aid.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The designated health authority (DHA) and the facility
administrator (FA) signed and dated all respective treatment FOPs on September 24, 2025. The
psychiatrist reviewed and signed the FOPs on September 25, 2025. The nursing staff signed a
cover page acknowledging review of all FOPs and treatment protocols on January 2, 2025. The
annual review of medical FOPs and protocols was conducted on September 24, 2025.
Reviewed documentation confirmed all newly employed healthcare personnel received a
comprehensive clinical orientation to the Department’s healthcare policies and procedures,
given by a registered nurse or designated healthcare professional. All approvals of treatment
protocols or standing procedures were written and were authorized by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a written policy and procedures for authorizing treatment for the youth. The
program’s policy requires each youth in custody to have a valid Authority for Evaluation and
Treatment (AET). A review of seven youth records confirmed six youth’s Individual Healthcare
Records (IHCRs) had an original dated AET signed by the parent/guardian and Department
representative. One AET was not signed by the parent/guardian. The AET indicated the
parent/guardian refused to sign. Documentation confirmed the parent/guardian gave consent for
over-the-counter medications prescribed. A court order authorizing treatment was obtained for
the youth. None of the youth were in the care of the Department of Children and Families. Two
of the youth had a court order authorizing treatment in the youth’s IHCR. Two of the seven
youth were eighteen and had a signed AET form completed prior to the youth’s eighteenth
birthday by their parent/guardian. An interview with the nurse confirmed an AET is not used for
youth eighteen years or older. Both youth who turned eighteen while in the program, had a
documented release of information in their IHCR. The interviewed nurse stated the AETs for
youth are in the medical records within the Department's Juvenile Justice Information System
(JJIS). The medical staff will call the parent/guardian to notify them of any treatment and to
obtain consent and signature.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a written policy and procedures for parental notification and consent. The
program’s policy requires the parent/guardian to be notified regarding medical changes. A
review of seven youth records confirmed all youth had documentation of parental notification for
over-the-counter (OTC) medications beyond those indicated on the Authority for Evaluation and
Treatment (AET). All seven youth records indicated a new medication was ordered and
documented in the progress notes. Three of the seven youth were taking psychotropic
medication upon admission. The reviewed documents confirmed the written notifications were
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sent utilizing the Department’s Parental Notification of Health-Related Care forms including the
acknowledgement receipt of the Clinical Psychotropic Progress Note (CPPN). The nurse
witnessed a telephone call attempt to the parent/guardian regarding the youth’s psychotropic
medication changes for the applicable youth. Parent/guardian verbal consent for psychotropic
medications was documented on page three of the CPPN. None of the youth receiving
psychotropic medications were in the care of the Department of Children and Families (DCF). A
review of the seven youth records confirmed all youth vaccinations were verified within thirty
days of admission. None of the youth were applicable for having a refusal to consent for
immunizations, a Religious Exemption from Immunization, or for having the Department’s
Parental Notification of Health-Related Care Vaccination/Immunizations forms. An informal
interview with the nurse indicated immunization records are retrieved from the Florida Shot
records website. Other youth records are sent over prior to placement. A review of the nurse’s
interview indicated a verbal and written consent is needed for all medications including obtaining
new or discontinued psychotropic medications, activity restrictions, or procedures. Examples of
procedures include but are not limited to dental and X-rays and ultrasounds. Parents/guardians
are notified by telephone at the time the doctor’s order is received. Written consent notification
is mailed to the parent/guardian within twenty-four hours. In the instance of an emergency, the
facility administrator (FA), designated health authority (DHA), the Department's Central
Communications Center (CCC), and parents/guardians are all notified and updated. The nurse
explained the process of obtaining youth immunizations and vaccination records. The records
are verified at the time of each youth’s admission. If records need to be obtained, staff will utilize
the Florida Shots website and review school records. If a youth is still in need of a vaccination,
youth may obtain it at the program, if available at the pharmacy, or by going to the local health
department. A youth’s medical record is reviewed on the day of intake. If a youth or
parent/guardian refuse immunizations, a Religious Exemption from Immunization form is
retrieved from the department of health.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a written policy and procedures for youth admission screenings. The
program’s policy requires each youth to have a healthcare admission screening. A review of
seven youth records indicated all youth had a completed Facility Entry Physical Health
Screening (FEPHS) form completed on the date of admission. Four screenings were completed
by the licensed practical nurses (LPNs). Three of the FEPHS were completed by the registered
nurse (RN). One youth was applicable for having a change in physical custody greater than
twenty-four hours and two new FEPHS re-screenings were completed. The interviewed nurse
confirmed youth are seen by medical immediately upon arrival to the program, and the nurses
start the intake process. The medical staff are notified prior to the youth’s arrival through an
email from the departing location and during the morning management meetings. The youth
admission screening is completed by the licensed medical staff. In the occasion a direct care
staff completes the admission screening the licensed medical staff will review and sign the
FEHPS within twenty-four hours. The nurse indicated when a youth is returning to the program’s
custody a FEPHS is completed along with a urine drug screening.
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4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a written policy and procedures for educating the youth on the delivery of
healthcare services. The program’s policy requires each youth to be orientated about the
general process of the healthcare services the youth will receive at the program. A review of
seven youth records confirmed all the youth received a general healthcare admission
orientation. The orientation included sick call practices, access to medical care, medication
process including side effect monitoring, “emergencies”, the right to refuse care and how it is
documented, the non-disciplinary role of the healthcare providers, and standard universal
precautions. The program utilizes an education/orientation binder for youth who refused to sign
an orientation sheet. A review of the Health Education sign-in sheets confirmed from January to
September 2025, healthcare topics were covered. Youth are educated on seatbelt usage,
alcohol and drug related problems, sexually transmitted disease/infections, tobacco products,
including smoking, dental and basic personal hygiene, immunizations, infection control,
prevention of sexual and other physical violence, nutrition, physical fitness, testicular self-
examination, and chronic conditions monthly.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a written policy and procedures for notifying the designated health authority
(DHA) of newly admitted youth. The program’s policy requires the DHA/designee to be notified
when newly admitted youth require emergency care. A review of seven youth records confirmed
four youth were applicable for having known or suspected chronic conditions, needing a referral
to the physician. None of the youth records indicated the youth was in need of emergency care
upon admission. All seven Individual Healthcare Records (IHCRs) confirmed documentation on
the youth’s chronological progress note indicating the DHA was notified within twelve hours of
admission. Three youth were applicable for taking psychotropic medication upon admission and
documentation confirmed the psychiatrist was notified. A review of the nursing staff interview
indicated youth admitted with serious or chronic conditions are evaluated by the licensed
medical staff. The DHA is notified of the conditions at the time of each youth’s admission. The
medical staff then document the admission progress note for each youth in the IHCR, DHA Log,
and nursing progress notes/orders.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a written policy and procedures for authorizing treatment for the youth. The
program requires the Health-Related History (HRH) form to be used for each youth in their
physical custody. A review of seven Individual Healthcare Records (IHCRs) indicated each HRH
form was updated/completed prior to the Comprehensive Physical Assessment (CPA). A
physician reviewed and signed each HRH form. According to the nursing staff interview the
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admitting registered nurse (RN) is responsible for completing the HRH form at the time of the
admission or within seven days.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a written policy and procedures for admitted youth receiving a Comprehensive
Physical Assessment (CPA). The program’s policy requires all youth admitted having a
standardized CPA upon arrival. A review of seven Individual Healthcare Records (IHCRs)
confirmed each youth’s CPA was completed on the required form. Documented on the CPA
were the times of admission and Medical Grade. A Medical Grade of five was documented for
two youth. Medical Grades of two and four were documented for two youth. One youth received
a Medical Grade of one. The remaining two youth received a Medical Grade of three which were
all noted on the youths’ CPAs. Each CPA was completed by the designated health authority
(DHA). A review of the CPAs confirmed each section was answered the with “O” or “X”;
however, all seven-youth refused part of the exam. Documentation was provided for a signed
refusal form and confirmation of self-examinations for all youth. The youth’s Problem List was
updated for all the IHCRs reviewed. All seven youth had at least one documented Tuberculosis
Skin Test (TST) completed. Results of the TSTs were documented and correlated on the CPA
and Infectious and Communicable Disease forms. A review of the nurse’s interview indicated
the DHA completes a new CPA within seven days of the youth’s admission and then yearly. A
Tuberculosis (TB) test is administered to youth within seven days of the youth’s admission to
the program.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a written policy and procedures for treating sexually transmitted infections
(STIs). The program’s policy requires youth to be evaluated and treated if needed for STIs and
human immunodeficiency virus (HIV). A review of seven youth Individual Healthcare Records
(IHCRs) indicated all seven youth were clinically screened and evaluated for STIs. The seven
youth were all referred to the licensed physician (MD). The referrals were documented on the
required STI screening tool and tests were ordered. The testing results were documented on the
Infectious and Communicable Disease (ICD) forms and filed in the lab section of the IHCRs.
None of the youth required STI rescreening. A review of seven youth records indicated all the
youth were offered counseling and testing for HIV. Documentation review confirmed six of the
seven youth consented to HIV testing. All six youth gave written consent for HIV testing
conducted by the health department, which is an outside provider. Reviewed documentation
confirmed the MD reviewed youth results and pre/post counseling was documented on the
Individual Health Education Record and the HIV chronological progress note. All youth
confidentiality is protected by not including the HIV status and/or any other STI diagnosis on the
program’s internal alert system. Additional review of the program’s policy on HIV testing
confirmed the results are only disclosed to the youth, legal authorized representative, healthcare
providers during the diagnosis, consultation, or treatment, the Department of Health, health
facility staff committees conducting monitoring, medical personnel who have been subjected to
significant exposure, and healthcare facility personnel or agents for the healthcare provider who
have a need to know in the course of patient care activities or administration operations. The
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program’s nurse interview indicated youth are screened for STIs during the intake/admission
process by youth providing a urine sample. If screening indicates further evaluation, the DHA
orders the additional confidential STI screening. Evaluations, testing documents, and referrals
are documented on the ICD form, progress notes, and the lab sections in the youth’s medical
binder. The program nurse stated all youth are provided a HIV Consent Form. The youth are
provided with HIV pre-counseling, testing, and post-counseling, which is all conducted with the
DHA. Seven youth were interviewed and all agreed they can request HIV testing while at the
program.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a written policy and procedures for submitting a sick call. The program’s policy
requires all youth to have access to submitting a sick call request and treatment in an
appropriate timely manner. A review of seven Individual Healthcare Records (IHCRs) indicated
none of the youth had a sick call complaint three or more times within a two-week period. Five
of the seven youth were applicable and had sick calls which were completed by the youth on the
Sick Call Request form. The nurse completed the appropriate section of the Sick Call Request
form for all five youth. All five sick calls were completed by the licensed practical nurses (LPNs)
and documentation of sick call was reviewed by the registered nurse (RN). None of the
reviewed youth were applicable for restricted housing of any kind. A review of the Sick Call
Request forms confirmed all five were filed in the youth’s IHCR. Each sick call was documented
as a progress note and on the Sick Call Index. A review of the program’s Sick Call Referral Log
indicated all sick calls were documented with the correct dates listed on the Sick Call Index.
While conducting the program tour, Sick Call Request forms were observed on each living unit,
with deposit boxes located by the east and west sub control windows. A review of the posted
daily schedule confirmed sick call is conducted daily at 10:15 a.m. and 3:15 p.m. When a
licensed nurse is not on-site the shift supervisor and/or facility administrators review all sick call
requests. An exam table and equipment used to perform sick call was observed during the
program tour in the medical office. The sick call process was observed during the annual
compliance review. The youth was escorted to the medical office by the shift supervisor. The
RN obtained the youth’s consent for the observed sick call. The youth was introduced to the RN
and was seen in a private area with no other youth present to hear or see the examination. The
supervisor was observed standing outside the exam room. The youth received an ice pack and
over-the-counter medication. A review of the nurse interview confirmed the program’s sick call
and episodic care process. Youth are referred to the designated health authority (DHA) as
needed. Sick calls are conducted by the medical staff twice a day in the medical exam room.
While on-site, the DHA does not conduct scheduled sick call. A youth placing a health complaint
will be seen within one to two hours of submitting a sick call. The nurse indicated youth with
repeated or similar sick call complaints three times in a two-week period are referred to the
DHA. A review of the DHA approved treatment protocols confirmed the logbook is maintained in
the medical office. A follow-up is conducted daily and as needed for youth approved for
restricted housing by the supervisor. Five of seven interviewed youth stated they are seen by
medical within one day of submitting a sick call request. Two youth reported they are seen
immediately after filling out a Sick Call Request form.
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4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a written policy and procedures for emergency care. The program’s policy
requires the program to provide episodic care and first-aid to youth as an intervention to
medical, mental health, substance abuse, or dental emergency care. A review of seven youth
Individual Healthcare Records (IHCRs) indicated all seven youth required on-site first-aid or
episodic care. Documentation review confirmed the on-site care provided by the licensed
healthcare staff was documented in the subject, objective, assessment, and plan (SOAP) format
for all youth. None of the youth were provided care from a non-healthcare staff requiring a
follow-up evaluation. The program’s episodic and emergency care procedures were observed in
the medical office. The program has a total of eight first-aid kits. One kit is in the kitchen, one is
in medical, one in east sub control, one in the Home Builder’s Institute (HBI) classroom, and one
in west sub control. The remaining three first-aid kits were in master control. The program’s two
transportation vehicle kits were located in master control. The first-aid kits are checked monthly
by the clinical manager and documented on the first-aid monitoring log. Observations of three
first-aid kits and documentation confirmed the first-aid kits had all the required contents. The
program has two automated external defibrillators (AED) and procedures books located in the
medical office and master control. Documentation verified the AED battery and pads were up to
date and checked by the medical staff on the first of each month. The AED in medical had pads
expiring on May 13, 2026, and batteries expiring on October 31, 2027. The AED in master
control had a battery expiration date of August 2, 2027. The pads on the AED in master control
will need to be changed on November 17, 2025. While on the program tour with the nursing
staff, a self-test of each AED was conducted. Green lights were observed on both the AED
battery indicators. Emergency numbers including the Poison Information Control Center was
observed posted in the medical office and master control inaccessible to youth. A review of
seven staff training records confirm staff conducted the training requirements regarding
episodic, first-aid, and emergency care. Additional training records confirmed the direct care
staff were trained in the administration of the epinephrine auto-injector. Documentation review of
the emergency medical drills confirmed during the past twelve months the program conducted
emergency drills once a month on each of the two shifts. Emergency drills contained elements
utilizing lifesaving measures including the use of cardiopulmonary resuscitation (CPR), AED,
first-aid, contacting 9-1-1 emergency response, epinephrine pen, and the use of the suicide
rescue tool. A review of documentation confirmed the direct care staff had the opportunity to
participate in at least one announced or unannounced drill containing the use of CPR and “man-
down” drill within the last year. Video observations confirmed the simulated drills contained an
episodic care event which called for immediate first aid and the administration of CPR
techniques. No episodic care was observed during the annual compliance review. The
program’s policy regarding overdose prevention training outlines the training for recognizing and
treating symptoms for overdose. The program has a total of seventeen NARCAN ® nasal
sprays on-site. One was currently in the medical cart and the additional sixteen boxes are in a
locked cabinet. The locked cabinet is only accessible by the medical staff and the facility
administrator (FA). Provided documentation confirmed staff are trained quarterly on when and
how to use NARCAN ®. An informal interview with the clinical manager confirmed the medical
staff will document the amount of NARCAN ® on the Medical Inventory Log in the inventory
binder. An inventory count is conducted weekly. A review of five staff interviews regarding
calling 9-1-1 for medical emergencies indicated all five staff are allowed to call 9-1-1. One
interviewed staff stated a medical code is called, and master control will call 9-1-1. Five
interviewed youth stated they have access to the doctor and the dentist if needed. An interview
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with the program’s nurse described the location of the first-aid kits and AEDs. According to the
nurse, the program has a total of eight first-aid kits. Two kits are available for transports and the
other kits are located inside of the program. The program has two AEDs, and their logs are in
the medical office and master control. Additionally, the nurse stated the AEDs are checked
monthly by medical staff and as needed to ensure they have up-to-date pads and batteries. The
program’s nurse reported on-site episodic care is documented through a progress note. In the
instance a non-healthcare staff provides episodic care, the treatment is documented on the
Department’s Report of On-Site Health Care by Non-Health Care Staff form. The nurse added,
for the youth who are sent off-site for emergency care, documentation is maintained on the
transport log. To ensure the direct care staff can respond effectively, the medical drills are
conducted by the registered nurses (RNs) monthly with both shifts. CPR drills are conducted
quarterly. According to the nurse interview, the list of emergency numbers is posted in the
medical offices and master control, inaccessible to youth.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site healthcare provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a written policy and procedures for youth receiving off-site healthcare. The
program’s policy requires the program to coordinate and create referrals for off-site care for
medical services. A review of seven youth Individual Healthcare Records (IHCRs) confirmed
four of the youth were applicable for having received off-site care. All four-youth had a summary
of Off-Site Care Consultation Report form filed in the IHCR. All applicable youth had the off-site
care visit documented on the Episodic Care Log. Each applicable notification to the youth’s
parent/guardian about the off-site emergency care visit was documented. Three of the four
youth were applicable for having discharge documentation filed in the IHCR. One youth was off-
site for a scheduled dental appointment. A review of the documents confirmed the designated
health authority (DHA) reviewed and signed all off-site care findings. A review of the program’s
nursing interview indicated youth sent off-site are tracked on the transport log and DHA weekly
logbook. The medical staff indicated orders from the off-site care are reviewed with the DHA
when the youth return to the program. The DHA reviews all off-site care findings which are listed
in the DHA log and in the youth’s chart, which is flagged. In the event a youth needs a follow-up
appointment, the medical staff will keep track of the appointments on an email and bulletin
calendar.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a written policy and procedures for identifying youth with chronic conditions.
The program’s policy requires each youth with an identified chronic condition to have a
treatment plan. A review of seven youth Individual Healthcare Records (IHCRs) indicated three
youth were applicable on their Facility Entry Physical Health Screening (FEPHS) form for having
chronic conditions, not including psychotropic medications. A review of documentation
confirmed none of the youth had any communicable diseases. All three youth were undergoing
treatment for a physical health condition. All three applicable youth were prescribed medication
on an ongoing basis. All three youth were assigned an appropriate Medical Grade. Reviewed
documentation confirmed all three youth were on the chronic illness list and received periodic
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evaluations at least every ninety-days. None of the youth were currently taking anti-tuberculosis
medications. A review of the periodic evaluations confirmed the evaluations were conducted
prior to renewing a prescription medication for each youth. None of the reviewed youth were
applicable for having a lapse in care or a missed evaluation. The Department’s Problem List
was updated for all youth. An interview with the facility administrator (FA) noted the medical staff
are present in the morning management meeting, and weekly for designated health authority
(DHA) update reviews, in order to update the direct care staff with any important medical
concerns pertaining to the youth. The DHA stated in an interview all periodic evaluations for
chronic conditions are tracked every ninety-days or less as needed. Chronic conditions/periodic
evaluations are placed on the calendar and then schedule for the next DHA visit. The program’s
nurse interview indicated the internal alerts and an alert board in the conference room is how
the program staff monitor youth with chronic conditions.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a written policy and procedures for medication management. The program’s
policy requires the program to maintain the youth’s medication routine upon admission. A review
of seven youth Facility Entry Physical Health Screening (FEPHS) forms and progress notes
confirm only three youth were applicable for taking medication when admitted into the program.
The current prescriptions and medications for each youth was verified prior to admission and
documented on the chronological progress note in the youth’s Individual Healthcare Record
(IHCR)/electronic medical record (EMR). Reviewed documentation confirmed the designated
health authority (DHA) and psychiatrist were notified upon each youths’ arrival to the program
about the medication prescribed. The youth had current, valid orders for medications
prescribed. All changes to the medication were placed on the Practitioner Order form by the
DHA. None of the youth were applicable for being in restricted housing. A review of seven youth
Individual Healthcare Records (IHCRs) confirmed all the youth were applicable for having over-
the-counter (OTC) medications administered, which were not listed on the AET. All seven
records had Medication Administration Records (MARs) which clearly stated the medication
start and stop times, youth name, Department identification number, date of birth, allergies,
precautions, and Medical Grade. The MARs contained a picture of the youth and initials of staff
and youth on each medication entry. One youth was applicable for having a trained non-
healthcare staff assist in the delivery of medication only when a licensed staff was not available.
A review of the MAR confirmed the staff initialed each administrated medication entry.
Additional review of MAR documentation confirmed no medication errors or undocumented
explanations were present. All seven youth MARs had nursing staff document weekly side-
effect monitoring. Three of the seven youth refused medical treatment, and it was documented
clearly on the MAR and the Refusal of Treatment form. A review of the psychotropic medication
policies confirmed there were no standing orders or any emergency treatment orders, or pro re
nata (PRN) orders for psychotropic medication. During the annual compliance review an
observation of medication administration was completed. The youth was escorted to the medical
office by the shift supervisor. In the medical office there were no other youth present as the
nursing staff was administering the medication. The registered nurse (RN) identified themselves
and explained the reason the youth was taking the medication. Prior to the youth receiving the
medication the RN verified the youth’s name, allergies, alert status, right medication, dosage,
time, and route of administration. The RN prepared the OTC medication and administered the
youth’s medication. The youth was advised to open their mouth for the staff to confirm the youth
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swallowed the medication. The nurse and youth both initialed the MAR. Reviewed training
documentation confirmed non-healthcare staff were trained or provided a refresher training on
medication administration from January to August 2025 by an RN or higher. Five interviewed
youth responded to the process of how they receive their medication. One youth stated they are
not prescribed medication for the nurse to dispense. Four of the seven youth reported the RN
gives the youth their medication. All youth who were prescribed medication agreed the youth
were escorted to the medical office, and the nurse confirmed their medication. A review of the
nurse’s interview indicated the Prescription Medication Verification Checklist is completed by the
RN for the youth admitted on prescription medication. Prescription medication orders are
verified by the DHA and the pharmacy. The program utilizes the Department’s standardized
MAR. The non-healthcare staff are trained by the health services administrator (HSA) to
dispense medication in an occurrence where the RNs are not available. The daily medication
pass times are 7:30 a.m. and 6:00 p.m.
4.17 Psychiatric Services Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a written policy and procedures for the provision of psychiatric services within
the program. The program’s contracted psychiatrist is responsible for psychiatric evaluations,
consultation, medication management, and medical supportive counseling. A review of the
psychiatrist’s license indicated they held an osteopathic physician license which was free and
clear in the State of Florida with an expiration date of March 31, 2026. The psychiatrist is
available for emergency consultation twenty-four hours a day, seven days a week. The
psychiatrist provided psychiatric services briefly as a representative of treatment team and
psychiatric recommendations for youth are incorporated into evaluations and planning at the
program. Provided documentation confirmed the psychiatrist’s participation in treatment team
meetings and tele-health services. During the annual compliance review period the program
utilized two additional back-up psychiatrists. Provided email documentation confirmed the two-
back-up psychiatrist were approved by the Department’s Office of Health Services to provide
services from February to September 2025. The program uses a psychiatric advanced practice
registered nurse, who had a clear and active license expiring on April 30, 2026. A review of the
Collaborative Practice Protocol maintained in the medical binder confirmed the agreement was
valid from June 25, 2025, until June 2026. A review of the psychiatric sign-in logs confirmed the
psychiatrist provided services and actively participated in treatment teams. A review of the
program’s contract confirmed the psychiatrist shall be on-site four hours bi-weekly, not
exceeding a fourteen-day period. The program utilizes tele-psychiatry services as needed. A
review of the psychiatrist’s interview indicated the psychiatrist conducts assessments and
treatment. The interviewed psychiatrist reported providing tele-health services twice a month
and on-site services monthly. In addition, the program’s psychiatrist reported not having any
concerns with mental health or substance abuse services at the program and communicating
with the treatment team representative. The interviewed designated mental health clinician
authority (DMHCA) stated communication with the psychiatrist occurs as needed for youth
receiving psychiatric services. A review of seven youth Individual Healthcare Records (IHCRs)
indicated four youth were applicable for entering the program with prescribed psychotropic
medications. All seven reviewed youth were referred for a psychiatric interview documented on
the Departments Clinical Psychotropic Progress Note (CPPN), as it is the program’s practice to
refer all youth. Each of the youth admitted with psychotropic medications received a diagnostic
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interview within fourteen days of admission. All reviewed Initial Diagnostic Psychiatric Interviews
included history, a Mental Status Examination, a Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) diagnosis, and treatment recommendations. Four youth were
applicable for being prescribed medications. The Initial Diagnostic Psychiatric Interviews
included the explanation for the need for medications, target symptoms, initial treatment goals,
potential side effects, and frequency of medication management. Reviewed documentation
confirmed each youth prescribed psychiatric medication was seen by a psychiatrist at least
every thirty days. None of the reviewed records were applicable for a psychiatric evaluation
update. A review of page three of the CPPN indicated the psychiatrist documented the
identifying data, diagnosis, target symptoms of each medication, effects of the medication,
medication dosage, dosage range, frequency, route of administration, side effects, adherence to
the medication regime, height, weight, laboratory findings, and whether there was telephone
contact with the youth’s parent/guardian. Reviewed documentation confirmed each CPPN was
signed and dated by the psychiatrist. Each IHCR documented monitoring for Tardive Dyskinesia
monthly as indicated on the CPPN. All of the youth records were applicable for the use of tele-
psychiatry and contained documentation of parent’s/guardian’s given consent. An interview with
the psychiatrist and designated mental health clinician authority verified the psychiatric
treatment processes at the program.
4.18 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a written policy and procedures on tracking inventory of all medication and
medical equipment. The program’s policy requires all medical equipment to be classified and
perpetually inventoried. Observations in the medical office showed the controlled medications
were in a locked box in the secure medical cart. The medication cart was observed clean and
organized with stock items separated from youth medication. Three controlled medications were
inventoried on-site, and the counted medications correlated with each youth’s Individualized
Controlled Medication Inventory Record sheet and shift to shift administration counts. There was
no medication being stored in the medical refrigerator at the time of the annual compliance
review. The nurse was observed conducting a count of the program’s over-the-counter (OTC)
medications. Three reviewed OTC medications matched the inventory sheet, and the actual
count. The medications were stored in a separate secured area not accessible to the youth.
Three sharps were counted during the annual compliance review by the nurse and all sharps
counted matched the final count listed on inventory and the actual counts. Perpetual and weekly
inventories of the sharps and stock OTC mediations were documented. The medications,
sharps, and OTC medications were all stored in a designated locked area clearly labeled. A
review of seven supervisory-level, non-healthcare staff training records confirmed the registered
nurse (RN) conducted the training for delivery and oversight of medication self-administration.
An informal interview with the clinical manager confirmed in the instance of a discrepancy with
the inventory, the nurse who found the discrepancies will report the inventory discrepancies to
the medical clinical manager. The clinical manager will notify the medical supervisor and then
the facility administrator (FA) or designee on-site. An internal investigation will begin and the
Department's Central Communications Center (CCC) will be called for all medical incidents. An
interview with the program’s nurse explained the medical disposal process. The process
includes two medical staff disposing of the medication using a chemical disposal agent. The two
RNs or the pharmacist will sign the medication disposal form. Unused medication will be
returned to the pharmacy. The program maintains a copy of the local pharmacy license in the
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medical office. The pharmacy conducts monthly on-site checks of all the medications. The nurse
stated controlled substances such as narcotics are delivered by the pharmacy and stored
behind a double locked cabinet. Two nurses are required to count the controlled medications
shift to shift.
4.19 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according to OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a written policy and procedures for infection and exposure control. The
program’s policy requires infection control procedures for prevention, containment, and
treatment. The program has an infection control policy, procedures, and guidelines which were
signed by the designated health authority (DHA) on September 24, 2025. The facility
administrator (FA) signed and reviewed the policy on September 24, 2025. The nursing staff
reviewed the policy on September 24, 2025. The procedures included common, infectious
diseases of childhood, self-limiting, episodic contagious illnesses, viral or bacterial infection
diseases, Tuberculosis, hepatitis A, B, and C human immunodeficiency virus (HIV), Methicillin-
Resistant Staphylococcus Aureus (MRSA), bio-terrorist agents, chemical exposures, outbreaks
of lice, and epidemics. A review of documentation confirmed staff had access to protective
equipment and hepatitis B immunizations. A review of the facility/occupational exposure book
confirmed there were no incidents where the local health department or Department's Central
Communications Center (CCC) was notified for an infectious disease during the annual
compliance review period. The program’s Exposure Control Plan was located in master control
and was written in accordance with Occupational Safety and Health Administration (OSHA)
standards. The plan was signed on September 24, 2025. The program maintains separate
records for youth and staff who experience a facility/occupational exposure. An informal
interview with the clinical manager confirmed the program’s process for needle stick post-
exposure evaluation is for the staff to immediately wash the exposed area and dispose of the
needle into the sharp’s container and notify the supervisor or FA on-site of the incident. The
program staff will then contact the CCC and transport the exposed person to urgent care for
additional treatment. An interview with the FA confirmed the Exposure Control Plan was located
in master control and the medical office and is reviewed yearly with direct care staff. An
interview with the nurse explained training is provided by the health services administrator
(HSA) or director of nursing yearly for the staff and new hires. The training is provided for youth
at the time of admission. Copies of the Exposure Control Plan are in the medical office and
master control, accessible to all staff.
4.20 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a written policy and procedures requiring all program staff to promote safety
and security by maintaining active supervision of youth to include interacting positively with
youth, engaging youth in a full schedule of constructive activities, closely observing behavior of
youth, and consistently applying the program’s behavior management system (BMS). The
program’s contract requires staff-to-youth ratios of one staff to eight youth during awake hours
and one staff to twelve youth during sleeping hours. The ratio for off-site activities,
transportation, and visitation is one staff to five youth. A program tour verified the daily youth
activity schedule was posted throughout the program and is designed to keep youth engaged in
a full schedule of activities. The program staff are required to account for the whereabouts of
youth under their supervision and ensure staff-to-youth ratios are in compliance with contract
requirements. Observations of staff supervision for four days during the annual compliance
review week included classroom activities, line movement, school/education, meals, youth head
counts, mental health groups, vocational activities, youth searches, and outdoor/indoor
recreation activities. In addition, the youth were observed to be working in the kitchen and using
Class B tools while participating in cleaning duties. The observations ensured staff-to-youth
ratios were maintained, as required. A tour of the program verified the program and living units
were clean, well maintained, and graffiti free. A perimeter check was conducted, and fencing
appeared to be in good repair. Staff and youth were appropriately attired. During outdoor
activities and/or movement, observations verified staff were strategically positioned to ensure
proper supervision of youth and to ensure there were no physical obstructions in their view of
the youth. Observations of interactions between program staff and youth reflected the
interactions were positive and consistent with the program’s BMS. Three informally interviewed
staff knew how many youth they were supervising. The program’s policy states active
supervision ensures appropriate supervision of the youth is maintained at all times. Staff are to
provide effective positioning for optimal sight and sound supervision of youth. Staff shall
communicate with youth and co-workers effectively to ensure expectations are clearly defined.
Video observations of youth were conducted during sleep hours. The observations verified the
staff-to-youth ratios were in compliance and staff were awake and alert.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program has a written policy and procedures addressing the implementation and training of
the program’s behavior management system (BMS) which has not changed since the last
annual compliance review. The BMS is posted and outlined within the youth handbook allowing
easy access for youth and includes rules governing conduct and positive and negative
consequences for behavior including while in the classroom. A review of the youth handbook
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indicated the BMS is designed to promote safety, respect, and fairness. The BMS shall
complement the performance and treatment planning process, including the coordination of
individualized behavior plans, as applicable. The program utilizes the iChoose BMS, which is a
coordinated system of promoting, monitoring, recognizing, and rewarding a youth’s progress. It
is a program of incentives and consequences which promotes individualized skill building,
appropriate behavior, and accountability. Staff use point cards to monitor how well the youth are
progressing in the program. Youth earn points daily for complying with the program rules. The
youth receive rewards based on the number of points earned. At admission, youth enter the
program on an orientation level, prior to starting the BMS and progress their way up the four
levels. The four levels of the BMS include beginner, intermediate, veteran, and expert levels.
Youth learn about the BMS during the orientation process. The BMS promotes and protects
youth rights and has opportunities for positive reinforcement. The BMS includes positive and
negative consequences and uses constructive disciplinary actions. The BMS promotes socially
acceptable means for youth to meet their needs, includes a process for explaining to youth the
reasons sanctions are being imposed, youth have the opportunity to explain their behavior,
there are opportunities for staff and youth to discuss the impact of behavior to others, includes
reasonable reparations for harm caused by others, there are discussions of alternative
behaviors, promotes positive dialogue, and minimizes separation of the youth from the
population. A review of the BMS confirmed it is not used solely to increase a youth’s length of
stay, deny basic rights or services, promote the use of group punishment, allow youth to punish
other youth, or include disciplinary confinement. Youth have access to the youth handbook
which clearly outlines the BMS, program rules, and the progressive disciplinary system for the
youth. In addition, the parent/guardian handbook includes a description of the BMS. The facility
administrator (FA) ensures all staff having direct contact with youth are trained on the BMS.
Observations confirmed the BMS was posted throughout the program. A review of seven staff
in-service and seven pre-service training records indicated staff were trained on the BMS by the
staff development coordinator. A review of seven position descriptions confirmed the job
functions included implementation of the BMS. A review of seven youth case management
records indicated each youth participated in an orientation upon arrival to the program and
received a copy of the youth handbook. Observations of staff and youth interactions verified
staff were adhering to the BMS by utilizing a ratio of four-to-one positive rewards to negative
consequences when redirecting the youth as indicated in the program’s policy. The program
provides the youth with incentives which include using points to purchase items from the
canteen, or to participate in the activities such as “Mega Monday” and/or “Phat Friday.” Other
activities include board games, card games, and/or the receipt of extra snacks. Five staff were
interviewed, and each reported the BMS consists of a point and level system which consists of
incentives and consequences. Each of the interviewed staff verified youth receive incentives
which include the purchase of canteen items, receiving extra snacks, earning extra telephone
calls, and youth can participate in Mega Mondays and Phat Fridays. Five staff were interviewed,
four stated the youth’s basic rights cannot be taken away from a youth as a consequence, and
one staff indicated the youth’s late bedtime incentive can be taken as a consequence. Each
interviewed staff stated youth are informed of the consequences and they are able to explain
their behavior during the review of the Behavior Reports (BRs) and during treatment team
meetings. Five youth were interviewed, and each stated the consequences for negative
behaviors included not earning daily points, level freezes, controlled observation, privilege
restriction, and early bedtime. Each youth stated they receive incentives such as special meals,
snacks, canteen, tournaments, and participate in family days, Mega Mondays, and Phat
Fridays. Five interviewed youth indicated staff are consistent with the utilization of rewards and
consequences for all youth. All five youth were able to explain the difference between each level
and how they move from level to level. All five-youth verified youth are never allowed to punish
other youth. An interview with the FA confirmed the program utilizes the iChoose BMS. The FA
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indicated the BMS is responsive and designed to maintain order and security, while fostering
compliance with the program’s rules. Additionally, the FA indicated the program uses an
incentive calendar level tracker to monitor the BMS for incentives and consequences. The FA
confirmed the program monitors the staff implementation of the BMS to ensure consistency by
meeting with staff at the all-staff meetings and during annual performance evaluations. The
system is designed to maintain order and security, fostering compliance with the program rules
teaching youth alternative prosocial methods of dealing with problems using both rewards and a
system of progressive discipline. The BMS promotes safety, respect, fairness and protection of
rights within the community, provides for constructive discipline and a system of positive and
negative logical consequences to encourage youth in meeting expectations for behavior,
provides for positive reinforcement and recognition for accomplishments and positive behaviors
at a minimum ratio of four-to-one positive to negative consequences, promotes socially
acceptable means for youth to meet their needs, and includes processes which address the
needs of and cognitive capacity of youth. The FA stated rewards include incentive calendars,
nightly incentive, Phat Friday, Mega Monday, random reinforcers to include additional telephone
calls, food incentives, music, and free time. The program ensures consistency by reviewing the
BMS during behavior review team meetings, annual performance evaluations, all-staff training,
and monthly coaching.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, or room restriction; therefore, this indicator is rated
non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a written policy and procedures regarding conducting and documenting ten-
minute checks during sleep hours or at other times, such as during an illness, or room
restriction. The program has a total of 113 video cameras capable of recording thirty-days of
video footage. During the annual compliance review week, the program reported all cameras
were operational. Prior to conducting checks, staff are situated where they are able to see any
movement within the living unit. Staff are required to conduct room checks every ten minutes
when youth are in their rooms and document the time of the check on the Ten-Minute Check
Log. The facility administrator (FA) stated there were two shifts from 7:00 a.m. to 7:00 p.m., and
7:00 p.m. to 7:00 a.m. during the annual compliance review period. A video review of nine ten-
minute checks from the overnight shift and from the program’s six living units, verified staff were
conducting checks and documented the times accurately on the Ten-Minute Check Log with an
exception on September 14, 2025, at 3:00 a.m. in the Cowboys dormitory where the staff was
conducting checks every ten minutes; however, did not stop to look in the rooms during the
checks. In an informal interview the FA stated during weekly audits it was discovered the staff
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were not stopping to look into the rooms and they were disciplined prior to the review. The FA
provided documentation of the staff’s disciplinary record and retraining. All checks were
conducted at ten-minute intervals with the exception of one check conducted on September 20,
2025, in the Bucs dormitory was seven minutes late. In addition, the Ten-Minute Check Logs
since the last annual compliance review were reviewed. A sample of various days, times, and
shifts indicated the ten-minute checks were completed within the required frequencies, with the
exception of one check conducted on January 15, 2025, from 6:15 a.m. to 6:33 a.m., which was
eight minutes late. Five interviewed staff verified room checks were conducted every nine
minutes when a youth is placed in their room for sleeping or non-punishment reasons. In a
formal interview, the FA stated the program has 113 cameras and the program has video
recording capabilities for thirty days.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program has a written policy and procedures to ensure the continuity of custody and care of
youth and protection of the public. The program’s policy requires staff to conduct formal head
counts each hour and after outdoor activities. In addition, the policy indicates counts are
conducted during power outages, escapes, program disturbances, or any other disruptions
which may occur. Head counts are conducted before and after each movement, and during
emergencies and drills. A review of the Continuity of Operations Plan (COOP) verified program
staff must always account for the whereabouts of the youth in the care and custody of the
program. This includes the need for continual head counts to be conducted minimally at the
beginning of each shift, during any emergency situation, and at regular intervals. Twelve
randomly selected dates and times in the program’s logbook were reviewed for census counts
during the annual compliance review period. Documentation validated head counts and
movements were conducted at the beginning of each shift, after outdoor activities, during
emergency situations such as program disturbances, and during actual and/or simulated drills.
The logbooks included youth who were temporarily away from the program, transferred,
admitted, and released. Additionally, observations confirmed the program staff conducted a
physical head count during school and before and after each movement. Five interviewed staff
verified formal counts are conducted every hour, during emergencies, and during every
movement. Each staff stated if a count cannot be reconciled, the program is locked down, all
movement is stopped, and an emergency count is conducted until the count is reconciled. Each
staff stated emergency counts are conducted anytime a code is called, during power outages, if
there is a discrepancy in the count, if a youth is missing, and during drills.
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5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a written policy and procedures to ensure the maintenance of a chronological
record of events, incidents, and activities in a central logbook. The logbook documents head
counts, shift changes, and group movement. At a minimum, each logbook entry shall be legible
and include the date and time of the event, the names of staff and youth involved, a brief
description of the event, the name and signature of the person making the entry and the date
and time of entry. No logbook entries are to be obliterated or removed. All errors are to be
struck through with a single line and initialed by the staff correcting the error. All direct care staff
and supervisors are to be briefed when coming on duty. A review of the logbooks and
observations verified since the last annual compliance review, all errors were struck through and
initialed by staff, the logbooks were bound with numbered pages, and there were no loose, or
missing pages found. Logbook entries included shift briefing, youth movement, head counts,
emergency drills and situations, program checks, perimeter checks, and law enforcement data.
Internal incidents reported to the Florida Abuse Hotline and/or the Department’s Central
Communications Center (CCC) were documented. Reviewed logbooks showed recreation was
conducted. All entries included the dates and times of events, when education was scheduled,
documented when a youth arrived or departed, and logbook entries contained the names of the
staff and youth involved. The program ensures direct care staff, including each supervisor, are
briefed when coming on duty. Each staff signs the shift briefing sign-in sheet to acknowledge
receiving the information. A review of shift reports since the last annual compliance review
verified each report was completed on a daily basis. A copy of the shift report was made
available to staff for at least forty-eight hours. Reviewed documentation and a review of the
CCC reports indicated there were no instances of escapes or attempted escapes during the
annual compliance review period.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a written policy and procedures to ensure program safety and security, safety
of staff, youth and the public by implementing and maintaining a system of program key control.
All staff shall be provided with guidelines and training on the key control policy and required
procedures on the physical control and use of program keys, while ensuring the provision of
community protection through safe and secure programming for youth. The assistant facility
administrator (AFA) is assigned as the key control manager who is responsible for the security
and accountability of keys and key control systems as well as damaged keys. Observations
confirmed the program has a key log sheet for staff assigned permanent keys which they are
required to sign, indicating the number of keys issued and the key identification number.
Permanent keys are kept to a minimum and must be authorized in writing by the facility
administrator (FA). A review of the signed acknowledgment forms indicated each staff signed for
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the use of permanent keys. Program keys are maintained in master control on a board with the
corresponding tracking number. The program has a daily key log to track keys. Keys are bound
on a tamper resistant ring which includes a brass-colored tag with the number of keys and a
tracking number. The log indicates the name of staff and what type of key they are to be
assigned according to their position. The program maintains a master inventory list of program
keys. A random check of five different sets of program keys compared to the inventory list
indicated the keys were accounted for and the master control staff knew which area each key
was assigned to. Active keys are assigned to direct care staff while restricted keys are
designated for medical staff, kitchen staff, case managers, and therapists. Medical staff, kitchen
staff, case managers, and therapists receive their respective restricted keys from master control
after their personal keys are collected. An informal interview with the master control staff
indicated the program’s practice is when direct care staff arrive to the program, personal keys
are collected by master control and placed on a board in master control. Both the master control
operator and the staff receiving a program key initial the key log before keys are issued and
again at the end of the shift when the keys are returned. An informal interview with the AFA and
maintenance manager confirmed the program’s method of daily tracking and reconciliation of
keys. A review of the key logs and logbooks since the last annual compliance review verified
this practice. An informal interview of three staff confirmed each staff knew the number of keys
and each key’s function. A review of the Department’s Central Communications Center (CCC)
reports since the last annual compliance review indicated there was one incident related to key
control. Five staff were interviewed and were able to explain the program’s key control process.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures addressing safety and security and to control the
introduction of materials considered contraband into the program. Search practices shall be
initiated to assist in prevention, detection, and removal of all items considered contraband or
unauthorized within the program. The program’s youth handbook and policy include a list of
contraband items and informs youth of the consequences if found with contraband. All staff shall
be trained to properly identify contraband items and the steps required for removal of
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contraband. Search practices and observations shall be conducted throughout the program and
shall include searches of youth, staff, visitors, property, program grounds, and the program’s
physical plant. Each youth is provided with a written copy of the youth handbook upon
admission into the program and are oriented to the program rules including the list of items
considered to be contraband. The program’s policy and youth handbook included all items
considered contraband as outlined in Florida Administrative Code. The list of contraband items
include sharps, escape paraphernalia, tobacco products, lighters or matches, electronic or
vaporless cigarettes, unauthorized food or clothing, any intoxicating beverages, any controlled
substance, any prescription or non-prescription drug, any firearm or weapon, any explosive
substance, non-program issued keys, unauthorized currency, non-program issued cellular
telephones and/or equipment or electronic devices capable of taking pictures or video
recordings, and smart watches. In addition, the program’s policy and youth handbook include
consequences if found with contraband, search procedures of the physical plant, searching the
program grounds, youth searches, and searches of incoming and outgoing mail. The program’s
policy specifies the manner in which any unauthorized or contraband item is to be disposed of,
to include return to the sender, mailed to the youth’s home, returned to the youth upon release,
or, in the case of illegal contraband, turned over to law enforcement. Unannounced room
searches are conducted at least weekly at irregular and unpredictable times and common area
searches are conducted daily. During the program tour, several randomly selected rooms were
checked, and no contraband was observed. A review of shift reports, the master control
logbook, visitation forms, and common area search forms validated the program’s practice of
monitoring areas of the program, grounds, and youth rooms for contraband. The program’s
policy requires case managers to inspect all outgoing and incoming correspondence in the
presence of the youth for unauthorized items, contraband, or information which may breach the
security of the program. A review of the visitor’s sign-in log verified it included an attestation
statement regarding contraband. There was a total of thirty-one new staff hired during the
annual compliance review period. A review of thirty-one staff records found each included a
signed contraband attestation form. The program documents the confiscation and disposal of
contraband. Reviewed documentation included the procedures for searching incoming and
outgoing mail. The policy indicates all illegal contraband will be surrendered to law enforcement,
and unlawful activity will be reported to law enforcement. A review of the Department’s Central
Communications Center (CCC) reports since the last annual compliance review indicated there
were nine instances of contraband found at the program. Contraband was turned over to law
enforcement. The interviewed facility administrator (FA) reported the program adheres to the
Florida Statute and policy and procedures of the program, which addresses how contraband
and illegal contraband are handled and disposed of in residential programs. Search practices
shall be initiated according to the Department’s Right Interactions (RI) training curriculum to
assist in prevention, detection, and removal of all items considered contraband or unauthorized
within the program. Program staff, including school staff, subcontracted staff, visitors, and
volunteers are prohibited from introducing any item into the secure area without authorization
from the FA or designee. The introduction, removal, or possession of certain unlawful articles
and the associated penalties are outlined in Florida Statutes. Five staff were interviewed, and
each stated room searches are conducted at a minimum of at least once a week, during youth
shower time.
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5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a written policy and procedures to ensure searches and full body visual
searches, are conducted according to Florida Administrative Code at the time of admission,
after off-campus activities, and visitation. Parent(s)/guardian(s) are notified of searches during
visitation by way of the parent/guardian intake letter, which is mailed at the time of each youth’s
admission. Youth are searched before entering and prior to leaving the classroom, after outdoor
recreation activities, after work detail, and upon all movement. Youth who are a new admission,
re-admission, returning from visitation, returning from off-campus activities and/or appointments,
suspected of contraband, or are a security risk are full body searched. Observations made
throughout the annual compliance review week validated youth are provided instructions
regarding the search, youth searches were conducted by staff of the same gender as the youth,
were conducted in a manner so as not to degrade the youth and were based on the Right
Interactions (RI) training manuals. Observations during the annual compliance review week
verified youth were searched after every movement, after using Class B tools, or after
participating in any other activities or projects. During the annual compliance review week an
observation of a youth transport was conducted, and observations confirmed the vehicle and the
youth were thoroughly searched, and the youth was secured for transportation. The program did
not have any new admissions, visitations, and there were no youth returning from off-campus
activities; therefore, searches for those activities were not able to be observed. In-person
observations and a video review of five staff and/or visitors confirmed searches were conducted
as required. Logbook documentation and video review verified youth were being thoroughly
searched before and after each movement. Five staff were interviewed, and each stated youth
are searched randomly and after every movement. Five youth were interviewed, and all
indicated searches occur after outdoor activities, when items are missing, after meals, and after
visitation.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a written policy and procedures to ensure all program vehicles used in the
transportation of youth are properly maintained and documentation of use and vehicle services
are maintained. Transporting staff shall have a cellular telephone for use in case of an
emergency during transport. Mechanical restraints shall be used in the secure transportation of
youth, and all mechanical restraint equipment will be double locked. Youth shall never be
restrained to stationary objects. Each vehicle being used for transportation of youth shall pass
an annual safety inspection. The program has a total of three vehicles. Two are used to
transport youth and one is for program use. Each of the three vehicles used at the program had
an annual safety inspection conducted by a certified automobile mechanic. Observations of the
vehicles confirmed each vehicle was locked when not in use. An observation of the two vehicles
used to transport youth showed they had the appropriate number of seatbelts, a seatbelt cutter,
a window punch, an up-to-date fire extinguisher, and a first-aid kit with items approved by the
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designated health authority (DHA). Documentation indicated weekly visual vehicle inspection
checks are conducted on all vehicles as required and documented on the preventative
maintenance check sheets. Observation of each of the vehicles used to transport youth had
passenger doors which could not be opened from the inside and had a safety screen separating
the front seat from the rear passenger’s compartment. A random check of seven staff personal
vehicles and the three program vehicles was conducted during the annual compliance review
week, which found all of the vehicles were locked and secured when not in use.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a written policy and procedures to ensure an appropriate minimum staff-to-
youth ratio is maintained while youth are transported off program grounds ensuring the safety
and security of youth, staff, and the public. All transporting staff shall have a valid Florida
Driver’s License and an acceptable driving record. Any staff whose driving record is deemed
unacceptable shall not be permitted to operate a program vehicle for the purpose of transporting
youth. Human resources staff shall obtain monthly driving record information from the
Department of Motor Highway Safety and Motor Vehicles (DMHSMV) for all staff. The program’s
policy states youth are not permitted to drive program or staff vehicles. The program uses a
minimum staffing ratio of one staff for every five youth; however, at least two staff shall
accompany youth on all transports with one staff present of the same gender as the youth. The
program provides transportation for secure maximum-risk youth determined to be at greater
risk. During the annual compliance review week an observation of a transport was conducted,
and observations confirmed the program’s practice. Five staff were interviewed, and each stated
prior to conducting a transport the youth and vehicles are searched for contraband and youth
are secured in the vehicle with hand and leg cuffs, and by wearing the seat belt. All five
interviewed staff stated they use the program’s cellular telephone during transports. Each of the
five interviewed staff confirmed the safety equipment in the transport vehicles included a first-aid
kit, suicide response kit, seatbelt cutter, and fire extinguisher. All five staff confirmed they are
not allowed to use personal vehicles to transport youth. All five interviewed staff stated the
transport vehicles are searched for contraband prior to and after each use. All five interviewed
staff indicated in case of an emergency, they would call 9-1-1, and/or contact the program. Each
interviewed staff knew the staff-to-youth ratio during transport. Each staff confirmed there are
safety screens in the vehicles used to transport youth. Five youth were interviewed, and each
stated they were not secured to any part of the vehicle during transportation. Five interviewed
youth stated they never witnessed anyone placing contraband in a transport vehicle. An
interview with the facility administrator (FA) confirmed all vehicles used for transporting youth
have a safety screen.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a written policy and procedures to ensure safety and security is maintained.
The policy addressed who is responsible for conducting the audits, procedures to implement
corrective actions for deficiencies, and an internal system to verify deficiencies are corrected.
Weekly safety and security audits are conducted by the facility administrator (FA) or designee
and documented on the Weekly Safety and Security Audit Inspection form. Any deficiencies are
addressed on the form, and a work order is submitted to the appropriate staff for corrections. In
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addition, deficiencies are discussed during the morning management meeting. A review of the
Weekly Safety and Security Audit Inspection forms since the last annual compliance review
indicated inspections were completed as required. Supervisors conduct perimeter checks on
each shift and checks are documented in the program’s logbook. A review of the program’s
logbooks verified this practice. A review of deficiencies entered in the Department’s Juvenile
Justice Information System (JJIS) verified there were no deficiencies assigned regarding safety
and security audits during the annual compliance review period. A review of the program’s
Preventative Maintenance Checklist verified the maintenance schedules and repairs were
conducted as required. An interview with the FA indicated Weekly Safety and Security Audit
forms are submitted to the Department each week and they identify any security issues or
deficiencies.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a written policy and procedures to have a tool management system which
ensures youth do not use tools or equipment as weapons or for security breaches. The policy
addresses the issuance, inventory, and control of equipment and tools. The policy states
prohibited tools at the program include machetes, bowie knives, and other long bladed knives. A
review of inventory logs and observations verified tools are securely stored when not in use,
easily marked for identification, and inventoried prior to, and following work activities. All sharp
edged and pointed tools are inventoried daily when in use. The maintenance staff are
responsible for conducting the inventories and securely maintaining all Class A tools and
equipment. The maintenance staff completes a tool inventory list which documents each tool in
inventory. All maintenance tools were inaccessible to youth and were observed to be secured in
the maintenance building. Observations of the tool storage area found it was organized and
secure. Class B tools including mops, brooms, and buckets are maintained in a locked closet in
the hallway between the east and west wings which are inaccessible to the youth. The items are
used by staff and youth when performing daily cleanup activities. Staff are required to complete
a sign-out and sign-in log when items are taken and are returned to the designated storage
room. Kitchen staff are responsible for securing, maintaining an inventory log and sign-out/sign-
in log for kitchen utensils and sharps. A random review of ten unique kitchen utensils and
sharps and unique tools in the maintenance building verified the tool inventory and the logs
were accurate, with the exception of the tape measure, which had the same identification
number as a drop light. Maintenance staff corrected the identification number of the tape
measure and updated the inventory log during the annual compliance review week. Reviewed
documentation and the Department’s Central Communications Center (CCC) reports verified
there were no instances of missing or lost tools since the last annual compliance review. If a tool
is broken or inoperable, the physical plant manager is responsible for replacing the broken tool.
If a tool is missing staff will notify administration, fill out an incident report, document the incident
in the logbook, call the CCC, and the program will be searched until the tool is found. The
program has a vocational woodshop program on-site which is operated by the Home Builder’s
Institute (HBI) in which Class A tools are utilized by the youth. Observation of tools in the
vocational building indicated tools are maintained under lock and key with access only to HBI
staff.
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5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. The program’s policy and procedures include
supervision requirements when youth are using tools, the issuing of tools to youth and staff, a
youth assessment to determine the youth’s risk, and established ratios which include one staff
to five youth during work detail or vocational training. A review of the program’s procedures
verified staff are required to complete a sign-out and sign-in log when Class B tools are taken
and are returned to the designated storage room. A Youth Risk Assessment is completed by the
case manager for youth to use Class A and Class B tools. In addition, the Home Builder’s
Institute (HBI) program completes a risk assessment prior to youth participating in the program.
Seven youth case management records were reviewed, and each youth had a Youth Risk
Assessment completed by the case manager prior to youth using tools. Seven youth case
management records included documentation each youth was trained on the intended and safe
use of Class B tools. An observation of four youth working kitchen detail and two youth
conducting cleanup duties verified the youth were properly supervised and followed safety
protocols. Five youth were interviewed, and each stated they use mops, brooms, and scrub
brushes. In addition, four youth participating in the HBI program stated they use saws,
hammers, and screwdrivers. Five staff were interviewed, and each indicated youth are allowed
to use mops and brooms.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a written policy and procedures establishing guidelines for outside contractors
who come on-site to complete repairs. When a contractor or vendor enters the program, they
sign the Outside Contractor On-Site Work Project Log which lists unauthorized items. The
program’s policy states personal cellular telephones, electronic devices capable of taking
pictures and/or audio/video recording, including smart watches are prohibited in the secure
area. The physical plant manager or designee inspects all tools upon the arrival of outside
contractors and is responsible for providing approval if such tools are required. The program’s
guidelines for external workers include checking of tools upon arrival and departure, searching
of all vendors prior to entering the program, tool restriction while in the program, missing tool
follow-up, and restriction of youth from the work area. The outside contractor completes the
program’s Outside Contractor form upon entrance to the program, where they document, which
tools are needed to complete the work order. Maintenance staff will review the form and sign
once the tools are inventoried and approved. Upon exiting the program, the Outside Contractor
form is reviewed, all tools are verified, then the form is signed. Any tools required to be used
within the program are inventoried and recorded on the contractor’s agreement form before and
after the repair is completed. Reviewed documentation for three project invoices showed the
vendors signed contractor agreements. Documentation for the Outside Contractor forms verified
the forms were completed and all requirements were met. A review of the work project logs
since the last annual compliance review verified the contractors signed the log confirming
notification of what items are considered unauthorized. If any unauthorized items are needed by
the contractor while in the program, approval is obtained by the facility administrator (FA) or
designee. An observation of outside contractors installing a new water heater system was
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conducted during the annual compliance review week. There were no youth in the work area,
and program staff were with the contractors during the work project.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program’s Continuity of Operations Plan (COOP) addresses fire, safety, and evacuation
emergency processes and the frequency of conducting drills at random times, and under varied
conditions. The informally interviewed facility administrator (FA) stated the program had two
shifts from 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. during the annual compliance
review period. Reviewed documentation validated fire, escape, and COOP drills were
conducted for all shifts each month, as required. Reviewed drill documentation included the type
of drill, date and time, participants, a brief scenario description, deficiencies identified during the
drill, and applicable corrective actions. Observations and an informal interview with the FA
verified there were thirty annually inspected fire extinguishers and egress plans were posted
throughout the program. Five interviewed staff all reported they had participated in COOP drills,
fire drills, mental health, and medical drills. Five youth were interviewed, and each indicated
drills are conducted at least monthly and they have been instructed on what to do in the case of
an emergency. An interview with the FA indicated the program facilitates emergency/COOP,
medical, mental health, fire, and Right Interactions (RI) drills. Drills are conducted according to
the program’s drill calendar.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program has a Department approved Continuity of Operations Plan (COOP) available for all
staff to review. The COOP was reviewed and submitted to the Department on January 22, 2025.
The Department approved the COOP on February 3, 2025. The COOP provides for basic care
and custody of youth in the event of an emergency or disaster. The COOP addresses phases of
a disaster plan, emergency management, including preparedness, response, and recovery. The
COOP addresses emergencies including fire prevention, severe weather, riots, bomb threats,
hostage situations, chemical spills, flooding, and terrorist threats. In addition, the COOP
includes staff roles and responsibilities, equipment and supplies needed, youth information,
provisions for continuity of care and custody of youth, and provisions for public protection. The
COOP is readily available to all staff and is located in the administration conference room, the
facility administrator’s (FA) office, and in master control. A review of the plan indicated
alternative housing has been identified should the program require evacuation due to an
emergency or disaster. The program has provisions of equipment and supplies maintained in
the kitchen and master control to ensure a continuous operation of services during emergency
or disaster situations. In addition, the program has a generator to provide continuous power.
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The program maintains identifying information on each youth in the program in the event the
program has to evacuate, and the youth record accompanies the youth to the temporary
location. A review of seven youth case management records indicated each had the youth’s
name, Department identification number, admission date, gender, race, contact information,
emergency contact, assigned juvenile probation officer (JPO), committing judge, victim
information, physical description, health status, and a photograph. The interviewed FA reported
staff have full access to the COOP. The COOP is located in the administrative conference room
and in the program’s administrator's office.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a written policy and procedures for the storage and inventory of flammable,
poisonous and toxic materials. Toxic items are stored outside the program in locked cabinets
within a locked chain link fence. A list of staff which includes the facility administrator (FA),
assistant facility administrators (AFA), unit managers, medical staff, shift supervisors, and food
service staff are authorized to use chemicals maintained in the storage cabinets. All caustic
materials are stored according to type and use. A Safety Data Sheet (SDS) binder is located
inside the storage area with a picture of each material and a number corresponding to the SDS
for each chemical. A perpetual chemical inventory list is maintained, and the chemicals are
checked daily. A review of the inventory list verified this practice. The program has a Chemical
Daily Usage Log used to track all toxic items when in use by authorized staff. Observation of the
storage area indicated it was clearly marked for hazardous chemicals and securely locked.
Items were stored on metal shelving and numbered according to the SDSs. Flammable items
are stored in a metal cabinet clearly marked as flammable items. Some of the metal chemical
storage lockers were heavily rusted. Chemicals used to clean the program are stored in locked
closets located in the main hallway of the program and in a secured closet in the kitchen. An
inventory sheet is maintained and documents the daily use. A review of the storage closet
verified the number and type of chemicals were maintained on the inventory list. A random
sample of ten chemicals verified the actual count matched the inventory logs, with one
exception. The inventory log stated there were four bottles of bleach in the kitchen storage area;
however, the actual count was five bottles of bleach. The inventory was corrected during the
annual compliance review week. All of the chemicals were secured, and the SDSs were present
for the items reviewed. In addition, the program maintains a written policy and procedures to
ensure all flammable, toxic, caustic, and poisonous items are disposed appropriately. The FA or
designee and maintenance staff are responsible for the control and accountability of all caustic,
toxic, poisonous, flammable, hazardous fluids, substances, or chemicals used in the program.
All unused hazardous materials are kept in the secured storage area located outside the
program and are disposed of according to the SDS. In an informal interview the physical plant
manager stated the program makes every effort to use up all chemicals. Any unused chemicals
are taken to a local bio-hazardous waste contractor. The physical plant manager stated there
were no chemicals disposed of during the annual compliance review period. Used kitchen
grease and waste is stored in a large container outside the kitchen area and is disposed of by a
local vendor. All liquid waste from work details is disposed by pouring the liquid down plumbing
drains. The program’s policy states all chemical spills are reported to master control
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immediately and the shift supervisor. An evacuation of the affected area is conducted and
determination by the FA is made as to whether to contact outside assistance to contain the spill.
Staff and youth are not allowed to return to the affected area until it has been deemed safe by a
qualified professional. The interviewed FA stated hazardous items and toxic substances, or
chemicals are disposed of in accordance with Occupational Safety and Health Administration
standards.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a written policy and procedures prohibiting youth from handling any
flammable, poisonous, and/or toxic items, or materials. Youth are not to clean, handle, or
dispose of any toxic, bio-hazardous materials, bodily fluids, or human waste. Youth are strictly
prohibited from the maintenance area where toxic items and chemicals are stored. An
observation of two youth conducting cleanup detail and four youth in the kitchen detail cooking
and washing pots and pans was conducted during the annual compliance review. None of the
observed youth were handling chemicals or cleaning products. Observations of completed
projects at the Home Builder’s Institute (HBI) verified youth used paint after receiving a risk
assessment. Five youth were interviewed, and each youth stated they have used bleach, four
stated they have used toilet cleaner, four stated they have used paint, and three stated they
have used floor wax. Youth stated when using cleaning chemicals staff spray the cleaning agent
and are supervised by staff. Youth participating in HBI have an assessment completed prior to
handling chemicals.
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5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
This program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a written policy and procedures to allow youth to have visitation and
communication with family members while in the program. The program assists youth and
families in maintaining connections in a visitation environment which provides monitoring,
control of movement, and security practices to ensure visitor, youth, staff, and program safety.
The program’s policy provides each youth opportunities to promote communication and
engagement which fosters family reunification and community connections. The program
maintains a list of approved visitors; however, attorneys, representatives of the court, juvenile
probation officers (JPO), other agency representatives, and clergy are authorized to visit at any
time. Searches of visitors will be conducted upon entry, and all youth are to be searched
following visitation sessions. The program’s visitation policy indicated considerations for
requests of alternative visitation arrangements with parents/guardians are made, if needed.
Youth are informed about visitation upon their admission to the program during the orientation
process. The visitation and communication procedures are covered in the youth handbook,
parent/guardian handbook, and addressed on the orientation checklist. Visitation is held in the
administration area on Saturdays from 10:00 a.m. to 12:00 p.m. and 1:00 p.m. to 2:00 p.m., and
on Sundays from 1:00 p.m. to 3:00 p.m. Youth are given opportunities to communicate with their
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family in person, by telephone, and by mail. Each youth is provided an opportunity to
correspond on a regular basis with identified individuals specified on their Approved
Correspondence List and legal representatives. Youth are permitted weekly telephone calls.
The youth’s use of telephone calls is documented in each youth’s case management
chronological documentation. A review of the telephone chronological notes verified youth have
consistent telephone communication with family members. Youth can write to the parents
/guardians at least once each week and are encouraged to correspond with their assigned JPO
and committing judge. All outgoing and incoming mail is searched by the case manager. A
review of the logbooks, visitation sign-in logs, and outgoing and incoming mail logs verified the
program allows visitation and mail only for approved immediate family members to include
parents, stepparents, legal guardians, siblings, grandparents, and spouses. The JPO must
approve the immediate family members. It is the program’s practice for the assigned case
manager to follow-up with the JPO regarding human trafficking victims to determine whether the
parent/guardian should be permitted to communicate with the youth; however, there were no
youth applicable for a history of human trafficking during the annual compliance review period.
Five youth were interviewed, and each confirmed they can call and/or send letters to their
parent(s)/guardian(s). The interviewed facility administrator (FA) stated for youth whom English
is not their primary language, the program uses interpreter services and a language assistance
program.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a written policy and procedures to ensure each youth has a variety of
recreation and leisure activities. A review of the program’s contract verified there were two
recreation therapist positions slated for the program. A review of the staff roster confirmed the
program has one recreation therapist, who met all requirements for the position. Reviewed
documentation of seven youth records verified recreational therapy was part of each youth’s
Individualized Performance Plan. The program’s recreation calendar designates an activity for
the youth to participate in outdoor recreation each day, as well as a calendar of alternative
activities if recreation is indoors. The program’s activity schedule is posted throughout the living
units and common areas of the program. All activities promote social and cognitive skill
development, creativity, teamwork, healthy competition, mental stimulation, and physical fitness.
Youth are provided with at least one hour of large muscle activity daily. Reviewed
documentation of the logbook and daily activity schedule confirmed the program has a range of
supervised and structured indoor and outdoor recreation and leisure activities for the youth, for
at least one hour daily. Observations made throughout the annual compliance review week
validated youth are provided with at least one hour of indoor or outdoor recreation and leisure
time. Five staff were interviewed regarding the type of recreation activities the program provided
and how long the activities lasted. Staff indicated the program provides youth with at least one
hour each day. Each staff indicated the outdoor activities consist of basketball and football. The
indoor activities consist of board games, card games, watching television, and playing video
games. Five youth were interviewed, and each youth stated they are provided at least one hour
of physical activity which includes playing basketball, football, board games, and dodge ball.
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5.23 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program has a written policy and procedures to ensure staff search and inspect controlled
observation rooms prior to placing a youth in controlled observation. The program has a
designated area to house youth who have been placed in controlled observation. Observation of
the rooms indicated the program met the measurement and construction required by Florida
Administrative Code. The Controlled Observation Reports were reviewed, and the program had
265 controlled observation placements since the last annual compliance review. A review of
twenty-six Controlled Observation Reports indicated a staff as the same gender of the youth
searched the youth and staff inspected the room before the youth was placed in controlled
observation.
5.24 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program has a written policy and procedures regarding controlled observation. Program
staff are authorized to temporarily place a youth in a controlled observation room if there is an
imminent risk to the youth harming themselves or others, or if the youth is causing major
damage to the program which may cause a security risk. If a youth is placed in controlled
observation for any of these reasons, a Controlled Observation Report is to be completed upon
the youth’s placement. The program had 265 controlled observation placements since the last
annual compliance review. A review of twenty-six Controlled Observation Reports verified
supervisors, or administration authorized the placement of youth in controlled observation. None
of the reviewed Controlled Observation Reports indicated the youth exhibited behaviors
indicative of a mental health crisis or had suicide ideation. Documentation indicated each youth
placed in controlled observation was identified as aggressive towards others and less restrictive
methods were ineffective, and staff needed to quickly gain control for program safety. Each
Controlled Observation Report indicated staff advised the youth of the reason for controlled
observation and the expected behavior to be released. The Controlled Observation Reports
indicated medical staff completed a Health Status Checklist for the youth in controlled
observation and there were two youth with complaints of injury. The Controlled Observation
Reports indicated twenty-two youth required approval for continued placement in controlled
observation and the facility administrator (FA) or designee gave approval for continued
placement at least every two hours throughout the extension period.
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5.25 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program has a written policy and procedures to ensure safety checks for youth in controlled
observation are conducted. A safety check is to be conducted every fifteen minutes to ensure
the youth is safe and observe the youth’s behavior. Once the youth is determined to be
appropriate for release from controlled observation, the facility administrator (FA) or designated
supervisor gives approval for the youth’s release. The release is documented on the Controlled
Observation Report. The program had 265 controlled observation placements since the last
annual compliance review. A review of twenty-six Controlled Observation Reports indicated staff
completed the first page of the report and the report was submitted to a supervisor. Staff
conducted safety checks at least every fifteen minutes and documented the Controlled
Observation Safety Check form. All Controlled Observation Safety Check forms indicated the
FA, or designee approved the release of the youth from controlled observation based on the
youth’s behavior and no longer being a threat to self and others. A review of twenty-six
Controlled Observation Reports verified the FA, or designee approved the report within fourteen
days of the youth’s release from controlled observation. Documentation verified staff decided if
an alert was warranted after the youth was released from controlled observation.
Documentation showed the Controlled Observation Report, Health Status Checklist, and
Controlled Observation Safety Check forms were maintained in an administrative record and in
the youth’s individual case management record. Reviewed documentation verified staff
designations for controlled observation placements were included in the program’s operating
procedures.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 71 of 71 (Revised August 2025)

report_type: QI Residential

program_name_raw: Everglades Youth Academy - Max