summary: QI Residential - FY24-25 - 1 finding

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
St. Augustine Youth Academy
Youth Opportunity Investments, LLC
(Contract Provider )
4500 Avenue D
St. Augustine, Florida 32085
Review Date(s): April 8-11, 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:
Bradley Taylor, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Jeff Campbell, Office of Education, Northeast Education Coordinator (Standard 6)
Renette Crosby, Office of Accountability and Program Support, Regional (Standard 4)
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Gail Goldberg, AMI Kids, Certified Peer Reviewer (Standard 2)
Forrest Hallam, Office of Accountability and Program Support, Regional (Standard 4)
Kristine Harshaw, Office of Accountability and Program Support, Co-Lead Reviewer (Standard
1)
Michele Maynard, Office of Accountability and Program Support, Regional (Standard 5)
Devon Whitten, Office of Accountability and Program Support, Regional (Standard 6)
Program Name: St. Augustine Youth Academy MQI Program Code:
Provider Name: Youth Opportunity Investments, LLC Contract Number: 10794
Location: St. Johns County / Circuit 7 Number of Beds: 64
Review Date(s): 4/8/25-4/11/25 Lead Reviewer Code:
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, (5) Safety and Security, and (6) Educational
Services, which are included in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
5.09 Searches and Full Body Visual Searches
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 64 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Non-Applicable
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 64 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 64 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Non-Applicable
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 64 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 64 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Limited
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 64 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Satisfactory
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Non-Applicable
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Non-Applicable
6.08 Florida Youth College (Post-Secondary Contract) Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 64 (Revised September 2022)
Program Overview
The St. Augustine Youth Academy is a sixty-four-bed program, for fourteen- to twenty-one-year-
old males, located in St. Augustine, Florida. The program is operated by Youth Opportunity
Investments LLC, through a contract with the Department. The program provides the following
services: Mental Health Overlay Services (MHOS) or Substance Abuse Overlay Services
(SAOS). In addition, the program fosters each youth by providing Seven Challenges,
Aggression Replacement Training, Moral Reconation Therapy, Skillstreaming the Adolescent,
SNAP Youth Justice, and Impact of Crime. Additional treatment services provided includes
Living in Balance, Certified Technician courses, family assistance with visitation, puppy/dog
training, pre-paid cards upon completion of Employ U, community-based employment
assistance, and two “Entertainment Zones”. Program administration is comprised of a facility
administrator, two assistant facility administrator (AFA), a human resources/administrative
assistant, a food service manager, and a physical plant manager. Case management services
are provided by the designated mental health clinician authority (DMHCA), licensed mental
health professional (LMHP), and five non-licensed mental health staff. Medical services are
offered from 7 a.m. to 7 p.m. and are provided by the designated health authority (DHA),
registered nurse, and two licensed practical nurses. Education services are provided by the
Florida Virtual School. The layout of the program includes: a main building which includes
administration, staff offices, youth living areas, a dining room, kitchen, classrooms, and large
meeting area/pavilion. The program has 110 operating security cameras providing coverage. At
the time of the annual compliance review, the program had one assistant clinical director
(ACD), one shift supervisor, and six direct care vacancies.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 64 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
A review of the staff roster found forty staff were hired during the annual compliance review
period. Each staff received a clear and eligible background screening in the Clearinghouse
system and their criminal history reports were reviewed prior to contact with youth or
confidential youth records. None of the staff required an exemption, and none of the staff were
applicable for a break in service. Twelve staff were applicable for being hired from another
provider and each received a new screening through the Provider Share process in
Clearinghouse. Each applicable staff was administered a pre-employment assessment tool, and
a passing score was obtained and documented in their personnel records. All of the forty staff
were added to the program’s roster in Clearinghouse. The program did not have any volunteers,
mentors, contract staff, or interns who required a background screening. The Annual Affidavit of
Compliance with Level Two Screening Standards was submitted for the program on January 6,
2025, and for the teachers who are provided by Florida Scholars Academy through a contract
with the Florida Virtual School on January 28, 2025.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures to ensure all staff are administered background re-
screenings every five years of employment. A review of the staff roster found no staff were
eligible for a five-year background rescreening; however, two staff required new fingerprints,
which were completed within the required timeframe.
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.
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Office of Accountability and Program Support Page 11 of 64 (Revised September 2022)
▪ 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 staff adhere to a Code of Conduct as evidenced by seven reviewed staff
personnel records. Each staff signed a receipt indicating they received the program’s Code of
Conduct. Within the staff’s training records, each indicated a training on Florida Reporting of
Child Abuse requirements. Observations were made throughout the program showing the
Florida Abuse Hotline and the Department’s Central Communications Center (CCC) numbers
were posted and available to staff and youth. The program has a written policy and procedures
on the abuse reporting process. All staff are trained as mandatory reporters. The expectation is
the staff who the abuse is reported to, will make the call. All steps necessary to keep the youth
safe, will be made. If a staff is in question, the staff will be removed from contact, pending the
investigation. All required calls will be made to leadership within the required two-hour
timeframe. Youth eighteen years of age or older are permitted to contact the CCC upon request
to report incidents of abuse. Five applicable incidents for abuse were reviewed. Four of the five
incidents are currently pending, with one incident being substantiated. Youth who request to
contact the abuse registry are provided with the opportunity to do so immediately upon request.
Youth are provided with a private space to make their report. The facility administrator was
interviewed concerning the Trauma Responsive and Caring Environment (TRACE) self-
assessment. The program’s assessment was completed on December 5, 2024. Seven staff
were interviewed. Six of the seven staff reported they notify the supervisor when a youth
requests a call to the abuse hotline. The remaining staff was a supervisor who responded they
notify the facility administrator when a youth is making a call, but they are authorized to give the
youth access to the hotline. Four staff said they notify the facility administrator, three said they
allow youth to make the call, two said the supervisor makes the call, and two said staff are
allowed to call. None of the staff have observed another staff telling a youth they could not call
the Florida Abuse Hotline. Four of the seven staff have never heard another staff use profanity
while speaking to youth, one staff said once and the staff was coached by supervisory staff, and
two said occasionally, but the profanity was in conversation, not directed at youth. Seven youth
were interviewed. Each of the seven youth reported they feel safe at the program, with reasons
being staff presence, overall comfort, and activities to keep them busy. None of the seven youth
have been stopped from reporting abuse to the Florida Abuse Hotline. Six of seven youth either
knew the hotline number or knew where to locate it. All seven youth confirmed staff are
respectful when speaking with youth, with one youth saying staff use profanity occasionally out
of frustration, and one youth saying staff use profanity often, in regular conversation. None of
the youth reported they have exchanged emails, telephone numbers, or social media contact
information with staff. The facility administrator stated the program maintains site-specific
policies and procedures which are aligned with organizational mission, vision, beliefs,
contractual requirements and mandated guidelines. Policy reviews are conducted annually.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 64 (Revised September 2022)
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had five allegations of physical, psychological, or emotional abuse in the program
during the annual compliance review period. Documentation was reviewed, including the
Department’s Central Communications Center (CCC) reports and internal reports, showing
proper follow-up to the incidents. The facility administrator stated there have been no staff
disciplined during the review period due to allegations of abuse; however, CCC reports
indicated a substantiated incident and documented the teaching, coaching and retraining of the
staff. ted. All allegations of child abuse or suspected child abuse shall be immediately reported
to the Florida Abuse Hotline. Florida Statute mandates any person who knows or has
reasonable cause to suspect a child is abused, neglected or abandoned by a parent, legal
custodian, caregiver or other person responsible for the child's welfare shall immediately report
such knowledge or suspicion to the Florida Abuse Hotline and make a report, whenever he or
she knows or has a reasonable suspicion a child has been abused or neglected. If the youth is
eighteen years old or older, the call must be placed to CCC. Mandatory reporters are required
by law to report suspected abuse regardless of the youth's willingness, or lack thereof, to make
the call themselves.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program had a total of thirty-three reports made to the Department’s Central
Communications Center (CCC) during the annual compliance review period. A review of internal
incidents and grievances was conducted, as a result no additional calls to the CCC were
warranted. A sample of five CCC reports were reviewed for completion requirements. All five
documented calls were made to the CCC within the two-hour required timeframe. A review of
the program’s master control logbooks showed all three applicable incidents reviewed were
documented. The program has not experienced an increase of reportable incidents to the CCC
since the last annual compliance review period.
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program had five Right Interactions (RI) incidents during the annual compliance review
period, all of which each were reviewed. One of the five RI incident reports was not completed
by the end of the staff’s workday. Four of the five reviewed RI incident reports were missing one
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Office of Accountability and Program Support Page 13 of 64 (Revised September 2022)
or more staff statements. Each of the five reports included documentation the reports were
reviewed by the supervisor, RI instructor, and the administrator within the required timeframe.
One of the five reviewed reports indicated a need for a RI medical review, which resulted in an
injury to the youth. Two reviewed records showed documentation the Department’s Central
Communications Center (CCC) was contacted. None of the reviewed records involved the need
for contact to the Florida Abuse Hotline. None of the incidents involved the use of mechanical
restraints. Each RI report was filed in a centralized record and submitted to the Department in
accordance with Florida Administrative Code. The program’s RI Plan was last updated on
December 10, 2024 and was approved by the Department on December 10, 2024. This is the
program’s first annual compliance review; therefore, there is no past data to compare for RI
incidents. The program’s RI rate during the annual compliance review period was 0.00, which is
below the statewide Residential RI rate of 1.71.The facility administrator was interviewed and
reported the RI escalation matrix should be used and physical intervention should be used when
all alternatives have been exhausted. Five of the seven interviewed staff are RI certified and
confirmed they use verbal de-escalation techniques and only use physical interventions as a
last resort. Two of the interviewed staff are not in RI certification required positions.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
Seven staff training records were reviewed for pre-service training requirements. Each of the
seven staff completed their 120 hours of pre-service training within 180 days of employment. All
seven records included essential skills completed prior to contact with youth. Each of the seven
records included documentation of staff completing all required training, including essential skills
training prior to contact with youth, within the required timeframe. All instructors were qualified
to provide the delivered trainings.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
Seven staff records were reviewed for in-service training requirements. Each staff completed
more than the required twenty-four hours of annual in-service training, which included each of
the required training topics. Each of the staff maintained required certifications. Three of the
reviewed records were applicable for supervisory training, with thirty-two hours of supervisory
training were documented, including coaching, leadership, and personal accountability. All
training was documented in the Department’s Learning Management System (SkillPro). All
instructors were qualified to deliver training provided. The program has an in-service training
plan and an in-service training calendar which is updated as changes occur and signed by all
required parties.
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1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures in place which includes the training requirements of
the grievance process. The process includes the informal phase, formal phase, and appeal
phase. Documentation showed the program’s practice correlates with their process and copies
of the grievances are maintained for the past twelve months. Five grievances were reviewed
which showed each were reviewed within the required timeframe and each were resolved in the
formal phase. Seven interviewed youth were asked if they know how to file a grievance. All
seven knew how to complete a form and turn it in, and all seven said they can ask staff for help
completing a grievance. Four youth were aware of the locations of grievance forms, and one
youth was able to give details about the timeframes for grievance responses. Seven interviewed
staff were able to confirm forms are placed throughout the program and staff are able to assist
youth in completing the grievance if needed. Six staff were able to explain the timeframes and
all said the supervisor responds to the grievances. Five staff explained the process has three
phases and five reported the program director answers the grievances. One staff said the
assistant facility administrator answers the grievances as well, and one staff said they try to see
if they can help before the youth needs a grievance. The facility administrator was interviewed,
stating all youth may grieve the actions of staff or peers and conditions or circumstances of care
and treatment. Youth have the right within the program to make an informal verbal grievance or
to file a formal written grievance. Parents/guardians or agency representatives may file a
grievance on the behalf of a youth. Parents/guardians are informed of the process during the
initial admission process. All youth are informed of their rights regarding the grievance process
during the initial orientation process. Review of the grievance process is conveyed verbally and
in writing (youth handbook) and verification of the review is documented by case management
staff on the orientation checklist. When a grievance is about a specific staff member, the youth
is not required to present their grievance through the staff who is the subject of the complaint, if
not comfortable in doing so. The program will ensure every youth will be treated fairly,
respectfully, and without discrimination.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
Five staff training records were reviewed for interventions and facilitator training requirements.
Each of the five staff had the required education and experience necessary for working with
juvenile offenders. The staff’s education and work experience were considered by the program
when determining staff delivery of intervention services. Each of the five staff received
appropriate training for the group being facilitated. A review of the program’s contract confirmed
there is one non-primary, non-clinical group applicable for review. A review of the program’s
schedule was completed, and all non-primary groups are included in the daily program
schedule. The program’s non-primary group conducted is the Stop Now and Plan (SNAP)
program. The sign-in sheets for the non-primary groups were reviewed and verified groups were
provided as required and in accordance with the daily schedule. The facility administrator was
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interviewed and advised the program shall provide a delinquency intervention model or strategy
which is an evidenced based practice, promising practice or a practice with demonstrated
effectiveness as well as life and social skills training for each youth. Life skills training shall
provide interventions or instruction focusing on developing life and social skill competencies in
youth.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a policy and procedures which ensure interventions or instruction
focusing on developing life and social skill competencies in youth are provided. The program
currently utilizes the Stop Now and Plan (SNAP) program for life and social skills activities. A
review of sign-in rosters showed the program conducts the instructor led course once a week for
thirteen weeks. Two of the seven interviewed youth reported they participate in the SNAP
program. The remaining five youth listed clinical groups when asked about life skills groups. The
facility administrator was interviewed and stated all youth participate in group four times a week.
Staff whose regularly assigned job duties include implementation of a specific delinquency
intervention model, strategy, or curriculum shall receive training in its effective implementation.
To provide effective delinquency and treatment programming targeted to reduce recidivism and
meet the treatment needs of youth in care. The designated mental health clinical authority
(DMHCA) was interviewed and stated the program has three separate groups of additional life
skills activities covering The Seven Challenges, substance abuse treatment, Skillstreaming the
Adolescent, mental health treatment, and Moral Recognition Therapy. Six of seven interviewed
youth reported they have been able to practice the skills they have learned in group. One youth
said they have not been at the program long enough to practice new skills.
1.12 Restorative Justice Awareness for Youth <---Update--->
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at the St. Augustine Youth Academy program. For details related specific to IOC
service delivery, please refer to the annual SPEP report.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
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The program has a policy and procedures regarding the alert process which outlines alerts shall
be consistent in the internal alert system and the Department’s Juvenile Justice Information
System (JJIS) and only authorized staff shall update or close applicable alerts. The program
utilizes an alert board in the administrative conference room to track all internal alerts. A total of
seven youth records were reviewed, consisting of fourteen applicable alerts between them.
Each of the fourteen applicable alerts were completed on time, by the appropriate staff and
matched the alert board. Each of the seven youth’s alerts were also documented in the logbook.
The facility administrator was interviewed and reported the program has established a
continually updated, an internal alert system easily accessible to program staff and keeps them
alerted to youth who pose a risk to security or safety including escape, sexual offending and
other assaultive or violent behavior risks, suicide, other mental health as well as health related
concerns, including food allergies and special diets. Approved staff shall immediately update the
internal program alert, along with JJIS. Program alerts must be consistent with internal alerts.
Only authorized staff may recommend downgrading or discontinuing a youth's alert status. The
nurse was interviewed and stated only medical staff verify alerts are correct. Seven staff were
interviewed. All seven staff were aware of the places to find youth alerts. Six of seven staff
reported alerts are discussed during shift briefings, three staff said the alert board in the
conference room, and one said in JJIS.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program maintains Individual Healthcare Records (IHCR) and individual case management
records for each youth. Seven youth l case management records were reviewed, and each
contained the youth’s name, Department identification (DJJID) number, date of birth, county of
residence, and committing offense. Each record included sections for legal information,
demographic and chronological information, correspondence, case management and treatment
team activities, and miscellaneous information. All youth records are labeled, “Confidential” and
are secured in locked cabinets, which are also labeled, “Confidential” in the medical and case
management offices.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a policy and procedures in place to ensure the program has a community
support group or advisory board meeting at least every ninety to 120 days. There was
documentation of the facility administrator (FA) soliciting active involvement from law
enforcement, judiciary community, community partners, business community, school board or
district, faith community, a parent/guardian of a former youth involved in the juvenile justice
system, a victim advocate, and the LGBTQI community. The program holds meetings on-site, in
person, which was confirmed by a reviewed of sign-in sheets and agendas from quarterly
advisory board meetings. None of the meetings were cancelled or rescheduled. An interview
with the FA confirmed meetings are held quarterly and include a review of an agenda detailing
program updates and community advisory board member updates. Following each meeting,
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meeting minutes are shared with all board members to provide information to members who
may not have been present. Recruitment letters are mailed out periodically to solicit new
membership and ensure each position on the board is properly represented. One community
advisory board member responded to a request for an interview. The business community
board member stated they participated in meetings on a quarterly basis. The board meets with
youth and families to discuss what can be done to enhance youth while at the facility and to see
how they can help youth outside of the academy and into the community. The board provides
family fellowship and an opportunity to meet with professionals in the area, to provide
community service.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures in place to ensure a system for evaluating staff, at
least annually, based on established performance standards. Each staff receives an evaluation
after their ninety-day introductory period and annually thereafter. A review of seven position
descriptions confirmed each staff’s performance standards were clearly identified. A review of
seven staff personnel records confirmed each staff received an annual performance evaluation
on established performance standards. The performance standards matched the position
description for each staff. A review of the contract confirmed required positions were maintained
and performed as outlined with the exception of one shift supervisor, six direct care staff
positions, and one assistant clinical director (ACD) position which has been vacant since May
23, 2024. The facility administrator (FA) confirmed the evaluation process as annually unless a
new hire which occurs at ninety days. Seven staff were interviewed and five staff reported they
received evaluations monthly, two said every ninety days, one said quarterly, and one said
annually. Two staff additionally said they get evaluations often.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
A review of the program’s contract revealed nine special contract conditions, all of which are
being met, or are in progress, as evidenced by documentation or observation by the annual
compliance review team. Special contract conditions being met at this time are conducting
“Living in Balance” substance abuse intervention, Aggression Replacement Therapy (ART),
certified technician (C-Tech) courses, assisting families with visitation, puppy/dog training, pre-
paid cards for successful completion of Employ U, community based employment assistance, to
exhaust all clinical resources within the program, and to provide two “Entertainment Zones”. An
interview with the facility administrator confirmed all contract items are being provided and
documented in the facility administrator’s (FA) office.
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1.18 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program’s practice regarding data trend analysis includes satisfaction surveys to be
incorporated into the monitoring and verification activities as a part of the program's quality
assurance program. Satisfaction surveys shall be provided routinely and will be completed on at
least a quarterly basis. Surveys include youth surveys, family surveys, and staff surveys at a
minimum. Surveys will target admission activities, topic-specific assessments, and discharge
satisfaction. Survey data is reviewed and evaluated monthly in program-level and corporate
leadership meetings. Survey outcomes are collected and communicated as a part of ongoing
program communication and quality improvement activities. Monthly incident trackers are
distributed to the programs which describe trends. Standardized Program Evaluation Protocol
(SPEP) internal and external evaluation is conducted using SPEP Quality of Service Delivery
Evaluation Guidelines and findings are incorporated in monthly monitoring and verification
reporting and within the annual SPEP report. Quarterly monitoring and verifications are
conducted by the Youth Opportunity compliance team which formulates a report and will provide
support, technical assistance, and coaching to promote improvement, professional
development, and implementation and assurances of corrective strategies as appropriate.
Program and corporate leadership meetings include monthly quality assurance review
processes which incorporate review of facility data, surveys, and findings of formal monitoring
and verification activities. Within each meeting, progress to date, program strengths,
improvement needs, and corrective action will be discussed. Recommendations are made by
the team with ongoing review and follow up and technical assistance will be provided as
applicable. Data gathered by the program and Department is used for long-term planning,
provisions for staffing, and a system of communication to keep staff. Stakeholders are informed
and provided opportunities for feedback, performance improvement, and budgeting.
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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 maintains a written policy and procedures regarding initial contacts to
parent/guardian and court notification. Seven youth case management records were reviewed,
each record contained documentation of the youth’s chronological sheet, telephone call log, and
youth handbook. Review of the chronological form confirmed the program notified the youth’s
parent/guardian within twenty-four hours of the youth’s admission to the program. All seven
youth case management records established the youth’s parent/guardian were notified in writing
within forty-eight hours of the youth’s admission to the program and written notification was
provided to the committing judge and juvenile probation officer (JPO) within five working days of
the youth’s admission. Each record contained a signed form indicating the youth received a
copy of the youth handbook and an orientation.
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 maintains a written policy and procedures delineating youth orientation. A review
of seven youth case management records found the program provided an orientation to each
youth on the day of admission. Each record included documentation demonstrating the youth
completed the orientation process to include all required elements. Each record contained a
signed acknowledgement and orientation checklist form signed by the youth and residential
case manager documenting the orientation process which included all required elements. The
program did not have any youth admissions during the annual compliance review week;
therefore, an admission was not observed. Seven interviewed youth confirmed they received an
orientation within twenty-four hours of entering the program including program rules,
procedures, and schedules. All seven were able to explain the process.
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 maintains a written policy and procedures outlining consent for youth eighteen
years of age or older. Seven youth case management records were reviewed, and three were
applicable for being eighteen years of age or older. All three applicable records contained a
consent form signed by the youth to allow the program to share, or prevent sharing, information
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related to the youth’s physical or mental health screenings, assessments, or treatment with the
parent/guardian.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program maintains a written policy and procedures outlining the classification process for
youth upon admission to the program and completion of reassessments. Seven youth case
management records were reviewed for classification factors, procedures, and reassessment
for activities. All seven youth records indicated an admission classification form was completed
on the day of admission and prior to assigning newly admitted youth to a living unit and sleeping
room. The initial classification form included a pre-classification management briefing, factors
included, at a minimum, current and or past psychotropic medication, suicide risk, victim
notification required, sexually violent predator status, deoxyribonucleic acid (DNA) testing,
current or prior history of sexual misconduct, sexual aggression, sexual offenses, predatory
behavior, sexual victimization status, vulnerable to victimization, runaway risk, escape risk,
arson risk, the youth’s physical characteristics, gender, height, weight, and general physical
stature, age, maturity level, identified special needs, including medical, mental health,
development or intellectual and physical disabilities, history of violence, gang affiliation, and
criminal behavior. The program’s practice is to complete reassessments for each youth prior to
considering an increase in privileges or freedom of movement, participation in work projects or
other activities involving tools. An interview with the facility administrator (FA), indicated the
program has a policy to ensure an effective classification system promoting safety and security
as well as effective delivery of treatment services based upon the determination of each youth's
individual needs and risk factors. The program also ensures all youth are 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 is completed in the Department’s Juvenile Justice Information System
(JJIS).
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 maintains a written policy and procedures outlining gang identification and
notification to law enforcement. Seven youth case management records were reviewed, and two
were applicable for gang notification. A third record was requested to meet the minimum of
three records reviewed. All three records included documentation for notification to law
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enforcement, the assigned juvenile probation officer (JPO), education staff, and the youth’s
applicable post-residential services counselor. Reviewed documentation reflected gang status
was shared as required for each youth. A review of the Department’s Juvenile Justice
Information System (JJIS) indicated the gang alerts were identified or previously existed.
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 maintains a written policy and procedures to address youth’s participation in gang
prevention and/or intervention activities. The program utilizes a prevention and intervention
activities for youth identified with gang affiliation, which is inclusive of providing youth with
assistance and guidance in formulating a plan to disassociate from their respective gang
affiliation. The program implements the Gang Resistance and Drug Education (GRADE)
curricula to the gang affiliated youth. A review of seven youth case management records was
conducted, and two were applicable for review. A third record was requested to meet the
minimum of three records. All three youth were identified as a gang member, suspected gang
member, or being gang affiliated. The GRADE group sign-in sheets were reviewed and
validated all three youth participated in gang prevention and intervention strategies. Each
youth’s performance plan included relevant goals and objectives related to gang intervention
strategies for the youth to complete prior to being released from the program. An interview with
the facility administrator (FA) confirmed the program provides each youth with resources to
disaffiliate from a criminal street gang and assists in developing a plan to dis-affiliate from a
criminal street gang.
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 maintains a written policy and procedures to ensure a Residential Assessment for
Youth (RAY) is completed for each youth within thirty days of admission. Seven initial RAYs
were reviewed. One initial RAY was completed nine days late. A review of the Department’s
Juvenile Justice Information System (JJIS) validated each initial RAY was maintained in JJIS for
all seven youth case management records. Seven youth case management records were
reviewed and six were applicable for RAY Re-Assessments to be completed at least every
ninety days. A total of ten RAY-Reassessments were reviewed and seven were completed
every ninety days as required, the remaining three RAY Reassessments were completed
sixteen, thirty-six, and forty-two days late. All initial RAYs and reassessments were maintained
in the youth official case management records.
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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 maintains a written policy and procedures regarding the completion of the Youth
Needs Assessment Summary (YNAS). Seven youth case management records were reviewed,
and each contained a completed YNAS report. Two YNAS reports were not completed within
thirty days of the youth’s admission, both were completed fifteen days late. Each YNAS report
was documented in the Department’s Juvenile Justice Information System (JJIS) and a copy
was maintained in each youth’s case management record.
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 maintains a written policy and procedures outlining performance plan
development, goals, and transmittal. Seven youth case management records were reviewed.
Six of the seven Individualized Performance Plans (IPP) were developed after completion of the
Youth Needs Assessment Summary (YNAS), the remaining IPP was developed before
completion of the YNAS. Each IPP was signed by the treatment team leader, youth,
administrative representatives, treatment staff, living unit representatives, and education staff.
Reviewed documentation for each youth case management record demonstrated each IPP was
emailed to the parent/guardian with request for signature. None of the signature pages were
returned. Six of the seven IPPs were completed within thirty days of admission, the remaining
youth record documented the IPP was developed fifteen days late. Each of the seven youth
case management records found the IPPs were mailed or emailed to the youth’s committing
court and juvenile probation officer (JPO) within ten days of completion. Each reviewed IPP
included individualized goals based upon the prioritized needs identified during the initial
assessment. All seven IPPs addressed the youth’s three top criminogenic needs, specific
delinquency interventions based on RAY results, court-ordered sanctions, and transition
activities targeted for the last sixty-days of the youth’s anticipated stay. Each IPP outlined
program staff responsibilities and target dates for goal completion. Seven interviewed youth
reported they participated in the development of their IPP.
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.
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The program maintains a written policy and procedures in place regarding revisions to a youth’s
Individualized Performance Plan (IPP) and incorporation of other plans. Six of seven youth case
management records were applicable for and documented revisions to the performance plans
based on the Residential Assessment for Youth (RAY) reassessment, newly acquired
information, transition status, and demonstrated progress, or lack of progress towards goal
completion. The IPPs documented they were reviewed during formal treatment team meetings
with all the multidisciplinary team members. Each of the seven youth had additional plans,
including academic or treatment which were included in the youth’s performance plan. None of
the youth were applicable for Department of Children and Families (DCF) or Agency for Persons
with Disabilities (APD) 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 maintains a written policy and procedures outlining the completion of
Performance Summaries and transmittal letters. Six of seven youth records were applicable for
a total of ten youth Performance Summaries. Eight were completed within the required
timeframe and prior to each youth’s transition, the remaining Performance Summaries were
thirty-six and forty-eight days late. The program stated they were aware of the identified
deficiency and had already addressed the issue with the case management team. Each of the
reviewed Performance Summaries included all required information. Each summary was
reviewed and signed by all treatment team members. The Performance Summaries were mailed
or emailed to the committing court, juvenile probation officer (JPO), and parent/guardian. Three
closed youth case management records were reviewed for release summaries. All three release
summaries were completed within the required timeframe. Each record contained the original
summary which included reason of release from the program. All three closed case
management records documented a Performance Summary and Pre-Release Notification
(PRN) was submitted at least forty-five days prior to the tentative release date. Each closed
case management record documented notification to the youth’s parent/guardian of the youth’s
release date once the program obtained the approved PRN from the youth’s committing court.
Each youth’s case management record contained a Residential Assessment for Youth (RAY)
exit assessment. There were no youth applicable for the sexually violent predator program or
victim notification.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program maintains a written policy and procedures outlining the process to encourage
parent/guardian involvement in case management services. A review of seven youth case
management records confirmed each demonstrated the parents/guardians were informed of the
youth’s treatment team meetings. Reviewed documentation found each youth’s case
management record reflected the program encouraged and facilitated involvement of youth’s
parents/guardian in case management activities, to include the assessment process,
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development of the youth’s performance plan, and monthly progress reviews. Documentation
supported the program provided notice of formal treatment team meetings and transition
planning. An interview with the facility administrator, noted the facility promotes family
involvement by providing conferences and family outreach in order to address family issues and
prepare youth for return to the community. The program also conducts family days. Seven youth
were interviewed. Each of the seven reported their parent/guardian is involved in their treatment
teams and therapy.
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 maintains a written policy and procedures outlining the required treatment team
members and meetings. The director of case management and the youth’s assigned case
manager oversee the coordination of the treatment team and are responsible for leading the
treatment team meetings. A review of seven active youth case management records found each
youth participated in formal and informal treatment team meetings. Each record confirmed each
of the required treatment team members, to include the youth, an administrative representative,
treatment staff, the assigned juvenile probation officer (JPO), parent/guardian, and educational
staff participated in treatment teams. The youth’s parent/guardian and JPO were invited to
participate in treatment team meetings through correspondence mailed prior to the meetings.
Documentation verified the treatment team staff provided a brief synopsis of the youth’s
progress in the program by reviewing and discussing the youth’s performance plan. Each record
documented which youth was provided an opportunity to demonstrate skills acquired in the
program and comment on progress. All seven youth case management records contained
monthly formal treatment team and informal treatment team meeting documentation occurring
within the required timeframes and containing all required elements with the exception of one
formal review which was completed fourteen days late. The program had treatment team the
week of the annual compliance review; therefore, an observation of treatment team was
completed. Two youth were observed through the process. Parents/guardians and JPOs were
involved by phone. Each of the seven interviewed youth reported staff talk with them about their
performance to include performance plan goals, positive and negative behaviors, and treatment
progress. All seven were able to detail how they show the skills they have learned during
treatment team.
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.
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The program maintains a written policy and procedures to ensure the intervention and treatment
team is planning for each youth’s successful transition to the community upon release from the
program. The policy outlines the process for transition planning, conferences, and Community
Re-Entry Team (CRT) meetings. A review of three closed youth case management records
documented each youth had a transition conference at least sixty days prior to the youth’s
targeted release date. Transition conference documentation reflected the youth, treatment team
leader, facility administrator, or designee, and other applicable team members were in
attendance. Notification documentation supported each juvenile probation officer (JPO) and
parent/guardian, were encouraged to participate. Transition documents supported the
conference included a review of transition activities, necessary performance plan revisions,
additional transition activities, target completion dates, and persons responsible for transition
activities. Transition conference documentation contained acknowledgement of transition goals
and responsibilities of members through signatures of participants. A copy of each transition
plan was sent to the assigned JPO and any members sharing responsibility of plan completion.
None of the youth were applicable inclusion of a Department of Children and Families
caseworker. Three closed case management records were reviewed, each had documentation
a CRT invitation was sent, and a meeting was held prior to the youth’s release in which the
youth and case manager participated as required.
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 maintains a written policy and procedures regarding the assembly of an exit
portfolio for each youth to assist the youth with transitioning back into the community. A review
of three closed youth case management records demonstrated the exit portfolio was discussed
during the exit transition meeting. Each youth’s record included an exit portfolio which contained
a copy of the youth’s birth certificate, social security card, and Florida identification card. Each
contained a copy of the youth’s transition plan, exit transition plan, a calendar with all the dates,
times, and locations of upcoming community appointments, educational/vocational certificates
earned at the program, educational records/documents, school transcripts, a sample
employment application, and a résumé. Reviewed documentation supported an exit portfolio
was provided to each youth upon release and forwarded to the assigned juvenile probation
officer. Each of the three secure risk youth were provided completed forms and clear
instructions as to how to obtain documents for employment. During the transition conference,
each of the three youth had a plan put in place as to who will be responsible for working with the
youth to obtain the required items.
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 maintains a written policy and procedures for the review and finalization of
transition conference items and release plans by way of the exit conference. A review of three
closed youth case management records was completed. Each reviewed case management
record documented an exit conference was held after the program notified the assigned juvenile
probation officer (JPO) of the youth’s release and two of the three were held at least fourteen
days prior to release. The remaining exit conference was held three days late. Documentation
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included all required topics for discussion and the dated signatures of attendees. Attendees
included the team leader, parent/guardian, education representative, JPO, youth, and other
pertinent parties. Documentation supported the exit conference was held separately from the
transition conference and Community Re-Entry Team (CRT) meeting for each youth. A review
of the Department’s Juvenile Justice Information System (JJIS) admission and release dates
corresponded with each youth’s record.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program maintains a written policy and procedures to address written provisions for youth
input. The program utilizes “Speak-Out” forms, grievance forms, and student surveys in addition
to town hall meetings to promote a formal process for youth to have constructive input regarding
the program which provides youth with the opportunity to communicate with staff about any
issues or concerns. Documentation was provided to support these activities occurred as
required. Seven youth were interviewed and reported they provide input to the program through
weekly town hall meetings, the youth advisory board, and “Speak-out” forms. The interviewed
facility administrator reported youth could provide input during treatment town hall meetings and
can submit a “Speak-Out” form to provide input.
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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 designated mental health clinician authority (DMHCA) who is responsible for
the administrative oversight and management of mental health and substance abuse services in
the program. The DMHCA is a licensed mental health counselor with an active license expiring
March 31, 2027. The program had two previous DMHCAs during the annual compliance review
period who both hold an active license in the State of Florida. The DMHCA was on-site weekly,
or as required by contract, to ensure appropriate coordination and implementation of mental
health and substance abuse services were taking place. Copies of the DMHCA agreement and
position description were reviewed. The program offers mental health overlay services and
substance abuse overlay services. The DMHCA is responsible for the coordination and
implementation of mental health/substance abuse services. The back-up DMHCA holds an
active licensed expiring March 31, 2027. An interview with the DMHCA confirmed during the
intake process, the licensed mental health professional (LMHP) gathers current and historical
information about youth, and based on the information received, each youth is assigned a
therapist. The LMHP provides clinical supervision for non-licensed mental health professionals,
provides a weekly group schedule, and monthly fidelity monitoring. The mental health
professional submits a monthly service calendar of scheduled individual and family sessions to
the clinical director or designee. The DMHCA has daily communication with the non-licensed
therapists and provides weekly clinical supervision.
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 clinical supervisor ensures the licensed clinical staff working under their supervision are
performing services they are qualified to provide based on education, training, and experience
based on a review of their job description and an informal interview with the designated mental
health clinician authority (DMHCA). The licensed mental health and substance abuse clinical
staffing is in accordance with the current contract and Florida Administrative Code. Copies of
the licenses of all licensed mental health professionals and licensed qualified professionals
were available on-site and reviewed. The program had a vacancy for the assistant clinical
director position, which is a licensed position, for the duration of the annual compliance review
period. At the time of the annual compliance review, this position had been hired but the staff
had not yet started at the program.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
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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 clinical supervisor assures the non-licensed clinical staff working under their supervision
are performing services they are qualified to provide based on education, training, and
experience. Reviewed documentation reflected each non-licensed mental health clinical staff
working under the direct supervision of a licensed mental health professional received a
minimum of one hour a week of on-site, face-to-face direct supervision by a licensed mental
health professional for the purpose of overseeing and directing the mental health services
provided in the program during the annual compliance review period, as required. Direct
supervision is recorded on a form which included all information included in the Department’s
Licensed Mental Health Professionals and Licensed/Certified Substance Abuse Professionals
Direct Supervision Log form. The program has a Chapter 397 license expiring October 15,
2025. Non-licensed mental health and substance abuse clinical staffing was in accordance with
the current contract, to include the number of hours. The vacancy for the assistant clinical
director is being filled with a new assistant clinical director starting May 5, 2025.
The program had five non-licensed mental health clinical staff who hold a master’s-level degree
from an accredited university or college in the field of counseling, social work, psychology, or
related human services field. The non-licensed substance abuse clinical staff are employees of
a facility licensed under Chapter 397. All non-licensed mental health clinical staff who conducted
Assessments of Suicide Risk complete twenty hours of training and supervised experience in
assessing suicide risk, mental health crisis intervention, and emergency mental health services.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Seven youth records were reviewed for mental health and substance abuse admission
screenings. All seven youth had a Massachusetts Youth Screening Instrument-Version Two
(MAYSI -2) completed during intake. 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 in all seven records, as required. Six
of seven youth had the screening completed in the Department’s Juvenile Justice Information
System (JJIS) on the date of admission, by a trained staff. One youth had a paper MAYSI-2
completed during a period when the Department’s JJIS was inaccessible. All six applicable
MAYSI-2 forms were completed in full. Five of the MAYSI-2 forms indicated further assessment
was required, and a referral was made for further evaluation in all five records. In the five
applicable records, the MAYSI-2 indicated the need for an assessment, crisis intervention, or
emergency services. Documentation also showed the facility administrator or designee was
notified, and a referral was made to alert the designated mental health clinician authority
(DMHCA). An Assessment of Suicide Risk (ASR) was completed on all youth within twenty-four
hours in all five records, regardless of where the hit occurred in the MAYSI-2. None of the youth
were applicable for emergency services or were in crisis. None of the youth were placed on
Precautionary Observation as a result of the ASR during intake processing. All seven youth
received an ASR and comprehensive evaluation as part of the intake process and the referral
reason was documented, as required, in all seven records.
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Office of Accountability and Program Support Page 29 of 64 (Revised September 2022)
The facility administrator is responsible for developing a written policy and procedures for the
implementation of a standardized admission/intake mental health and substance abuse
screening process. The policy addresses a standardized screening process which includes
review of the commitment packet information, along with any reports and records.
Administration of the MAYSI-2 in JJIS is completed by a licensed mental health professional and
Clinical Substance Abuse Screening by a “qualified professional” and referral of juvenile
offenders identified by screenings as in-need of further evaluation or immediate attention. The
policy also includes staff training in mental health and substance abuse issues, administration of
the MAYSI-2, and a standardized process for referral of youth identified as in-need of further
mental health and/or substance abuse evaluation to an appropriate service
provider/professional or, when immediate attention is needed, to a hospital or Baker Act or
Marchman Act receiving facility. An interview with the facility administrator confirmed the
program’s policy regarding the screening process to identify youth at risk for mental health and
substance abuse problems and suicide.
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.
An interview with the designated mental health clinician authority (DMHCA) determined youth
complete the intake process to include classification. Problem areas are discussed with youth
and parent/guardian. During the intake process, the licensed mental health professional (LMHP)
gathers current information from youth and within five days, the LMHP confirms youth reports by
referring to collateral information obtained in the youth's records to complete the Brief
Behavioral Health Status Exam. Each youth receives a comprehensive assessment within thirty
days of the intake based on their current and past behavior by licensed or non-licensed mental
health professional which is reviewed by the clinical director or designee.
Seven youth records were reviewed for mental health and substance abuse /evaluations. The
program completed a new, combined mental health and substance abuse evaluation for all
seven youth on the day of admission. Three of the youth records were applicable to substance
abuse treatment and all three youth records had a consent for substance abuse services. All
three of the evaluations were completed by a non-licensed clinical staff and were reviewed and
signed by a licensed mental health professional. All seven youth combined mental health and
substance abuse evaluations contained all the required elements including relevant background
information, behavioral observations, mental status examination, procedures administered,
discussion of findings, diagnostic impression, patterns, impact, and risk factors of alcohol and
drug abuse, and recommendations.
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.
Seven youth records were reviewed for initial mental health and substance abuse treatment
plans. All seven youth records showed the plans were developed on the youth’s day of
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Office of Accountability and Program Support Page 30 of 64 (Revised September 2022)
admission, regardless of psychotropic medication status. All seven initial mental health and
substance abuse treatment plans included all the elements of the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. One youth record was applicable for psychiatric
needs, and the information was included in the plan, as required. All seven plans included
signatures of clinical staff, the youth, treatment team leader, program management, living unit
representative, and medical staff. Three of seven plans also included signatures from the youth,
juvenile probation officer (JPO), and parent guardian. The four remaining plans were missing
the parent/guardian and/or JPO signature, but documentation reflected the program attempted
to solicit involvement in all four records.
Seven youth Individualized Treatment Plans (ITP) were reviewed. All seven plans included
psychiatric services, including psychotropic medication, when applicable, and frequency of
monitoring by the psychiatrist for all youth who received psychotropic medication. All seven
plans were completed on a form which contained all the elements of the Department’s
Individualized Mental Health/Substance Abuse Treatment Plan Review form. Treatment plan
reviews were completed every thirty days, as required, in all seven records reviewed. The ITPs
and reviews included signatures of all the required parties in all seven records reviewed.
Prescribed services were outlined in the youth’s ITP and included family, individual, and group
therapy and psychiatric services, when necessary, in all seven plans reviewed. Goals and
objectives were individualized for each of the seven youth, as required. A comparison of video to
the logbooks, sign-in sheets, verification of the facilitator, and groups were conducted for the
required group time/length, as required.
An interview with the facility administrator confirmed mental health professionals utilize internal
forms to track services provided as well as completion of documentation for the services. Mental
health professionals complete master treatment plans created within thirty days and treatment
plan reviews are completed monthly, which are reviewed by the clinical director 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.
Seven youth records were reviewed for treatment and discharge planning. All seven youth were
assigned to a treatment team upon arrival to the program. Documentation reflected treatment
teams included the youth, program administration, residential living unit representative
education, vocation, medical, mental health, substance abuse staff, and the parent/guardian for
all seven youth. All seven youth were determined to need substance abuse treatment and
receive individual, group, and/or family counseling provided by a licensed qualified professional,
or a non-licensed substance abuse clinical staff in accordance with the youth’s initial or
individualized substance abuse treatment plan. All seven youth who received mental health
treatment have a properly executed Authority for Evaluation and Treatment (AET) form, unless
the youth was eighteen years of age or older. Three youth were applicable to receiving
substance abuse treatment and all three provided consent through a signed Youth Consent for
Substance Abuse Treatment form. Therapy notes were documented on the Department’s
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Counseling/Therapy Progress Notes form in all seven records. Mental health and substance
abuse therapy included individual psychotherapy or counseling and psychosocial skills training
for all seven youth records. Progress notes determined all seven youth receive services as
stipulated on the treatment plan.
An interview with the facility administrator confirmed after completing the comprehensive
assessment, mental health professionals assist youth with identifying problem areas and an
individualized treatment plan is created within thirty days and treatment plan reviews are
created monthly, which are reviewed by the clinical director or designee. Updates are made
using a treatment addendum if treatment adjustments are needed.
A sample of three closed youth records were reviewed for treatment and discharge planning. All
three discharge plans were documented on the Department’s Mental Health/Substance Abuse
(MH/SA) Treatment Discharge Summary form. None of the youth were released while on
suicide alert/precautions. The MH/SA Treatment Discharge Summary documented the future
services needed for all three youth. A review of documentation reflected the discharge plans
were discussed with the youth, parent/guardian (when allowed), and juvenile probation officer
(JPO) during the exit conference in all three records. A copy of the Mental Health/Substance
Abuse Treatment Discharge Summary was provided to the youth, JPO, and to the
parent/guardian in all three records.
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 offers mental health overlay services and substance abuse overlay services as
part of their specialized treatment services. The program’s required clinical groups include
Seven Challenges, Aggression Replacement Therapy, Moral Reconation Therapy, and
Skillstreaming the Adolescent. Seven youth were interviewed. All seven youth confirmed they
were participating in family counseling once a month and individual counseling every other
week. Seven staff were interviewed, and all seven staff denied facilitating any mental health or
substance abuse groups. An interview with the designated mental health clinician authority
(DMHCA) confirmed individual, family and group therapy are provided at the program. The
facility administrator stated the program provides specialized treatment services in accordance
with Florida Statute and the program contract outlines the mandated guidelines for specialty
services delivery. Treatment services are provided on-site through the provision of mental health
overlay services (MHOS), and substance abuse overlay services (SAOS). All program youth are
prescreened and placed by the Department based upon identified treatment needs. The focus
of treatment services shall include targeting and reducing risk factors and addressing the
youth’s symptoms and co-occurring mental health and substance related disorders, as
applicable, and enabling the youth to improve functioning and ultimately functioning within the
community. Ancillary services are provided directly or through referral in instances where the
program cannot or does not provide certain services needed by the individual youth.
The DMHCA is on-site for forty hours each week. Licensed mental health staff are on-site five
days each week. The counselor to youth ratio is one-to-sixteen. All non-licensed staff hold a
master’s level degree. Individual therapy is provided at least once every two weeks, and family
is provided at a minimum of once every month, as applicable. A review of documentation shows
the psychiatrist provides services at least once every two weeks, as required. A licensed mental
health counselor provides on-site services, as needed, and is involved in treatment planning.
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Office of Accountability and Program Support Page 32 of 64 (Revised September 2022)
Group therapy includes four total mental health and substance abuse groups each week for all
youth, as required. No youth missed services due to being in medical quarantine.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
Psychiatric services are provided by a psychiatrist with a clear and active license in the state of
Florida, with a license expiring January 31, 2026. The psychiatrist is available for emergency
consultation twenty-four hours a day, seven days a week. The psychiatrist or psychiatric
Advanced Practice Registered Nurse (APRN) providing psychiatric services brief a
representative of the treatment team regarding the psychiatric status of each youth receiving
psychiatric services who is scheduled for treatment team review. The psychiatrist or psychiatric
APRN’s evaluation and recommendations for the youth are incorporated into the mental health
clinical staff’s evaluations of the youth and the youth’s individualized mental health or substance
abuse treatment plan. The program also utilizes the psychiatric APRN for clinical
responsibilities. The psychiatric APRN’s education, experience, and certification/licensure is in
psychiatry/mental health, as stated on the Department of Health website, with a clear and active
license expiring April 30, 2026. The program’s psychiatrist and psychiatric APRN have a
Collaborative Practice Protocol in place. A copy of the protocol was available at the program and
specifies to be with the psychiatrist when on-site. A review of sign-in/out logs confirmed visits
during the annual compliance review period were conducted as required by the contract and
agreement. A review of documentation showed the psychiatrist actively participates in,
manages, and supervises psychotropic medication services in the program. When duties were
delegated to the psychiatric APRN, the psychiatrist was available to the APRN by telephone or
by another communication device when not physically available on the premises. One back-up
psychiatrist, with equal education to the psychiatrist, was used during the annual compliance
review period. The back-up psychiatrist has a clear and active license, expiring January 31,
2026. The program’s contract includes tele-psychiatry.
An interview with the program’s psychiatrist confirmed the psychiatrist is on-site every other
week. The psychiatrist participates in treatment team and discusses the youth’s treatment
progress with staff. The psychiatrist is required to review any youth who are a new admission to
the program, youth with a referral, or who take medication, and provide psychiatric services.
The psychiatrist confirmed meeting with the designated mental health clinician authority
(DMHCA) and facility administrator, as needed, to discuss youth receiving psychiatric services.
The formalized procedure in place with the healthcare staff to review the important medical
issues pertaining to the youth at the program receiving psychiatric services includes meeting
with youth and staff every other week, or by phone when the psychiatrist in unable to be on-site,
however, communication is most often completed face-to-face. An interview with the DHMCA
confirmed the DHMCA and psychiatrist meet bi-weekly, as required.
Seven youth records were reviewed for psychiatric services. Only one of the seven youth
entered the program on psychotropic medication, but all seven youth were referred for a
psychiatric interview as part of the program’s intake process. All seven youth received a
diagnostic interview within fourteen days of admission. All seven Initial Diagnostic Psychiatric
Interviews included the youth’s history, mental status examination, diagnosis, treatment
recommendations, prescribed medications, explanation of the need for psychotropic
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medications, target symptom, treatment goals, potential side effects, risks and benefits of taking
the medication, and frequency of medication monitoring. The initial diagnostic psychiatric
interviews were documented on the Department’s Clinical Psychotropic Progress (CPPN) form.
The CPPN was clearly identified as an “Initial Diagnostic Psychiatric Interview” in all seven
records. For one youth, the initial psychiatric diagnostic interview resulted in the prescription of
psychotropic medications or changes to the youth’s existing psychotropic medication regimen,
and page three of the CPPN was completed, as required. Four youth were applicable to
receiving psychotropic medication. For all four youth, the reviewed documentation supported the
youth was seen for a medication review by the psychiatrist or psychiatric APRN every thirty
days, as required. For all four applicable youth, page three of the CPPN documented identifying
data, diagnosis, target symptoms, evaluation, and description of the effect of prescribed
medication on target symptoms and the name, dosage, and quantity of the medication, normal
dosage range, ordered dosage, frequency and route of administration, and reasons for changes
in medication and/or dosage. The CPPNs for the four youth also included side effects, youth’s
adherence to the regimen, height, weight, blood pressure, whether there was telephone
contacts with the youth’s parent/guardian, the signature of the psychiatrist or psychiatric APRN,
and Tardive Dyskinesia monitoring, as applicable. None of the youth reviewed were applicable
for tele-psychiatry.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a written plan detailing suicide prevention procedures which includes
identification and assessment of youth at risk of suicide, staff training, suicide precautions,
levels of supervision, referral process, communication, notification, documentation, immediate
staff response, and a review process. The review process for suicide attempts and mortality
review includes circumstances surrounding the event, facility procedures relevant to the
incident, all relevant training received by the staff involved, pertinent medical and mental health
services involving the victim, possible precipitating factors, and recommendations, if any, for
changes in policy, training, physical plant, medical or mental health services, and/or operational
procedures. The Suicide Prevention Plan was reviewed November 1, 2024, and signed by the
facility administrator, designated mental health clinician authority (DMHCA), and designated
corporate staff.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
Seven youth records were reviewed for suicide prevention services. Six of the seven records
were not applicable for needing suicide prevention services, as such, the program provided two
additional records for review. The youth were determined to be at-risk through staff observation
or youth self-representation. The Assessment of Suicide Risk (ASR) was completed on the
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Department’s Assessment of Suicide Risk form for all three records reviewed. All three youth
were placed on constant supervision. The youth’s parent/guardian was notified of the youth’s
potential suicide risk, as indicated by the ASR, in all three records. The parent/guardian and
juvenile probation officer (JPO) notification was documented on the ASR in all three records.
Mental health staff provided support services in all three records. The ASRs were completed by
licensed mental health professional or clinical staff under the supervision of licensed mental
health professional in all three records. For all three records reviewed, the ASR was completed
within twenty-four hours of screening/concerns, by a licensed staff or an appropriately trained
non-licensed staff. Two of the records showed the ASR was completed by a non-licensed staff,
in which case, both ASRs were reviewed by a licensed staff within twenty-four hours either in
person or telephonically, or the next time the licensed staff was on-site. All three records
required one or more Follow-Up ASR’s to be completed prior to removing the youth from
precautionary observation. The Follow-up Assessments of Suicide Risk (FASR) were
documented on the Department’s Follow-Up Assessment of Suicide Risk, in all three records. All
three youth were maintained on suicide precautions and either one-to-one or constant
supervision until the Follow-Up ASR indicated suicide precautions could be discontinued. When
the youth’s Follow-Up ASR indicated suicide precautions could be discontinued, the youth was
stepped down to close supervision prior to transition to normal routine and standard supervision
in all three records. Close supervision was maintained for all three youth until it was determined
no longer necessary by the designated mental health clinician authority (DMHCA), or licensed
mental health professional. There was documentation of a conference held by the facility
administrator and licensed mental health professional to reduce the level of supervision in all
three records. The discontinuation of close supervision was documented in accordance with the
program’s suicide prevention plan, a suicide alert was initiated in the Department’s Juvenile
Justice Information System (JJIS) for the youth placed on suicide precautions, and the JJIS
Suicide Risk alert was accurately closed following the recommendations of the ASR or FASR in
all three records. There was evidence in the facility logbook indicating administration or
supervisory staff provided instructions related to the suicide risk assessment findings and
suicide precaution decisions in all three records. While on Precautionary Observation (PO), all
three “at-risk” youth were allowed to participate in select activities with other youth in designated
safe housing/observation areas of the facility. No youth were on PO during the previous thirty
days, and as such, video review was not able to be completed.
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program has policy and procedure where a youth placed on suicide precautions may be
maintained on secure observation when less restrictive means are not effective. The program
has not utilized secure observation during the annual compliance review period; therefore, this
indicator is rated “Non-Applicable.”
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
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Seven youth records were reviewed for suicide precaution observation logs. Six of the seven
records were not applicable for needing suicide prevention services, as such, the program
provided two additional records for review. The Suicide Precaution Observation Logs were
maintained for the duration each youth was on suicide precaution and the appropriate level of
supervision and observations of the youth’s behavior was documented in real time and not
exceeding thirty-minute intervals. When warning signs were observed, notification was made to
the facility administrator or designee and mental health clinical staff documented on the Suicide
Precaution Observation Logs as required. Suicide Precaution Observation Logs were reviewed
and signed by each shift supervisor and mental health staff and documented safe housing
requirements for all three records reviewed. Seven direct care staff were interviewed regarding
their responsibilities if a youth expresses suicidal thoughts. Seven staff stated they would notify
mental health and maintain constant sight and sound of the youth. Five staff additionally stated
they would search the youth’s room for sharp objects. Three staff stated they would document
supervision of the youth, and two staff stated they would refer the youth to mental health. Seven
staff stated the program keeps a suicide response kit in sub-control. Four of the staff stated a
suicide response kit is also kept in master control.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Seven in-service and seven pre-service direct care staff training records were reviewed for
suicide prevention training. All fourteen staff were trained to recognize verbal and behavioral
cues indicating suicide risk, suicide prevention, and implementation of suicide precautions, as
required. The program has two suicide response kits, co-located with first-aid kits, with one kit
located in each sub-control. A review of mental health drills showed training includes mock
suicide drills held no less than quarterly on each shift, for all staff who come in contact with
youth including kitchen and maintenance staff. A review of video confirmed mock mental health
drills were in response to a suicide attempt and/or incident of serious self-injury and were
simulated. No program youth were used in drill simulations related to mental health or
substance abuse care. The program provides semi-annual training on emergency response
procedures which includes “mock” training in emergency response to a suicide attempt or
incident of serious self-inflicted injury and includes the use of cardiopulmonary resuscitation
(CPR). Staff who were not present during a quarterly drill were given the opportunity to review
each drill scenario and procedures 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 in
the facility, as required.
An interview with the facility administrator (FA) determined the Emergency Response Plan for
Mental Health and Substance Abuse Emergencies is used to ensure the highest quality of care,
safety, and management of youth. The plan is maintained and annually reviewed by the FA and
designated mental health clinician authority (DMHCA). The FA and DMHCA ensure all
emergency plans are implemented immediately to effectively prevent, de-escalate, and manage
potentially harmful mental health and substance abuse events. The Emergency Response Plan
serves as the program’s emergency response procedures. The plan outlines facility operation
procedures for emergency mental health and substance abuse services and Baker and
Marchman Acts. All staff are trained in the Emergency Response Plan and know where it is
located within the facility. Seven direct care staff were interviewed regarding the number of
times they participate in an emergency or suicide drill on their shift. All seven staff stated the
participate in drills monthly.
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3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
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 which includes a notification and alert system,
means of referrals, including youth self-referral, communication, supervision, documentation,
and review.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
Seven youth records were reviewed for crisis assessments. None of the youth were applicable,
as such, the program provided one youth record which was applicable to having a crisis
assessment during the annual compliance review period. A review of documentation showed the
crisis assessment was conducted immediately or within two hours for emergencies, or within
twenty-four hours based on the needs of the youth, as required. The crisis assessment included
the reason for the assessment, mental status examination, determination of danger to self and
others, initial clinical impressions, supervision, treatment and follow-up recommendations, and
notification to the parent/guardian. The crisis assessment was conducted by a non-licensed
mental health clinical staff working under the direct supervision of a licensed mental health
professional. A mental health alert was entered into the Department’s Juvenile Justice
Information System (JJIS) when the youth was placed on precautions after completion of a
crisis assessment. Constant supervision of the youth while on the mental health alert was
documented on the Department’s Mental Health Alert Observation Log. The youth did not
require off-site care and it was not a Prison Rape Elimination Act (PREA) related event.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a written emergency mental health and substance abuse services and crisis
intervention plan which includes immediate staff response, notifications, communication,
supervision, authorization to transport for emergency mental health or substance abuse
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services, transport for emergency mental health evaluation and treatment under Florida’s Baker
Act or Marchman Act, documentation, training, and review.
3.18 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The safety planning process for youth was reviewed in seven youth records. All seven youth
had a safety plan completed on their date of admission. The plans were prepared jointly with the
youth, parent/guardians, and clinical staff. Two youth safety plans were missing the
parent/guardian involvement, and six youth safety plans were missing juvenile probation officer
(JPO) involvement; however, the program attempted to solicit involvement from the
parent/guardian and JPO in all seven records. All seven youth safety plans incorporated
recommendations from previous or current clinical assessments or screening instruments and
incorporated trauma responsive practices. The plans were reviewed and updated as necessary
following any significant behavioral or mental health event identified by the youth’s intervention
and treatment team, or at least every thirty days, in all seven records, as required. All seven
safety plans included warning signs, the youth’s baseline behavior, crisis recognition, jointly
developed coping strategies, intervention strategies preferred by the youth and debriefing
process. Safety plans are reviewed by staff who have contact with the youth and are maintained
in the safety plan binder in master control. Seven youth were interviewed and all seven
confirmed they contributed to the creation of their safety plan. An interview with the facility
administrator confirmed safety plans are updated every thirty days or following significant
behavioral or mental health events.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a policy which meets the requirements for the designated health authority
(DHA). The program has a contract with an Osteopathic Physician (DO) who holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
the State of Florida. The program does not utilize an Advanced Practical Registered Nurse
(APRN) or a Physician’s Assistant (PA) for medical services. A Medical Doctor (MD) is the back-
up DHA with current licensure. A review of sign in/out logs indicated the DHA was present
weekly with only one exception when the back-up DHA was utilized. There were two instances
over the last year when the DHA visits were eight days apart. The DHA is available
electronically twenty-four hours a day, seven days a week and documented reviews of any
emergency, acute, and off-site care, which was visible from progress notes and communication.
The DHA interview indicated they are knowledgeable of their role in the coordination and
implementation of health services. The program does not utilize telehealth for youth medical
services.
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 registered nurse (RN) who is designated as the health services
administrator (HSA). The RN has a clear and active license on file with an expiration date of
April 30, 2027. The program has two licensed practical nurses (LPNs) who are employed full-
time as well to provide licensed medical professional services. Both LPNs have an active and
clear license, each expiring on July 31, 2025. The facility also has a back-up RN from another
program who has a clear and active license on file with an expiration date on July 31, 2026. All
nurses have the required certification in cardiopulmonary resuscitation, expiring on February 5,
2027, May 28, 2026, and November 3, 2025.The RN provides daily oversight of the clinical
duties and review of the licensed practical nurses’ documentation. The schedule was reviewed
and found the facility is compliant with contract requirements.
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.
Facility operating procedures (FOP) were present for all health-related protocols utilized at the
program and were last signed by the facility administrator (FA), psychiatrist, and designated
health authority (DHA) on March 12th, 2024. Nursing staff completed and signed off their annual
review of all procedures and healthcare protocols on January 6, 2025. All newly appointed
healthcare staff are provided with a clinical comprehensive orientation by the health services
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administrator (HSA). The facility treatment protocols are written and authorized by the DHA and
this responsibility was not delegated to any other persons.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) authorizing treatment of youth in the program’s custody. Seven
youth Individualized Health Care Records (IHCR) were reviewed for AET forms. Three of the
seven youth records were for youth over the age of eighteen. All three youth over eighteen had
documented releases present in their IHCRs. The remaining four youth all had signed copies of
the AET located in their records. All AETs were signed by the parent, Department
representative, and were valid. The nursing staff interview indicated they request a new AET
from the juvenile probation officer (JPO) within seven days of intake and they obtain the signed
copy from the Department’s Juvenile Justice Information System (JJIS) within each youth’s
electronic commitment packet (ECP).
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is notified of any
changes in the youth’s condition and to document informed consent for youth healthcare. A
review of seven youth Individual Health Care Records (IHCR) found Parental Notification of
Health-Related Care Forms were present in all youth records for the four applicable youth under
the age of eighteen. The Department notification form was sent and a copy maintained in each
of the four applicable youth’s IHCRs for all required medical incidents. Verbal consent was
obtained but not witnessed for one youth who entered the program on psychotropic
medications. None of the youth were applicable for prescription and consent of psychotropic
medications following admission. All youth records had documentation of immunization records
present and signed on the date of admission. None of the records reviewed had refused
consents present. An interview of nursing staff indicated vaccination records are reviewed upon
admission and during intake. Parental notifications are made in real time. If there are no
responses, they document attempts in the progress notes. Parental notifications are obtained
for any changes in treatment or new orders. Consents are obtained verbally with a witness and
then sent by mail in writing. If emergency services are required, 9-1-1 is called immediately and
notification is provided to the designated health authority (DHA), facility administrator (FA), and
parent/guardian. The psychiatrist obtains consent witnessed by medical staff for any new order,
discontinuances and adjustments. The clinical psychiatric progress note is sent by mail with the
acknowledgement form. Influenza vaccines are offered during influenza season and youth are
sent off-site to receive those at the health department. If the youth have exemptions from
immunizations, it is documented on the "Religious Exemption from Immunization" form.
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4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures regarding youth healthcare admission screening and
rescreening each time the physical custody of the youth changes. Seven Individual Health Care
Records (IHCR) were reviewed. All seven had a Facility Entry Physical Health Screening
(FEPHS) Form completed on the date of admission. Three of the screenings were completed by
the licensed practical nurses (LPN) and the remaining four were completed by the registered
nurse (RN). None of the IHCRs indicated the youth left physical custody of the program for over
twenty-four hours. An interview with the nursing staff indicated youth are seen by the nurse
upon admission. Nurses are made aware of new admissions during the morning management
team meetings and e-mail. Medical staff complete the FEPHS form and if a youth does leave for
over twenty-four hours, a new FEPHS form and a drug screening is completed.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures ensuring all youth admitted to the program are
provided an orientation to healthcare services. Seven youth Individual Health Care Records
(IHCR) were reviewed and all indicated the youth received a general care orientation upon
admission. Required topics are listed on the Health Education Record and the program
maintains orientation forms which the youth sign to indicate the youth are made aware of how to
access medical care, sick call, what constitutes an emergency, medical process for side effects
monitoring, the right to refuse, what to do in the case of sexual assault or attempted sexual
assault, the role of the health care providers, and universal precautions. Health Education topics
include Seatbelt Usage, Alcohol and drug-related problems, sexually transmitted
disease/infections, tobacco products including smoking cessation, dental hygiene and care,
basic personal hygiene, immunizations, infection control, physical and sexual violence
prevention, nutrition, physical fitness, and self-examinations. Education is documented on each
youth’s health education record within the IHCR. Health Education Topics are reviewed upon
admission and 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 policy and procedures to notify the designated health authority (DHA) or
designee, by telephone or verbally, of each youth’s arrival at the program and provide
immediate notification when any youth admitted to the program requires emergency care. An
interview with nursing staff indicated the DHA is made aware of any admissions at the time and
notified of any medications, acute concerns, or chronic conditions. Seven youth Individual
Health Care Records (IHCR) were reviewed, and all contained documentation on the date of
admission where the DHA was notified shortly after admission. Four of the seven reviewed
youth records indicated youth had chronic conditions. Youth with chronic conditions were noted
in the admission note and were placed on the facility’s internal alert system.
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4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures ensuring the Department’s Health-Related History
(HRH) form is completed prior to the Comprehensive Physical Assessment (CPA) and
healthcare needs are identified. The health-related history is completed by the nursing staff.
Seven youth Individual Health Care Records (IHCR) were reviewed and each contained a
completed HRH on their date of admission. All CPAs were done within seven days of the
youth’s admission and had notated this on the youth’s HRH. An interview with nursing staff
indicated the HRH is done upon intake and the CPA completed within seven days of admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the acute and chronic condition healthcare
needs of the youth are addressed by completing a Comprehensive Physical Assessment (CPA)
within seven days of youth admission. A review of seven youth Individual Health Care Records
(IHCR) indicated a CPA was completed for all youth within seven days of admission. The CPA
is completed by the Designated Health Authority (DHA) and all fields on the CPA were
appropriately completed. All youth admitted had a Tuberculosis Skin Test (TST) completed
within the last year and results were documented in the IHCR as well as the Infectious and
Communicable Disease form. All seven youth refused the genital examination and their records
contained a Youth Refusal form. Refusals were indicated by the statement, “refused by youth”
and accompanied with a youth refusal form. The Department’s Problem List was updated with
current information for the CPA completed within seven days of admission for each of the seven
youth. Nursing staff interviews indicated comprehensive screenings for medical grades two
through five are completed during intake and then annually. Medical grade one youth
screenings are completed upon intake and then every two years. Tuberculosis (TB) screenings
are completed upon intake. If the TB screening is up-to-date, a questionnaire is completed.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures to ensure all youth admitted to the program are
screened, evaluated, and treated, if applicable, for sexually transmitted infections (STIs) and
human immunodeficiency virus (HIV). Each of the seven youth Individual Health Care Records
(IHCR) reviewed had STI screenings documented on the STI Screening Tool in the IHCR. All
seven met screening criteria and had an order in the doctor’s section for STI testing. All seven
youth had results documented on the Infectious and Communicable Disease orm as well as
documentation of labs located in their IHCR. All HIV tested youth had documentation of
pre/post-test counseling indicated in their IHCR along with documented consent. The pre/post
testing counseling was completed by the designated health authority (DHA). All HIV results
were maintained confidentially in the labs section in a sealed confidentially marked envelope
with the DHA’s signature on the outside of the envelope to indicate the results were reviewed.
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No STI documentation was observed on the alert system or on the problem list for the records
reviewed.
The program has a policy which limits results to the youth, authorized representative, and only
medical parties who have an active need for the information due to exposure concerns, or for
the treatment, care, and consultation of the individual along with health department for the
purpose of reporting and control the spread of disease. All seven youth interviews confirmed
they can request STI/HIV testing.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures addressing the program’s sick call process. Sick call
forms are available for all youth on the living modules and is conducted two times a day, seven
days a week at 8:00 a.m. and 2:55 p.m. Monday through Friday and 8:00 a.m. and 5:00 p.m. on
Saturday and Sunday. Sick calls are all completed by licensed medical professionals. Any sick
calls completed by licensed practical nurses (LPN) are reviewed with the registered nurse (RN).
Sick calls are in youth Individual Health Care Records (IHCR) and are completed with all
required elements according to Florida Administrative Rule. None of the seven youth records
reviewed had sick calls conducted while in restricted housing. Three of the seven youth were
applicable for requesting a sick call. All reviewed sick calls were in each IHCR and documented
on the sick call index. Four of the seven records reviewed had not completed or requested a
sick call. Sick calls are conducted in the medical clinic in a separate room with an exam table.
When a nurse is not on-site youth sick call requests are reviewed by the shift supervisor. Sick
call request forms are located on each of the living units, available to the youth. No examples of
this were observed. Seven youth were interviewed and two indicated they were seen
immediately, four stated they were seen within a day, and one youth stated they did not know as
they have never had to request a sick call. The nursing interview confirmed the designated
health authority (DHA) and registered nurse (RN) are available to the LPNs to review sick call
care. If a sick call is placed more than three times within a fourteen-day period for the same
issue, they are referred to the DHA for follow-up. A sick call was observed during the annual
compliance review week. The observed youth was escorted to the medical clinic, staff confirmed
the youth’s identity, verified why the youth was present, reviewed the sick call, and then the
staff proceeded to examine the youth then provided the youth care.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures to ensure the youth have access to episodic and first-
aid care. All fourteen reviewed non-healthcare staff, seven pre-service and seven in-service,
maintained current first-aid, cardiopulmonary resuscitation (CPR), and automated external
defibrillator (AED) certifications. All licensed medical professionals had the appropriate licensure
and current certifications in CPR. All staff are trained on epinephrine injector (EPI) pen usage in
orientation. The program did not have any examples of episodic care provided by non-
healthcare staff during the annual compliance review period. Episodic care completed by
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licensed medical staff was written in problem orientated subjective, objective, assessment and
plan (SOAP) format as required. The program maintains an episodic care log which was
reviewed with a sample of seven episodic care incidents from youth Individual Health Care
Records (IHCR) and they were all located on the log. Emergency phone numbers were
maintained in master control and the medical clinic outside of youth areas. A sample of three
first aid kits were observed. First-aid kits contained current elements as approved by the
designated health authority (DHA) and a log is maintained for each kit indicating they are
reviewed monthly by medical personnel. Emergency drills were reviewed and located for each
month during the last review period for both shifts. Drills simulated realistic scenarios and
included scenario examples, attendance rosters, and feedback from medical staff and the
facility administrator. Two drills involving CPR were present for each shift during the annual
compliance review period. The program has an AED located in the sub-control and master
control areas. Both AEDs were functional and had current pads and batteries. The AED pads
expire on November 1, 2027 for the AED in the sub-control and May 15, 2026 for the AED in
master control. The pads have not been changed as they are new units. The batteries for both
AEDs expire on November 1, 2027, both of which were last changed on November 18, 2022. An
AED test log is maintained monthly by the program nursing staff. Interviews with seven youth
confirmed they can request dental and medical services. All staff interviews confirmed staff are
aware they can contact 9-1-1 if needed. The nursing staff interview indicated drills are
conducted monthly for each shift.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures to ensure timely referrals and coordination of medical
services for an off-site healthcare provider. Out of the seven records reviewed, five youth
required off-site care. For each youth the Summary of Off-site Care form was utilized and
located in the Individual Health Care Records (IHCR) along with any discharge documents.
Each off-site care was documented in the episodic care log. There was documentation the
designated health authority (DHA) signed and approved the documents. One youth required
an additional appointment following the off-site care and there was evidence the follow-up
occurred. An interview with nursing staff indicated tracking of off-site care is conducted through
the transport log, calendar, and the youth’s IHCR. Hospital orders are reviewed by the nurse
and flagged for the DHA to review on their next visit. Nursing staff track follow-up, referrals, and
appointments on their calendar.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure any youth admitted to the program who
have chronic conditions receive regularly scheduled evaluations and any follow-up care when
needed. Two of the seven reviewed records were applicable for chronic conditions, and an
additional record was provided for review.. Youth had appropriate medical grades and were
documented as having chronic conditions on the admission note which indicated the designated
health authority (DHA) was made aware. The DHA saw each youth within seven days and
completed a new comprehensive physical assessment (CPA). One youth came in with
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psychotropic medications upon admission. The DHA and psychiatrist were notified. The
psychiatrist approved for the youth to continue medications. The youth was then seen within
thirty days for psychiatric evaluation. All youth with chronic conditions had timely periodic
evaluations completed within their Individual Health Care Records (IHCR) every ninety days and
prior to renewing any prescriptions. There were no indications of lapses in care and each youth
Problem List was updated as required. The DHA was interviewed and reported youth with
chronic conditions are reviewed every ninety days and are tracked using an internal tracking
system. The nurse was interviewed and advised chronic conditions are entered in the alert
system. The facility administrator was interviewed and advised the program has procedures in
place for addressing 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 policy and procedures to ensure the accurate and safe administration of
youth medications. Seven youth records were reviewed and only one youth record had
medications noted upon admission. The medications were verified by nursing staff at the time
the youth was admitted into the program using the Department form. Licensed medical staff
confer with the designated health authority (DHA) and document verbal approval for youth with
medication orders to continue medication if they arrive with medication or orders. Practitioner
orders were located for all youth to resume medications and any prescribed and over-the-
counter medications subsequently given. The program uses a standard Department Medication
Administration Record (MAR) which contains all required elements, to include a current photo of
the youth. The reviewed MARs indicated appropriate start and stop dates. No medication errors
or lapses in care were observed on the logs. One youth record indicated a youth required
parenteral medications and it was administered by a licensed healthcare staff. None of the
reviewed records indicated youth required medications while in restricted housing. The one
youth reviewed who had psychotropic medications had medication reviews completed every
thirty days as required. The program had no standing orders, emergency treatment orders, or
pro re nata orders for psychotropic medications. The program has trained non-healthcare staff
which can assist in the delivery of medications; however, all MARs in the reviewed records
during the annual compliance period only had medication administered by nursing staff.
Refusals were clearly indicated on MAR logs and had the Refusal of Treatment Forms located
in the Individual Health Care Record (IHCR). A medication pass was observed during the
annual compliance review week. The nurse followed the six rights of medication delivery;
provided the youth the medication and followed up with searching the youth’s mouth following
the medication pass. The staff passing medication was only responsible for passing medications
and was not supervising youth or conducting any other activities at the time. The MAR log was
updated following the medication pass and medications. Six of seven interviewed youth advised
they do not take medications. The remaining youth stated the nurse has them verify their name,
date of birth, the medication, and then provides the medication followed by checking their mouth
with a swab. Nursing staff advised they use the standard Department MAR. Medical staff use
the medication verification form and verify with the pharmacy or previous prescribing doctor any
medications brought in with youth. Non-healthcare staff do not verify medication; medications
are verified by medical staff, and they then notify the DHA. Non-healthcare staff are authorized
to assist in medication administration and are trained by the program’s registered nurse. The
training documents are maintained in a binder in the medical clinic. Medication pass is
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conducted daily at 7:00 a.m. and 7:00 a.m.. The facility has a modified class II pharmacy permit
and medications are procured through a vendor.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures to ensure medical equipment classified as sharps
and medications are secure and inventoried utilizing a routine perpetual inventory. All
medications and sharps are maintained in secure carts or cabinets within the secured medical
office. Controlled medications are secured in a double locked cabinet within the medication cart.
All controlled medications had shift-to-shift counts documented. Three random controlled
medications were checked against the controlled inventory record and were accurate. Nursing
staff were interviewed and stated any discarded/expired medications are sent back to the
pharmacy, destroyed using a chemical solution, or the pharmacy consultant assists in the
destruction of the medication. Over-the-counter (OTC) medication was maintained in a secure
cabinet. A review of the inventory for three OTC medications was accurate. Sharps were
maintained in a separate cabinet and a review of three items conferred the counts were also
accurate. Any inventory discrepancies require a recount and are reported to the facility
administrator and the consult pharmacist.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, according
OSHA federal regulations and the Centers for Disease Control and Prevention (CDC)
guidelines. The Comprehensive Education Plan is to include pre-service and in-service
training for all staff. Education for youth regarding infection control shall also be provided at
the time of intake and subsequently when the need is identified.
The program has a policy and procedures related to an Infection Control and Exposure Control
Plan. The Infection Control and Exposure Control Plan was signed on November 1, 2024. The
plan includes all required elements and staff are trained on the exposure control plan upon
orientation. The exposure control plan contains the process for needle stick exposure. Youth
infection control and youth hygiene are completed as part of the youth’s admission and were
documented in the Individual Healthcare Records (IHCR) for all seven youth. The program has
a separate binder for occupational exposure. Staff are provided with Hepatitis B immunizations
upon orientation and upon request thereafter. Protective equipment was found to be stocked
and available to staff within the program. No instances of exposure were documented or
reported to the local county health department or other required entity. The facility administrator
(FA) advised staff are trained upon orientation and they have a separate file in the event of a
staff exposure. The nursing staff interview advised medical staff conduct infection and exposure
control plan training annually. Youth are provided with training and education upon admission
and as necessary.
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4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a 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 staff are required to account for the whereabouts of youth under their
supervision and ensure staff-to-youth ratios are following contract requirements. The program’s
contract requires staff-to-youth ratios to be one-to-eight during awake hours and one-to-twelve
during sleep hours. The ratio for off-site activities, transportation, and visitation is one staff to
five youth. Observations of staff supervision for four days during the annual compliance review
week included classroom activities, line movement, school breaks, youth head counts, mental
health groups, youth searches, and outdoor/indoor recreation activities. The observations
verified staff-to-youth ratios were maintained, as required. A program tour confirmed 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 common areas and living units were clean,
well maintained, and graffiti free. Observations of youth rooms confirmed windows were not
covered in ways which would affect the direct line of sight of youth. A perimeter check was
conducted, and fencing appeared to be in good repair. Staff and youth were appropriately
attired. During classroom activities and/or movement, observations confirmed staff were
strategically positioned to ensure proper supervision of youth. Observations of interactions
between program staff and youth reflected the interactions were positive and consistent with the
program’s BMS. An informal interview with three staff verified each knew the number of youth
they were supervising. Video observations of youth supervision during sleep hours were
conducted. The observations verified youth-to-staff ratio was in compliance, staff were awake
and alert, and conducting ten-minute checks as required.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program maintains a written policy and procedures addressing the implementation and
training of the program’s behavioral management system (BMS), which included all required
parties in the development, implementation, and on-going maintenance of the system. The
policy includes a protocol where staff are provided feedback on the implementation of the BMS.
There is an agreement between the program and the contracted education provider related to
the BMS. Documentation reflected both the program and education staff were trained in the
BMS. A sample of seven pre-service staff training records reflected newly hired staff completed
training in the program’s BMS. Seven youth case management records were reviewed
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confirming youth orientation included a review of the program’s BMS. Seven position
descriptions were reviewed verifying each job’s functions include implementation of the
program’s BMS. Displays of the program’s BMS, which incorporates the rules governing
conduct and positive and negative consequences, were posted throughout the program in areas
accessible to youth to include the dormitories, cafeteria, classrooms, and meeting spaces. The
BMS is presented in the youth handbook and includes all the required elements. The BMS does
not include increasing lengths of stay, denial of a youth’s basic rights, promotion of group
discipline, punishment of youth by other youth, or disciplinary confinement. Staff and youth
interactions were observed during the review week for adherence to the elements of the BMS,
including rewards and negative consequences. Documented negative consequences appear to
be in direct relation to the severity or seriousness of the inappropriate behavior exhibited. The
program’s BMS includes a process wherein staff explain to the youth the reason for any
sanctions imposed. The youth are given an opportunity to explain their behavior, then staff and
the youth discuss the behavior’s impact on others and reasonable reparations for harm caused,
as well as alternative acceptable behaviors. The program offers a variety of rewards and
incentives, including canteen, snacks, access to the game room and recording studio, game
nights and holiday related activities.
Seven staff were interviewed and all staff were familiar with most aspects of the BMS used by
the program. Staff reported the program rewards youth with daily and weekly incentives, a point
store every other weekend, and other award ceremonies. All seven staff confirmed no rights
may be taken as a consequence. Staff reported youth are able to explain their behaviors during
the process of getting a problem behavior report. Youth are offered the opportunity to write
about the situation on the report which is taken to treatment team for consideration and review.
Seven youth were interviewed and they provided examples of consequences they are given for
negative behavior. These include emergency treatment teams, early bedtime, privilege
restrictions, and level freezes. Youth also provided examples of rewards they can earn, which
included daily and weekly incentives, point store, extra phone calls, game room time, and studio
time. All seven youth said staff are consistent in the dissemination of rewards and
consequences. All seven youth were able to explain the BMS level system and progression
protocols, and each confirmed youth are not allowed to punish other youth. The facility
administrator (FA) was interviewed and stated the program adheres to the policy and
procedures regarding the BMS level system. The program utilizes incentive and level freezes for
inappropriate behaviors using a special treatment team form. Emergency Treatment Team
(ETT) forms, daily point cards, and phase-up requests are reviewed daily in morning
management meetings.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program maintains a written policy and procedures to ensure ten-minute checks are
conducted when the youth are asleep or in their rooms. The program has a total of 111 cameras
which were all operational at the time of the annual compliance review. The program’s video
recording has a thirty-day storage capacity. Staff are required to conduct room checks every
ten-minutes and document the time of the check on the Ten-Minute Check Log when youth are
sleeping or in their rooms. Checks are documented on the program’s Ten-Minute Check Logs
with the time of each check noted in real time along with the initials of the staff conducting each
check. A review of samples of fourteen nights of video footage of both dormitories and Ten-
Minute Check Logs, documented by staff, reflected discrepancies. Out of the fifty-seven, ten-
minute checks observed, five checks were late. One check was conducted six minutes late,
three were five minutes late, and one was one minute late. Upon review of the check sheets, all
checks were documented in real time with no discrepancies. The program administration was
made aware of the discrepancies and plan to address these with applicable staff. Seven staff
were interviewed and all seven reported room checks are conducted every eight minutes with
youth are in their rooms for sleeping or non-punishment reasons. The facility administrator (FA)
was interviewed and stated the program has 110 video cameras and recordings are kept 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 maintains a written policy and procedures to ensure youth are always accounted
for through a system of physically counting youth at various times throughout each day. The
program’s policy is 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. 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 at the beginning of each shift, during any emergency, and at regular intervals.
Observation of a count during the annual compliance review confirmed adherence with program
policy and procedures as youth movement ceased and counts were methodically relayed to
master control for reconciliation and clearance. Ten randomly selected dates and times in the
program’s logbook were reviewed for census counts during the annual compliance review
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period. Documentation validated head counts were conducted at the beginning of each shift,
after outdoor activities, and during actual and/or simulated drills. Seven staff were interviewed
and all reported youth counts are conducted hourly, with two staff also reporting two additional
counts completed per shift. The staff confirmed when the count cannot be reconciled, the
program is locked down, all youth are put in front of or behind their doors, and a physical
recount is done by the supervisor. A search begins as soon as youth are secured in their rooms.
All seven staff reported emergency counts are conducted after emergency situations, drills, or
codes.
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 requiring a chronological record of routine
events, incidents, activities, and emergency situations in a logbook in accordance with Florida
Administrative Code. A review of the program logbooks confirmed they were bound with pre-
printed numbered pages with all entries made in ink with no evidence of erasures, the use of
white-out, or destroyed or removed entries. Any errors observed were struck through with a
single line and initialed by the staff correcting the error. Reviewed documentation of randomly
selected days within the logbooks reflected each entry included the date and time of the event,
the names of the staff and youth involved, a brief description of the event, and the name and
signature of the staff making the entry. The logbook, as well as activity schedule, showed there
was minimal interference of educational instruction, showed youth arrived to and departed
school on time, and indicated recreation was conducted as scheduled. The program utilizes the
program’s logbook to brief all incoming supervisory staff, who sign the staff acknowledgement
signature field in the logbook indicating they have reviewed its contents. The program does not
utilize living area logbooks. A review of the logbooks demonstrated staff documented the
required events, incidents, and activities. The logbooks included documentation of incidents,
population counts, perimeter checks, youth transports, emergency situations, admissions,
releases, special instructions for supervision and monitoring of youth, requests by law
enforcement to access a youth, and calls to the Florida Abuse Hotline or the Department’s
Central Communications Center (CCC).
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 for assignment, inventory, tracking, secure
storage, missing or lost, and damaged program keys. Keys are placed on a tamper resistant
ring which includes a chit with the number of keys and the assigned access/post location for the
key set. Program keys are maintained in master control in a wall cabinet with the corresponding
key number which can be locked if necessary. Master control is secured and youth do not have
access. The program has a daily key log to track keys. The log indicates the name of staff and
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what key set they are to be assigned according to their position/posting assignment. The
program maintains a master inventory list of program keys. A random check of five different sets
of program keys were compared to the inventory list which indicated the keys were accounted
for and the master control staff were knowledgeable regarding key access and assignments.
Active keys are assigned to direct-care staff while restricted keys are designated for medical
staff, kitchen staff, case managers, and therapists. An interview with master control staff, as well
as observations made, indicated the program’s practice is when direct care staff arrive at the
program, personal keys are handed over, and assigned a numbered hook inside master control.
Medical staff, kitchen staff, case managers, and therapists receive their respective restricted
keys from master control after their personal keys have been collected and secured. Both the
master control operator and staff receiving a program key, initial the key log before and again at
the end of the shift when the keys are returned. A review of the key logs and logbooks during
the annual compliance review period verified this practice. In addition, the program has a list of
staff who are assigned permanent keys. Permanent keys are issued and staff sign an
acknowledgment form indicating a key identification number and the number of keys issued. A
review of the signed acknowledgment forms indicated each staff signed for the use of
permanent keys. An informal interview with the master control operator and the physical plant
manager confirmed damaged keys would be reported to the shift supervisor, an incident report
and maintenance request form is completed, and the key set is taken offline by the physical
plant manager until the key is replaced. A random check of three staff verified the number of
keys on the key ring which matched inventory, and each staff knew their function. A review of
the Department’s Central Communications Center (CCC) reports during the annual compliance
review period indicated there were no incidents related to key control. Seven interviewed staff
were asked to explain the process for personal and program keys. All seven said personal keys
are turned into master control and securely stored in the locked cabinet, five said program keys
are assigned by master control when personal keys are turned in and there is a key log. One
staff had a permanent issued key set. Four staff report visitor keys are given to master control
and a chit is given in return. One staff reported youth do not have access to keys, one said they
are to notify master control of missing keys, and one said broken keys are replaced.
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
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prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a written policy and procedures to identify materials considered to be
contraband, to prevent illegal and prohibited items from entering the program, and the
consequences when found in the possession of youth or staff in 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. Each youth is provided with a written copy of the youth
handbook upon admission into the program and each youth is re oriented to the program rules
including the list of items considered to be contraband. In addition, the program’s policy includes
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 way
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. The facility visitor log contained a contraband attestation
statement, which was observed in the lobby of the facility. The provider requires all staff to sign
an attestation form acknowledging their understanding of the contraband policy, of which all
forty newly hired staff had signed. The program’s policy and procedures, provided during
orientation training for all new staff, stipulates staff, including supervisors and administrators,
found in possession of contraband will be subject to disciplinary action up to and including
dismissal. The program documents the confiscation and disposal of contraband. All instances
involving confiscation of illegal contraband require the program to turn the item over to local law
enforcement authorities and file a criminal report. A review of the Department’s Central
Communications Center (CCC) reports since the last annual compliance review indicated there
were four instances of contraband found at the program of which one needed to be turned over
to law enforcement. A review of logbooks, incident reports, and search reports confirmed the
frequency and quality of searches and the results. During the program tour, all of the youth
rooms were viewed, and no contraband was observed. 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.
In an interview with the facility administrator (FA), it was indicated searches are documented on
the Room Search form and the monthly contraband log. If the CCC or law enforcement needs to
be contacted, the FA or assistant facility administrator (AFA) will make the contact. Items
requiring removal from the grounds are disposed of by the AFA or FA. Seven staff were asked
to explain how and how often room searches are completed. All seven staff reported room
searches are conducted weekly for each dorm, but can happen daily. One interviewed staff, a
supervisor, stated searches are completed thoroughly and neatly. Another staff reported
searches are called into master control and documented.
5.09 Searches and Full Body Visual Searches Limited 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 at the time of admission, after off-campus activities, and visitation.
Youth are searched before all movement, during a new admission, during re-admission, after
returning from visitation, when returning from off-campus activities and/or appointments, when
suspected of having contraband, or when a youth is determined to be a security risk. The
program conducts searches as a method to prevent the introduction of contraband and
unauthorized items into the program. Policy indicates searches of youth are conducted after off-
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site transports, after visitation, before moving youth from an outside area into the building, and
prior to moving youth from the building to an outside area. Three days of searches were
observed by video. Seven of eighteen youth searches were not conducted or done improperly.
Five searches were not conducted on any youth and two searches did not include all present
youth. During the annual compliance review, observations of a youth transport, admission, and
video observations of visitations support youth searches are completed as required by program
policy. Youth search and full body visual search forms were reviewed and confirmed the
program conducts full body visual searches at the time of admission and other off-site
appointments. Searches were documented in the program’s logbook. Observations made
throughout the annual compliance review week validated youth are provided instructions
regarding the search, searches were conducted by staff of the same gender as the youth, were
conducted in a manner as to not degrade the youth and were based on the Protective Action
Response (PAR)/Right Interactions (RI) training manual.
Visitor searches were also reviewed and out of eight visitor searches, two visitors were not
asked to remove their shoes. Staff were searched upon initial entry; however, when staff left the
building and went to the parking lot, they were not searched again upon return. This was
observed twice, once on video and once in person by a review team member. During the video
review, it was observed the staff completing visitor searches was using their personal cell phone
in the lobby, went into the hallway, and into master control with their personal phone, which is
into the secure area and past the door with the posting prohibiting cell phones. A report was
made to the Department’s Central Communications Center (CCC) by the program upon
discovery of the conveyance of contraband. An additional call to the CCC was initiated by the
review team upon the discovery of the conveyance of a personal cell phone into the program by
the peer assigned to the annual compliance review team.
Seven staff were interviewed and all seven confirmed youth are searched prior to all
movements. Seven youth were interviewed and all reported searches are conducted when they
come in from outside, six youth said after meals, five said when items are missing, two youth
said room searches are done daily, and two said they are searched when returning from off-
campus.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a written policy and procedures requiring the program vehicles be
properly maintained, contain safety and emergency equipment, and be operated in a safe
manner. The program has two vans used to transport youth. The program ensures both vehicles
are properly maintained, and the use and maintenance of each vehicle is documented in a
vehicle log. A review of the weekly inspections showed all were completed, as required. Each
vehicle used for transporting youth has passed an annual safety inspection. Both vehicles used
to transport youth are equipped with the appropriate number of seatbelts, a seatbelt cutter, a
window punch, a fire extinguisher, and an approved first-aid kit. Doors for the youth passenger
area cannot be opened from the inside. Both vans are equipped with safety screens as required
for secure/high risk programs. A random check of seven personal vehicles and the program’s
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transportation vehicles was conducted during the annual compliance review. The staff vehicles
and both transportation vehicles were found to be locked.
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 the safety and security of youth and
the community during transportation of youth, and to ensure the appropriate staff-to-youth ratio
is maintained while youth are transported off program grounds. The program has an approved
transport list which is updated monthly to ensure staff driver’s licenses are valid. Human
resources (HR) obtains monthly driving record information from the Department of Highway
Safety and Motor Vehicles for all staff in the Department's Staff Verification System (SVS)
system. The HR department notates designated transportation staff within the SVS system and
updates the approved driver’s list maintained in the administrative area by the facility
administrator’s (FA) office. Reviewed documentation verified all approved drivers had a valid
driver’s license. A transport was observed during the annual compliance review week and the
staff-to-youth ratio and staff gender requirements were in compliance with program policy. The
program provides secure transportation for secure high-risk and secure maximum-risk youth, or
non-secure youth determined to be at greater risk, as such, all transport vehicles are equipped
with a safety screen. An interview with the FA confirmed the program’s transportation process.
Seven staff were interviewed, and each reported youth are only secured within transport
vehicles by seatbelts. All seven staff reported they are given a radio and cell phone for
transports. The staff were able to recount the vehicles all contain a first aid kit, a fire
extinguisher, a seatbelt cutter, and a window punch. Two staff additionally reported the vehicle
contains a steering wheel lock. All seven staff confirmed youth are not allowed to use personal
vehicles to transport youth and transport vehicles are searched prior to and after transports. All
seven staff if an emergency takes place during a transport, they are to contact the facility or law
enforcement, depending on the circumstances, and the ratio of youth-to-staff during transports
is one youth to two staff. All program vehicles have a safety screen, as it is a high and maximum
risk program. Seven youth were interviewed and all seven confirmed they are not handcuffed to
any part of a vehicle while on transport and none of the youth have witnessed anyone put
contraband in a transport vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures for weekly safety and security audits. The program’s
physical plant manager is responsible for completing the safety and security audits. The audits
are completed utilizing a spreadsheet identifying deficiencies, needed repairs, timelines, and the
completion of identified repairs. The program utilizes a work order system to identify
maintenance issues, costs, needed materials, use of outside contractors, if required and
projected timelines for completion. This information is updated in the weekly safety and security
audit. The safety and security audit results are sent to the Department’s residential safety and
security specialist. A review of invoices confirmed outside contractors have been to the program
to conduct plant maintenance. A review of the weekly safety and security audits verified the
reports have been sent at a minimum of every seven days. The facility administrator was
interviewed and confirmed safety and security audits are conducted weekly by the physical plant
manager and discussed at weekly meetings.
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5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures for tool inventory and management which
ensure youth do not use tools or equipment as weapons or for security breaches. The
procedure addresses the issuance, inventory, and control of the equipment and tools. All tools
are inventoried prior to being issued for work and all tools are inventoried following work
activities. The program inventories sharp-edged tools daily except on days not used and there is
a monthly inventory of all tools without sharp edges or points. The tools in the maintenance
office are clearly marked for identification. A shadow board is kept in the locked maintenance
office area and a sign in/out system is utilized for accountability. Ten reviewed tools confirmed
each was secured, marked for easy identification, and the inventory matched for all tools.
Machetes, bowie knives, or other long blade knives are prohibited. If a tool is missing staff shall
notify the facility administrator (FA) immediately, the program is locked down, and all areas and
youth are searched. Additionally, an incident report, documentation in the program logbook, and
calls to the Department’s Central Communications Center (CCC) are completed within the
required time frame.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries to themselves, other youth, and staff. Seven youth
case management records were reviewed and all seven had a risk assessment completed
along with training, and a test, in which they passed. Procedures included established ratios,
tool distribution and collection, and search criteria during work projects. Youth using tools were
not able to be observed during the annual compliance review week. Seven staff interviews were
conducted, and all confirmed youth were allowed to use only class B tools, specifically mops
brooms, and scrub brushes. Seven youth interviews were reviewed and all reported they were
allowed to clean with 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 maintains a policy and procedures which establish guidelines required for outside
contractors, which includes information regarding tool control and restrictions. The sign-in
sheets were reviewed for outside contractors. There were no issues, and the forms were filled
out properly. The guidelines for the outside workers included the tools being checked at arrival
and departure. Youth were restricted from the area being worked on and there were no missing
tools noted. Three project invoices were reviewed and the dates on the invoices matched up
with the sign-in sheets. All tools were inventoried upon arrival and departure and contractor
visits were verified in the program’s master control logbook.
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5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program conducts 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. A review
of the drill documentation confirmed the program conducts the Department approved Continuity
of Operations Plan (COOP) drills monthly on all shifts. The drill forms documented the type of
drill, date and time, the participants, a scenario, and findings with recommendations if needed.
The program had evacuation routes and egress plans posted in areas of the buildings. There
are fifteen fire extinguishers at the program, and all were inspected annually with the date
clearly legible. The last inspection was completed on July 24, 2024. Seven staff were
interviewed and all reported participating in fire, mental health, and medical drills monthly, and
six staff also indicated they have participated in a COOP drill. Seven interviewed youth reported
they have been instructed on what to do in case of a fire, with four reporting fire drills are done
monthly, two youth said weekly, and one said not often. The facility administrator (FA) was
interviewed and stated drills are conducted at the proper frequency and required scenarios in
compliance with policy and procedures.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a Department approved Disaster and Continuity of Operations Plan
(COOP) located in the program’s master control where all staff can review. The COOP was
updated on March 1, 2025, and approved on March 7, 2025. The COOP contains listed
relocation sites in case of emergency and the program did have to relocate. The equipment and
supplies are in the kitchen, medical, and an outside storage container which included canned
goods, water, extra clothing, first-aid supplies, and blankets. The COOP addresses phases of
the disaster plan and management including preparedness, response, and recovery. Different
types of emergencies are included in the COOP such as fire, severe weather, program
disturbances, hostage situations, bomb threats, chemical spills, flooding, and terrorist attacks.
The program keeps a binder in master control with the COOP containing the youth’s
information. A review of the binder confirms the information includes full name, Department of
Juvenile Justice Identification Number (DJJID), admission date, date of birth, recent picture,
gender, race, guardian information, juvenile probation officer contact information, names of the
committing judge, state attorney, youth’s attorney, committing offense, notation of jurisdiction
retention, victim notification if applicable, a physical description of the youth, their overall health
status, and personal physician if known. The facility administrator was interviewed and stated
the administrative hard-copy file for the youth is kept in master control and updated upon every
youth admission and release from the program.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 64 (Revised September 2022)
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures for the facility administrator (FA) to maintain strict
control of flammable, poisonous, and toxic items and materials and a complete inventory of all
such items. The policy states hazardous materials shall be stored in secure areas inaccessible
to youth. All hazardous materials are inventoried monthly by the program’s physical plant
manager and any discrepancies shall be reported to the FA who also serves as the designated
safety and security coordinator. All cleaners and toxic items are stored and locked in
maintenance, janitor’s closet in the main hallway, and in the laundry rooms. Positions which can
handle toxic items are listed as maintenance staff, youth care workers, shift supervisors, master
control, kitchen, medical staff, Assistant Facility Administrator (AFA), and the FA. The program’s
policy states the maintenance staff is responsible for the safe and lawful disposal of hazardous
items. It should be noted no hazardous items were disposed of during the annual compliance
review period. The program disposes of hazardous waste at the county’s identified transfer
station site. Liquid waste is disposed of in one of the plumbing drains and kitchen waste, minus
grease, was disposed of in the kitchen. When staff become aware of a chemical spill, they notify
master control of the location, and the shift supervisor has control of the shut-down for all air
handlers and ventilations systems. If needed, the program contacts assistance from outside of
the facility. The FA was interviewed and reiterated policy and procedures. Ten chemicals were
observed, and all were secure with no inventory discrepancies. A Safety Data Sheet (SDS) was
included in a binder in the maintenance building, janitor’s closet, and in the laundry rooms.
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 policy and procedures regarding youth and supervision for flammable, toxic,
caustic, and poisonous items. Youth are prohibited from using and possessing flammable, toxic,
or caustic materials at the program and the program maintains strict control of these items. The
youth cannot clean up hazardous items nor do they handle or dispose of any person’s bio-
hazardous material, bodily fluids, or human waste. Seven youth were interviewed and asked if
they handle chemicals. Four youth responded they do not handle chemicals, two said they have
used laundry soap under staff supervision, and one said they have used rubbing alcohol to
clean nail clippers under the supervision of the nurse.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 58 of 64 (Revised September 2022)
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rate
as non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program allows visitation and communication for youth while in the program. The visitation
schedules are posted in all dorms and the lobby. The visitation log and schedule confirmed
visitation was held Wednesdays and every weekend. All paperwork and sign-in forms were filled
out properly and completely. Identification cards were checked, rules were provided, searches
were noted, and staff initials were all completed in the visitation log. The telephone log was
reviewed, and each youth is scheduled for a day to make a call, typically on weekends, and
additional times for calls can be scheduled for youth to communicate with approved individuals.
All mail, both outgoing and incoming, is searched in front of the youth by the youth’s case
manager. The mail log was reviewed, and mail can be sent and/or received Monday through
Friday. The youth handbook demonstrates how to address an envelope. Case management
verified any youth with a human trafficking background would require clarification from the
juvenile probation officer to verify the youth’s guardian and other family members are not under
current or past investigation for human trafficking-related charges. Seven interviewed youth
confirmed they can send a letter or call a parent or guardian. The facility administrator was
interviewed and stated translation services are offered to both youth and family members upon
need.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 64 (Revised September 2022)
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program shall provide a variety of recreational and leisure activities. The program’s activity
schedule documented a range of supervised and structured indoor and outdoor recreational and
leisure activities and large muscle activities . The logbook indicated recreation was conducted
as scheduled. The activities promote social and cognitive skill development, creativity,
teamwork, healthy competition, mental stimulation, and physical fitness. The program takes
precautionary measures to ensure youth are safe during activities. The program employs a
recreation therapist and a review of the therapist’s credentials, schedule, and services, are in
compliance with contractual requirements. A review of seven youth’s individualized treatment
plans supported the recreation therapist’s involvement. Seven interviewed youth confirmed they
get one hour of recreation time, which includes basketball, football, and soccer. Seven
interviewed youth confirmed they get one hour of recreation time, which includes basketball,
football, and soccer.
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 policy and procedures pertaining to youth searches and room inspections
prior to placing a youth in controlled observation. The program utilizes two rooms in the
admitting and processing area which meet all required elements. During the annual compliance
review period, the program has had no incidents of youth 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 policy and procedures regarding the placement of youth in controlled
observation when non-physical interventions would not be effective. During the annual
compliance review period, the program has had no incidents of youth placed on controlled
observation.
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 policy and procedures pertaining to safety checks for youth on controlled
observation and the release of the youth, as approved by the facility administrator, based on the
youth’s behavior when the youth is determined to no longer be a danger to themselves or
others. During the annual compliance review period, the program has had no incidents of youth
placed on controlled observation.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 64 (Revised September 2022)
Standard 6: Safety and Security
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program has a policy and procedures to implement career and technical education
services. The contract stated the program will offer career and technical education services
which lead to career pathways with student outcomes which must include Industry Certifications
earned from the Master Credentials Lists, collaborative partners in the education learned
process with a cooperative agreement or Memorandum of Understanding; Soft Skills credentials
which include Florida Ready to Work interactive training program; Occupational Safety and
Health Administration (OSHA) 10-hours training course; and First Aid/Cardiopulmonary
Resuscitation (CPR) training. The program shall provide partnership with Upper Iowa University
to provide post-secondary education options such as Bachelor of Science in Business
Administration and CTech. The program will also assist with appointments and transportation to
Career Source Northeast and partner with Employ U (Florida Division of Vocational Rehab,
Agency for Persons with Disabilities, and American Dream Employment Network). During the
annual compliance review period, twenty-nine youth participated in Florida Ready to Work, forty-
one participated in First Aid/Cardiopulmonary Resuscitation (CPR) training, seven participated
in CTech, and forty-one participated in the Occupational Safety and Health Administration
(OSHA) 10-hour training course. All youth in each program received a certification for
completion of the training. The Career and Technical Education (CTE) instructor advised they
are able to provide the youth who have graduated with CTE services Monday through Friday,
between 10 a.m. and 12 p.m. For the youth who have not graduated and participating in school,
the CTE instructor tries to get CTE services during breaks with regular school or after school.
The CTE instructor is certified in CPR, Florida Ready to Work, CTech, and TrasfrVR(Virtual
Reality). Seven youth were interviewed during the annual compliance review and one reported
they were participating in CTE services.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide educational access. The program
provides education services through Florida Virtual School (FLVS). A review of the facilities'
activity schedule and the daily academic schedule indicated that the facilities' activity schedule
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 64 (Revised September 2022)
incorporates the daily school schedule. One discrepancy was found with the morning break
time. The program listed the break time at 10:00 am, but it should be at 10:10 am. Seven
interviewed youth reported there were no interruptions. A review of twelve randomly selected
days in the logbook throughout the annual compliance review period indicated education
classes started and ended on time with the schedule, with the exception of on one day, in which
classes ended twenty-three to forty minutes early. Observations of the program video on three
days showed the youth were in school during scheduled times on two of the three days. The
remaining day showed school started late by ten minutes, youth left for lunch sixteen minutes
early, and classes ended three minutes early.
6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Education services are provided through a contract with Florida Virtual School (FLVS). The 250-
day calendar is distributed over twelve months and includes twenty days for teacher training and
planning. A review of the daily school schedule revealed education provides six fifty-minute
classes from 8:30 am through 2:45 pm with a sixty-minute lunch break from 12:05 pm through
1:05 pm, fulfilling the weekly requirement of twenty-five hours of instructional time. The interview
with the lead teacher indicated all youth receive credit for completing a course. They also
reported the school schedule is adhered to. Observations of the program video on three days
showed teachers were present during scheduled classroom time, except on one day when no
teacher was present from 10:45 am to 12:05 pm. The teacher was present at 1:00 pm, left at
1:05 pm, and never returned for the remainder of the school day. Video observation showed
teachers going from classroom to classroom for coverage due to teacher shortages.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures for developing and implementing a vocational
competency development program. A review of the career education program found it is
appropriate for the educational abilities and goals as well as the length of stay and classification
of the youth. The program provides a Type 3 education development program, which includes
communication, interpersonal, and decision-making skills. The interviewed lead educator stated
youth are provided career and technical education courses such as Digital Information
Technology and other courses in the career and technical world.
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The contracted educational provider is responsible for developing an Education Transition Plan
for each youth. Upon entering a residential commitment program, an education transition plan
must be developed for each youth. Three closed case management records were reviewed and
none of the records contained an education transition plan. The provider did not complete any
Education Transition Plans until the issue was identified and staff were provided a training.
.FLVS has recently developed an education plan template and trained its staff to implement an
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 64 (Revised September 2022)
education transition plan for each youth moving forward. Five of the seven interviewed youth
reported they were involved in the development of their education transition plan, and two
reported they were not. The interview with the instructional leader indicated Exceptional Student
Education (ESE) services are provided for students with disabilities. The instructional leader
reported most youth lead the meeting and stated their plans to return to the community.
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The contracted educational provider has procedures in place to provide qualified instructional
personnel. In reviewing the educational instructional staff for the program, including flex
teachers who provide virtual education at the program, it indicated all the teachers have an
active certification, according to the Florida Department of Education website. Flex teacher
certifications suggest all are currently certified in their teaching subjects. Three teachers were
teaching in field and out-of-field subject areas. There was an additional seven teachers who
were also teaching courses out of field. The provider sent parent notifications for those teachers
who were also teaching out of the field; however, the letter did not indicate which subjects were
taught out of field. One teacher provides Exceptional Student Education (ESE) services in the
program, and the provider provided the certification for the ESE instructor.
6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
The program has a policy and procedure for youth to be referred to Florida Youth College (FYC)
when a youth earns their high school diploma or General Education Diploma (GED). A review of
documentation found the program referred seven youth to FYC. The program is referring the
youth to FYC and providing services to them while they are still in the program. The program did
not have any youth who were referred to FYC and had services being provided once they left
the program. Seven youth were interviewed and none reported they were receiving post-
secondary instruction. One youth reported they are signed up to begin C-Tech classes, but they
had not yet begun. The interviewed lead educator stated youth who complete their diploma or
GED complete a survey with FYC and career exploration with FYC.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 64 (Revised September 2022)
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Seven youth were referred for post-secondary provider services through Florida Youth College
(FYC). All seven reviewed records documented the required information regarding the
completed orientation and career plan. The program is providing services to the youth while
they are still in the program. One reviewed youth was applicable for post-release follow-ups and
none of the follow-ups were completed. Seven youth were interviewed, and none were receiving
post-secondary services. E-mail communications were sent after the review asking for the
questions to be answered, but never received a response.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 64 (Revised September 2022)

report_type: QI Residential

file_name: SAYA-FINAL-FY2425 .pdf

rule: Indicator 5.09

excerpt: Searches and Full Body Visual Searches

rating: Limited Compliance