summary: QI Residential - FY24-25 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Palm Beach Youth Academy
Rite of Passage, Inc.
(Contract Provider)
9680 Weisman Way
West Palm Beach, Florida 33411
Review Date(s): January 14-17, 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:
Andrice Holley, Office of Accountability and Program Support, Lead Reviewer (Standard1)
Jillian Cumbo, Florida Youth College, Carrer and Technical Assistance (Standard 6)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Rondarrell George, Office of Accountability and Program Support, Regional Monitor (Standard
4)
Cindy Jones, Deputy Director of Education, Office of Educational Services (Standard 6)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Shakela Minns, Office of Accountability and Program Support, Regional Monitor (Standards 3,
4, and 5)
Danielle Penn, Office of Accountability and Program Support, Regional Monitor (Interviews)
Acasha Pressley, Office of Accountability and Program Support, Regional Monitor (Interviews)
Yvrose Sylvain, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Program Name: Palm Beach Youth Academy MQI Program Code: 1417
Provider Name: Rite of Passage Contract Number: 10341
Location: Palm Beach County / Circuit 15 Number of Beds: 78
Review Date(s): January 14-17, 2025 Lead Reviewer Code: 199
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, and (5) Safety and Security, 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
4.13 Episodic/First Aid Care/Emergency Care
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 68 (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 Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board 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 68 (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 68 (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 * Satisfactory
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 68 (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 Limited
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 68 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 68 (Revised September 2022)
Program Overview
Palm Beach Youth Academy is a seventy-eight-bed program for thirteen- to eighteen-year-old
males, located in West Palm Beach, Florida. The program is operated by Rite of Passage, Inc
through a contract with the Department. The program provides Mental Health Overlay Services
(MHOS) and Substance Abuse Treatment Overlay Services (SAOS). In addition, the program
fosters each youth by providing delinquency programming including Impact of Crime (IOC),
Aggression Replacement Therapy (ART), Coping with Stress: Cognitive Behavioral Therapy
(CBT), Adolescents Coping with Depression (CWD-A), Trauma Focused CBT, Seeking Safety,
and health and sexuality education. Additional treatment services included individual, group,
and family therapy, pre-vocational and vocational services, job training placement, self-
sufficiency planning, recreational and leisure time activities, religious/spiritual opportunities, as
well as restorative justice philosophy programming. Program administration is comprised of a
program director (PD), two directors of group living (DGLs), a designated mental health clinician
authority (DMHCA) who serves as the clinical director, a registered nurse (RN) serving as the
health services administrator (HSA), a director of student services (DSS), a training and
compliance manager, a community liaison, a human resources coordinator, a physical plant
manager, and a food services manager. Case management services are provided by the DSS,
and five case managers. Mental health staff at the program include a DMHCA, a licensed
therapeutic manager, six master’s-level therapists, and one recreation therapist. Medical
services are offered and are provided by a contracted licensed medical doctor (MD) who serves
as the designated health authority (DHA), a HSA, and two RNs. Educational services are
provided through the Florida Scholars Academy/Florida Virtual Schools. The layout of the
program includes two living modules comprised of six total living units. The program has one
hundred twenty-six operating security cameras providing coverage. At the time of the annual
compliance review, the program had one licensed therapist vacancy.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 68 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program maintains a written policy and procedures requiring all staff, volunteers, and
contracted staff to be background screened prior to contact with youth and youth records. All
newly hired staff and volunteers receive an initial background screening. The program has a
policy and procedures for volunteers, mentors, and interns who work with youth less than ten
hours a month, requiring sight and sound supervision. The Annual Affidavit of Compliance with
Level 2 Screening Standards was submitted to the Department’s Background Screening Unit
(BSU) on January 16, 2025, meeting the annual requirement. The program hired forty-nine new
staff and one volunteer since the last annual compliance review. A review of each record
verified the program completed a background screening prior to contact with youth and
confidential youth records. Each staff and volunteer’s criminal history report was reviewed.
There were fourteen staff applicable for an exemption prior to working with youth. The reviewed
documentation confirmed an exemption had been obtained prior to working with the youth. The
program reviewed the Staff Verification System (SVS), and criminal history report results for
each new staff member before hiring. There were no staff applicable for a break in service.
Reviewed records documented all staff and one volunteer had a background screening
completed prior to contact with the youth and confidential youth records. A pre-employment
assessment tool was administered to the hired direct care staff, and each received a passing
score. Each staff's record documented a passing score for the pre-employment assessment.
The program added each staff and volunteer to their Clearinghouse roster, and each staff
completed a background screening when a provider hired the Department staff or when another
contracted provider company hired a provider. Documentation supported each newly hired staff,
and each volunteer had a signed contraband attestation form in their record.
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 maintains a written policy and procedures detailing the background screening
process. Five-year rescreening due dates are based upon the initial hire/start date for all staff,
contracted providers, volunteers, mentors, and interns. Staff rescreenings are to be submitted to
the Department’s Background Screening Unit (BSU)/Clearinghouse no later than ten days prior
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 68 (Revised September 2022)
to the staff’s five-year anniversary. A review of the program’s staff roster confirmed there were
no staff, volunteers, mentors, contracted providers or interns applicable for a five-year
background rescreening since the last annual compliance review period.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
 The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
 All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
 Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
 The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
 A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program maintains a written policy and procedures addressing each youth’s rights, staff
rights, and other’s rights to feel safe and secure in an abuse-free environment. The procedures
for abuse and neglect reporting, along with the program’s manual, address the code of conduct.
Staff are required to sign the manual acknowledgment form indicating the required information
is reviewed. There were two incidents alleging abuse reported to the Department’s Central
Communications Center (CCC) since the last annual compliance review. Both incidents were
related to physical abuse and the staff were no longer employed at the program during the
annual compliance review week. The program completed a Trauma Responsive and Caring
Environment (TRACE) self-assessment on April 15, 2024. The Florida Abuse Hotline and the
CCC telephone numbers were observed to be posted throughout the program. The program’s
policy outlines the reporting procedures for all staff to follow when a youth requests to report
abuse. If a youth requests access to the Florida Abuse Hotline or the CCC to make a complaint,
staff shall notify the shift supervisor or master control. The youth will be allowed to speak with
the Florida Abuse Hotline or the CCC operator to report the issue. Once the call has been
completed, staff are to notify the shift supervisor or master control. A youth’s refusal to make the
abuse call themselves does not relieve the staff from their mandate to call the Florida Abuse
Hotline, if the staff has reasonable suspicion abuse has occurred. There were no applicable
cases for any potential human trafficking victims, children of sexual exploitation, or labor
trafficking reported. There were no Prison Rape Elimination Act (PREA) investigations and no
investigations with the Department’s Office of the Inspector General (OIG) pending at the time
of the annual compliance review. Nine youth were interviewed and reported they have never
been stopped from reporting abuse to the Florida Abuse Hotline or CCC, if eighteen years or
older, since being at the program. Each youth reported they know the Florida Abuse Hotline
number and where it’s located within the program. Each youth reported staff are respectful
when talking with them. Eight youth reported they have never heard staff use profanity when
speaking to them or other youth and one youth reported they have heard staff once use
profanity when speaking to a youth. Each youth reported they have never exchanged emails,
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 68 (Revised September 2022)
telephone numbers or social media contact information with staff. Nine staff were interviewed,
and each were able to explain the process for allowing staff and youth to call the Florida Abuse
Hotline or CCC to report suspected abuse. Each staff reported they never observed another
staff telling a youth they cannot call the Florida Abuse Hotline or heard a staff using profanity
while speaking with a youth. The program director (PD) was interviewed and reported the
program maintains a zero-tolerance policy regarding abuse, mistreatment, harassment, neglect
or sexual misconduct with youth. Any reports of misconduct involving physical abuse, threats,
profanity, or behaviors which could be interpreted as intimidating or bullying of youth will be
immediately investigated. Staff may be placed on administrative leave pending the outcome of
the investigation. All allegations of sexual misconduct will be reported immediately to the proper
authorities and a full investigation of the accused staff member will begin. All physical abuse,
threats, or profanities toward youth are taken seriously and will lead to disciplinary action, up to
and including termination.
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 maintains a written policy and procedures for abuse reporting, which follows the
Department’s criteria for reporting abuse. The program’s practice is to initiate an internal
investigation regarding the complaint and remove the staff involved from contact with youth,
when necessary. The program had two incident reports alleging physical abuse toward youth
since the last annual compliance review. There was evidence management took immediate
action to address the allegations. The program director (PD) was interviewed and reported
reports received by management or supervisory staff will be reported to the PD immediately.
Staff and youth shall have unhindered access to report alleged abuse. Supervisors shall
complete an internal incident report. All information will be submitted to the PD before the end of
the shift. The PD or director of group living (DGL) shall ensure notifications are made to the
Department’s Central Communications Center (CCC) and the Rite of Passage, Inc director of
Florida operations. The supervisor will ensure the youth is safe and any evidence is secured
until release to proper authorities.
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 maintains a written policy and procedures ensuring response to incidents in
accordance with Florida Administrative Code. The program had seventeen reportable incidents
since the last annual compliance review. A review of five incidents confirmed each was reported
to the Department’s Central Communications Center (CCC) within two hours of the incident or
staff becoming aware of the incident. All incidents were documented in the program’s logbook.
A review of the program’s internal incident reports found there were no additional internal
incidents/grievances which should have been reported to the Department’s CCC. The program
did not experience an increase in the number of reportable incidents to the CCC.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 68 (Revised September 2022)
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 maintains a written policy and procedures ensuring the utilization of physical
intervention techniques in accordance with Florida Administrative Code. The program had thirty-
five Right Interactions (RI) incidents during the annual compliance review period. Reviewed
documentation confirmed monthly summaries were maintained by the program for all RI
incidents submitted to the Department each month. The RI Plan was updated and approved on
December 6, 2024. Reviewed documentation confirmed the program experienced an increase
of five or more in the number of RI incidents since the last annual compliance review. The
program’s response regarding the reason for the increase was because three youth were
involved in twelve RI controlled techniques utilized for the prevention of self-harm. These
restraints were between the months of June through November, until the youth were
subsequently transferred to comprehensive mental health or intensive mental health programs.
Additionally, due to the change from secure to moderate risk, the program had an influx of youth
admissions from June through August, which included up to ten youth a week. This impacted
the culture until stabilized. The program’s RI rate during the first quarter was 1.23, which is
below the statewide Residential RI rate of 1.71. The program director (PD) was interviewed and
reported any potential physical response, including escorts, by staff is reported to supervisors
and entered into a system of recording all things pertaining to program youth such as case
management, demographics, intake, case notes, youth assessments, treatment planning,
medical documentation, incident tracking, and behavior management as an incident involving
particular youth(s) called FAMCare. FAMCare is designed to notify the leadership team of the
incident as soon as it has been entered and saved. The PD and director of group living or
designee conduct an on-site RI video review of the incident to determine if the incident requires
a RI Report or an incident report. Information pertaining to the RI incident is placed on the
communications board in administration for discussion at daily leadership meetings attended by
all departments. All RI incidents are reported on the monthly RI Summary Report which is
utilized for tracking and trends. Nine staff were interviewed and six were able to explain the RI
process and time frames. Three staff reported they did not know the process. A follow-up was
completed with the three staff, and it was reported they were only familiar with Protective Action
Response (PAR). A review of the five RI Reports confirmed all reports were completed by the
end of the staff’s workday and included statements from all staff involved. None of the reviewed
reports documented the use of mechanical restraints. All five reviewed RI Reports did not result
in injury to the youth or staff. Reviewed documentation indicated there were no allegations of
abuse by the youth during the RI incident. The RI Reports were reviewed by a RI-certified
supervisor. None of the reviewed post RI interviews indicated a need for a medical review. The
RI Reports were reviewed and processed within seventy-two hours by all required parties
excluding weekends and holidays.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 68 (Revised September 2022)
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program maintains a written policy and procedures ensuring pre-service training is
completed for all new staff. The pre-service training is provided through a combination of
instructor-led and web-based courses. Nine staff training records were reviewed for pre-service
training. All nine reviewed training records confirmed each staff completed the pre-service
training within 180 days of hire. All nine staff training records confirmed documentation each
staff exceeded the required 120 hours of pre-service training. Required trainings included child
abuse recognition, reporting, and prevention, cardiopulmonary resuscitation (CPR), first-aid,
automated external defibrillator (AED), emergency procedures, Prison Rape Elimination Act
(PREA), professionalism, interpersonal communication, and ethics, including standards of
conduct, and suicide awareness and prevention. Eight of nine staff completed RI trainings. One
staff was a registered nurse (RN) and did not have to be trained in RI; therefore, was not
applicable. In addition, staff completed active shooter preparedness, adolescent development
and behavior, balanced approach to restorative justice, the Department’s Central
Communication Center (CCC) reporting, civil rights, communication, confidentiality/Health
Insurance Portability and Accountability Act (HIPAA), Department of Juvenile Justice Legacy,
Equal Employment Opportunity, gang awareness, human trafficking intervention, infection
control/bloodborne pathogens, information security awareness, the Department’s Juvenile
Justice Information System (JJIS), mental health and substance abuse, Motivational
Interviewing (MI), quality report writing, safety, security, and supervision of youth, sexual
harassment, effective and respectful treatment of youth, and trauma responsive practices.
Reviewed documentation confirmed staff were trained in the grievance process, infection
control, the Exposure Control Plan, the behavior management system, and the intended and
safe use of tools. The nine reviewed records confirmed staff were trained in specialized
services. All completed training was documented in the Department’s Learning Management
System (SkillPro).
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program maintains a written policy and procedures ensuring in-service training for all staff is
completed. Nine staff training records were reviewed for in-service training which included three
supervisors. All nine reviewed staff training records confirmed each staff exceeded the required
twenty-four hours of annual in-service training. All nine staff had current certifications in
cardiopulmonary resuscitation (CPR), first-aid, Prison Rape Elimination Act (PREA), and Right
Interactions (RI). Each staff completed active shooter preparedness, CPR/first-aid, automated
external defibrillator (AED), human trafficking intervention, information security awareness,
mental health and substance abuse, PREA, RI update, professionalism, interpersonal
communication and ethics, sexual harassment, suicide awareness and prevention, and trauma
responsive practices. In addition, staff were trained in emergency response and emergency
drills, infection control, bloodborne pathogens, and the Exposure Control Plan. Reviewed
documentation confirmed applicable staff received specialized trainings in substance abuse
treatment services, comprehensive services for major disorders, developmental disability
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 68 (Revised September 2022)
treatment services, intensive mental health treatment services, juvenile sex offenders, and
specialized mental health services. Three supervisor records were reviewed, and each
supervisor exceeded the eight hours of management and supervisory training which included
coaching, leadership, and personal accountability. All instructors were qualified to deliver all
trainings provided. The program has an annual in-service training calendar which is updated as
changes occur. The program submitted an in-service training plan approved by the
Department’s regional director, the director of operations, the assistant secretary for Residential
Services, and the director of the Department’s Office of Talent, Leadership, and Culture.
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 maintains a written policy and procedures regarding the grievance process. The
program’s policy and procedures are in place to confirm each youth’s right to grieve and ensure
all youth are treated fairly, respectfully, without discrimination, and their rights are protected.
The program’s grievance procedures include informal, formal, and appeal phases. The informal
phase process consists of youth attempting to discuss complaints with staff. If the complaint
can’t be resolved, then youth shall complete and place a grievance in the grievance box, where
it is checked daily. The grievance officer will review the grievance with youth and provide a
response within twenty-four hours not to exceed seventy-two hours. Nine youth were
interviewed and reported they knew how to submit a grievance and knew where forms were
placed throughout the program. Each reported they can ask for assistance in completing a
grievance form. Nine staff were interviewed, and each was able to explain the grievance
process. The program director (PD) was interviewed and reported all youth have the right to
grieve actions of program staff and conditions or circumstances in the program related to a
violation or denial of basic rights. Youth have access to grievance forms and shall be provided
with assistance and instructions in preparing and submitting the grievance as needed. The PD
ensures actions taken to resolve complaints are communicated. Grievances are maintained in a
file for a period of one year from the date of the grievance. Staff shall handle the informal
grievance as expeditiously as possible once received. The formal phase process is conducted if
the grievance alleges a youth is substantially at risk for imminent sexual abuse or danger. The
formal grievance shall be immediately reported to the PD for immediate response. Response for
the grievance must take place within forty-eight hours. Afterwards, the youth will be met with in
person. The appeal process is when the youth has not obtained satisfaction in the response
from the PD or designee. All completed grievances are maintained for a minimum of twelve
months. During the annual compliance review week, the program had five informal grievances
filed. Reviewed documentation confirmed each grievance was resolved in the formal phase.
None of the grievances were applicable for an appeal. Each grievance was responded to within
specified time frames.
1.10 Interventions and Facilitator Training Non-applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
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The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a written policy and procedures for the provision of life and social skills
training to the youth. The program incorporates a positive organizational group three times
weekly as a structured group process, which is intended to provide an intervention for self-
reflection, accountability, and staff/peer feedback, while utilizing cognitive behavioral
approaches. The groups allow youth to identify risky thoughts and replace them with less risky,
pro-social thinking, and life skills ultimately leading to pro-social and acceptable behaviors in the
culture and their home settings. The program integrates life skills into the treatment process
including the facilitation of skill development strategies for youth which are based on cognitive
behavioral approaches. The intervention of skill building helps youth identify the thinking
necessary to reduce risky behaviors or actions. The skills learned in groups are found to be
highly effective when they target the needs indicated in the youth's clinical and case
management plan. This is done through the social learning theory reinforcing youth learning by
the process of either unplanned or planned models. Unplanned models are random behaviors
which a person encounters in their daily lives. Planned models are pre-determined for teaching
purposes. Skill development groups focus on planned models. The program provides life and
social skills activities addressing communication, interpersonal relationships and interactions,
non-violent conflict resolutions, anger management, critical thinking, problem-solving, and
decision-making. The program addresses the needs of the program’s targeted gender groups to
include health, hygiene, the physical environment, life and social skills training, and leisure and
recreational activities provided in a group setting. The program’s services are provided through
the behavior modification and level system. Reviewed Positive Skill Development (PSD) and
Positive Organizational Culture (POC) sign-in sheets and group facilitation guides confirmed life
skills services and activities are provided to the youth. In addition to the life skills intervention
services, the program did incorporate additional life skills for the youth to include health
education, positive skill development, employment skills, advance social skills, alternatives to
aggression, and planning skills. Nine youth were interviewed and reported they participate in life
skills groups/activities while at the program. The program director (PD) was interviewed and
reported the program addresses the needs of the targeted gender group through the
confidentiality of individual therapy sessions. The designated mental health clinician authority
(DMHCA) was interviewed and reported youth are practicing the skills in groups and are
afforded the opportunity to practice these skills in individual sessions, on the living units, during
family sessions, during family days, and when they participate on off-site outings.
1.12 Restorative Justice Awareness for Youth Non-Applicable
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.
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Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at Palm Beach Youth Academy. 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.
The program maintains a written policy and procedures ensuring consistent and effective
notification and communication of youth on alert status for security or safety risks, and health
related concerns. The program has a policy and procedures which determine how new alerts
are identified, documented, updated, and communicated to staff. Staff are informed of alerts
through shift briefings, an alert board, alert logs, and new alerts are documented in shift
logbooks. Alerts are updated as needed upon admissions and discharges. A review of case
management, medical, mental health, and safety alerts was conducted for nine youth records.
Records reflected each youth was placed on the alert system, as specified in the program’s
written procedures. Each applicable alert was initiated by the appropriate staff, documented in
the logbook, and dates of alerts entered in the Department’s Juvenile Justice Information
System (JJIS) all coincided. The program director (PD) was interviewed and reported a medical
alert log is completed with any changes at a minimum of weekly. Daily management meetings
are held to discuss important medical information on the program level. The program maintains
an alert board which is updated as needed by directors and managers. Each department is
responsible for closing any alerts in JJIS which is part of their department responsibilities. Food
service maintains an up-to-date food allergy list which is made available to all staff. The nursing
staff was interviewed and reported all registered nurses (RNs) are responsible for updating the
medical alert system. Nine staff were interviewed and reported they are informed of the youth's
alerts including mental health, medical, and security through the alert board and briefings.
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 Management Record
The program has a written policy and procedures ensuring the management of all records is
consistent across operations and programs, consistent with company philosophy, goals and
objectives, and consistent with legal and contractual requirements. A review of nine youth
healthcare, mental health/substance abuse, and case management records confirmed the
program separated the youth records into two separate records to include an Individual
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Healthcare Record (IHCR) and an individual case management record. Each individual case
management record contained the youth’s name, Department identification number (DJJID),
date of birth, county of residence, and committing offense. Individual case management records
contained sections for legal information, demographics and chronological information,
correspondence, case management, and treatment team activities. Each youth case
management record was labeled “Confidential”. Observations during the annual compliance
review week confirmed all IHCRs, mental health and substance abuse records, and case
management records were secured in a locked room, which was not accessible to youth.
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 community advisory board which meets quarterly, and reviewed meeting
minutes, sign-in sheets, and agendas documented meetings took place in person on March 20,
May 8, August 14, and November 13, 2024. The advisory board member roster consisted of a
law enforcement representative, judiciary community, interested community partners, business
community, school board representative, faith community, and the LGBTQIA+ community. The
advisory board includes a victim advocate and a parent/guardian whose child was previously
involved in the juvenile justice system. Reviewed sign-in sheets, agendas, and minutes
confirmed quarterly advisory board meetings were held. The program director (PD) was
interviewed and reported the community advisory committee meets quarterly at the program.
During the annual compliance review week, a telephone call made to a board member
confirmed program involvement, quarterly meetings, and membership.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program maintains a written policy and procedures ensuring requirements for evaluating
staff performance annually and upon completion of the first ninety-days of hire. The program
maintains a detailed position description for all staff and a written agreement outlining duties for
all contracted staff. A review of three position descriptions confirmed each staff’s performance
standards were clearly identified. A sample of performance evaluations were reviewed to ensure
evaluations were completed as outlined in the program’s policy at least annually, and it was
confirmed evaluations were completed as required. A review of nine staff records confirmed
performance standards matched the job descriptions for each staff. For staff whose job
functions included implementation of the program’s behavior management system (BMS), the
BMS was included in the job descriptions. The program’s contract was reviewed to ensure all
specific contractually required positions were maintained and performed, as outlined in the
contract. The program director (PD) was interviewed and reported a morale committee was put
in place to minimize the turnover rate and improve morale. Increased staff events, celebrations
to recognize staff, and annual holiday parties were put in place. The PD reported the
performance evaluation process for staff is ninety-day evaluations for the probationary period,
which is conducted by the staff’s direct supervisor. Annual evaluations are conducted with a
merit review, and ninety-day reviews are conducted for position changes/promotions. Nine staff
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were interviewed regarding performance evaluations. Four staff reported they received their
formal evaluation every ninety days, one staff reported annually, one staff reported they haven't
received one yet, and one staff was not sure.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program implements special contract conditions as outlined in the program’s contract. The
program’s contract had a Memorandum of Negotiation (MON) during the procurement process.
The special contract condition included a faith-based ministry, a military volunteer, and the
Sheriff’s office mentoring program. These volunteers/officers/mentors provide guidance and
support. A review of documentation supported the special contract conditions were met.
1.19 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 maintains a written policy and procedures for reviewing and analyzing data trends
to utilize in decision-making practices. The program shares data trends among administrators
and with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement. Monthly Key Performance Indicator (KPI) tracking, monthly
review of program site operations summary (SOS) reports, and data is posted and accessible
by staff, educators, and stakeholders. Documentation confirmed data is reviewed in the monthly
staff meeting with all staff.
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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 ensuring initial contacts to
parents/guardians and court notifications are completed. A review of five youth case
management records confirmed the program notified the parent/guardian by telephone within
twenty-four hours of admission. The other two youth were eighteen years of age or older;
therefore, parent/guardian notification was not needed. Each of the seven applicable reviewed
records confirmed the program notified the parent/guardian in writing within forty-eight hours of
the youth’s admission. Each record confirmed the court, juvenile probation officer (JPO), and
applicable post residential counselor were notified within five working days of the youth’s
admission.
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 regarding youth orientation. The
program’s orientation included services available, daily schedule, expectations, and
responsibilities of the youth. The written behavior management system (BMS) was posted
throughout the program and provided in a handbook to allow easy access for youth. The
orientation included rules governing conduct and positive and negative consequences for
behavior, availability of and access to medical and mental health and substance abuse services,
and access to the Florida Abuse Hotline or if the youth is eighteen years of age or older, the
Department’s Central Communications Center (CCC). Youth orientation included the program’s
zero-tolerance policy regarding sexual misconduct, including how to report incidents or
suspicions of sexual misconduct. Special accommodations are available to ensure all written
information about sexual misconduct policies, including how to report sexual misconduct, is
conveyed verbally to youth with limited reading skills or who are visually impaired, deaf, or
otherwise disabled. Additionally, orientation included the right to be free from sexual misconduct,
right to be free from retaliation for reporting such misconduct, the agency’s sexual misconduct
response policies and procedures, items considered contraband, including illegal prohibited
items in which possession may result in the youth being prosecuted, the performance planning
process involving the development of goals for each youth to achieve, dress code, and hygiene
practices. Furthermore, orientation services include procedures on visitation, mail and use of the
telephone, expectations for release from the program, including the youth’s successful
completion of their Individualized Performance Plan (IPP) goals, recommendation to the court
for release based on the youth’s performance in the program, and the court’s decision to
release, community access, grievance procedures, emergency procedures, including
procedures for fire drills and building evacuation, program tour, assignment to a living unit and
room, treatment team, and if applicable, a staff advisor or youth group. During the annual
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compliance review week, the program did not have any youth admitted into the program;
therefore, there were no youth observations of the program’s orientation process conducted.
Nine youth were interviewed and reported their orientation to the program included program
rules, procedures, and schedules. Each youth explained the orientation process and reported
the orientation to the program was conducted within twenty-four hours of admission.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program maintains a written policy and procedures regarding obtaining written consent of
youth who are eighteen years of age or older. Three reviewed youth case management records
confirmed each of the youth were applicable. Each reviewed youth case management record
confirmed a written consent was obtained before release of information related to the youth’s
physical or mental health screenings, assessments, or treatments.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program maintains a written policy and procedures regarding the classification process for
youth upon admission to the program and completion of reassessments as warranted. A review
of the program’s classification form revealed the form included physical characteristics of the
youth, age and maturity level, identified special needs, history of violence, gang affiliation,
criminal behavior, sexual aggression or vulnerability to victimization, youth’s perception of
vulnerability, youth’s history of potential or verified human trafficking, suicide risk, medical risk,
escape risk, and security risk. Nine reviewed youth case management records confirmed each
record contained an admission classification form including all required elements outlined by the
Department’s policy. A review of the Department’s Juvenile Justice Information System (JJIS)
alerts and the program’s internal alerts showed there were no issues affecting each youth’s
classification. Each youth was classified for the purposes of assignment to a living area,
sleeping room, and youth group or staff advisor. Each reviewed record confirmed medical,
mental health, substance abuse, security risk factors, and/or special needs identified during or
subsequent to the classification process are immediately entered into the program’s internal
alert system and JJIS.
Nine reviewed youth case management records revealed each had reclassifications completed
prior to considering an increase in the youth’s privileges or freedom of movement, participation
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in work projects, or other activities involving tools or instruments which may be used as potential
weapons or means of escape, and three of the nine youth were able to participate in off-campus
activities. The program’s policy and procedures clearly outlined the classification process and
included a classification system to promote safety and security, as well as effective delivery of
treatment services, based on the determination of each youth’s individual needs and risk
factors, which addresses, at a minimum, items outlined in Florida Administrative Code. The
program’s policy regarding reassessments entails prior to allowing a youth to participate in any
off-campus activity which is not a supervised necessary event, such as a medical appointment
or court, the treatment team shall ensure demonstration of youth progress within the program,
positive behavior, and completion of an assessment of youth risk to determine if the youth is
unlikely to re-offend when in the community. Eligibility and requests for temporary release
activities/home passes must be determined through the treatment team meeting process and
must be approved by the court through submission and return of a home visit plan approval.
Additionally, for all temporary releases/home passes, the treatment team shall initiate planning
at least fourteen days prior to the anticipated home pass date and shall establish goals and
objectives related to the youth's performance plan, community reintegration, and for appropriate
supervision while on the home pass. The case manager and youth shall complete the Home
Visit Plan Notification form prior to any temporary release. An interview with the program
director (PD) reported the youth undergo an assessment of the Massachusetts Youth Screening
Instrument, Second Version (MAYSI-2), the Vulnerability to Victimization and Sexually
Aggressive Behavior (VSAB) screening, an Assessment of Suicide Risk (ASR), and an inclusive
review of the youth record during classification meetings.
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 regarding gang identification including
notification to law enforcement. An interview with the case manager indicated the program’s
protocol includes notification by the program, detention staff, or the youth’s juvenile probation
officer (JPO) of the youth’s gang involvement. The youth’s home county law enforcement
program will be notified of the youth’s gang affiliation. Additionally, gang alerts will be entered in
the internal alert system and in the Department’s Juvenile Justice Information System (JJIS)
upon identification. The gang status will be shared with the educational provider at the
residential program and the youth’s assigned JPO. The program had only one youth identified
as gang affiliated since the last annual compliance review. The youth was admitted during the
annual compliance review week and the protocols were in process.
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 regarding youth’s participation in gang
prevention and/or intervention activities. The program’s policy addresses providing youth an
opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang. At the time
of the annual compliance review the program had one youth having gang involvement; however,
the youth arrived at the program during the annual compliance review week and had not yet
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participated in services. The program utilizes prevention and intervention activities for youth
identified with gang affiliations and provide youth with assistance and guidance to formulate a
plan to disassociate themselves from their gang affiliation. These intervention strategies consist
of Impact of Crime (IOC) and Gang Resistance and Drug Education (GRADE) curricula for all
gang affiliated youth. An interview with the program director (PD) confirmed the program
provides each youth with resources to disaffiliate from a criminal street gang and assists in
developing a plan to disaffiliate 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 requiring the Residential Assessment
for Youth (RAY) to be completed for each youth within thirty days of admission. Nine reviewed
youth case management records showed each youth case record contained a RAY completed
within thirty days of admission. Each record contained an initial RAY, which was documented in
the Department’s Juvenile Justice Information System (JJIS). Two of nine reviewed records
showed RAY Reassessments were completed at least every ninety-days after the completion of
the initial RAY. Seven of the nine were not applicable. All other updates or reassessments were
completed when deemed necessary by the intervention and treatment team to effectively
manage the youth’s case. All reassessment documentation was maintained in the youth’s official
case record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program maintains a written policy and procedures regarding the completion of the Youth
Needs Assessment Summary (YNAS). Nine reviewed youth case management records
revealed the YNAS was completed within thirty days of admission. Each YNAS was
documented in the Department’s Juvenile Justice Information System (JJIS). Each youth case
record confirmed the YNAS documented the youth’s top three criminogenic needs.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
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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. Nine reviewed youth case management records confirmed
each youth’s Individualized Performance Plan (IPP) was developed within thirty days of the
youth’s admission. Each IPP was developed after the initial Residential Assessment for Youth
(RAY) and Youth Needs Assessment Summary (YNAS) were completed. Each reviewed IPP
was developed and signed by the treatment team leader, youth, administrative representatives,
living unit representatives, treatment staff, educational staff, and all parties who had significant
responsibility in goal completion. One of the nine youth had Department of Children and
Families (DCF) services; therefore, DCF was involved. Two youth were eighteen years of age or
older; therefore, the parent/guardian participation was not applicable. Signature sheets were
reviewed and confirmed the parent/guardian signature sheet was returned to the program for
seven of the reviewed records. The sheet was attached to the youth’s original performance plan
and was filed in the official case record. Documentation showed nine completed IPPs included
the individualized goals based upon the prioritized needs reflecting the risk and protective
factors identified during the initial assessment process. Each plan included the youth’s top three
criminogenic needs and delinquency interventions were listed. Target court-ordered sanctions
which could be reasonably initiated/completed while in the program, transition activities targeted
for the last sixty days of the youth’s anticipated stay, youth’s responsibilities to accomplish
goals, program staff responsibilities to enable youth to complete goals, and target dates for goal
completions were all listed on the IPP. Reviewed documentation confirmed within ten working
days of completing the IPP, a transmittal letter and copy of the IPP were sent to the committing
court, juvenile probation officer (JPO), and parent/guardian. An interview with nine youth
indicated they actively participated in their IPP development. The youth reported their
parents/guardians were called to give feedback, as well as the parents/guardians receiving a
copy of the 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.
The program maintains a written policy and procedures in place regarding revisions to a youth’s
performance plan. Nine reviewed youth case management records confirmed each was
applicable for Individualized Performance Plan (IPP) revisions. Each IPP revision was
completed when the Residential Assessment for Youth (RAY) Reassessment results warranted,
and/or when the youth demonstrated progress toward completing a goal. None of the records
were applicable for the youth demonstrating lack of progress toward completing a goal requiring
revisions. Each of the nine reviewed IPPs had revisions made when needed to facilitate
transition activities during the last sixty days of a youth’s stay. Each youth was applicable for
education and mental health plans which were incorporated into the IPP. One of the nine youth
showed a current behavior support plan or case plan through the Department of Children and
Families (DCF).
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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 transmittals. A review of nine youth case management records showed
Individualized Performance Plans (IPP) were completed with documented completion dates.
Each of the Performance Summaries were completed every ninety calendar days following the
signing of the IPP, or at shorter intervals if requested by the court. The summaries documented
the date of the summary, the youth’s status on each performance plan goal, the youth’s overall
treatment progress, the youth’s academic status, grades in progress and credits earned in the
program if the youth is a high school student, including performance and behavior in school, the
youth’s behavior, level of motivation/readiness to change, interaction with peers, interaction with
staff, overall behavior adjustment to the program, and significant positive and negative events. A
review of documentation regarding Performance Summaries reflected each youth was allowed
to read and add comments prior to signing, each youth was provided a copy of the summary,
and the original summary was filed in the youth’s case management record. The Performance
Summary was signed and dated by the treatment team leader, staff preparing the summary,
program director or designee, and youth. Documentation confirmed a copy of the summary was
sent within ten working days to the committing court, the youth’s juvenile probation officer (JPO),
parents/guardians, and Department of Children and Families, if applicable. A review of three
closed case management records confirmed the release summary included the original
summary, along with justification for release, and was sent with the Pre-Release Notification
(PRN) to the JPO. None of the three reviewed case management records were direct
discharges. None of the youth were at the program for less than forty-five days and the release
summary and PRNs were sent at least forty-five days prior to the youth’s release with the date
noted. A signed copy was retained in each youth’s case management record. Documentation
confirmed once approved, the program provided written notification to the youth’s
parent/guardian regarding the planned release, and the program completed a Residential
Assessment for Youth (RAY) exit assessment. None of the three reviewed youth closed case
management records were applicable for the sexually violent predator program (SVPP) or
notification to a victim.
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 regarding parental/guardian
involvement in case management services. A review of documentation showed the program
makes efforts to include the parent/guardian in the assessment process, development of the
youth’s performance plan, progress reviews, and transition planning. If unable to attend, the
parent/guardian was given the opportunity to participate by telephone/video conferencing or
provide verbal/written input prior to the meetings. During the week of the annual compliance
review, an observation of a treatment team meeting was conducted and showed the program’s
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practice to have the parent/guardian participate by telephone. During the intake process,
families are mailed the treatment team and visitation schedules for the year and the invite is
mailed to the families thirty days in advance for family days, holiday celebrations, graduations,
or any other specialized activities. The interviewed program director (PD) reported the program
encourages parental/guardian involvement in monthly treatment team meetings, monthly family
sessions, quarterly family day, and communication as needed. An interview with nine youth
confirmed each youth stated they attend a treatment team meeting monthly and their
parents/guardians are called to participate.
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 regarding treatment team meetings.
Nine reviewed youth case management records showed formal treatment team meetings were
held every thirty days for each youth and informal meetings were held bi-weekly, as required.
A review of documentation for each of the formal treatment team review meetings confirmed
they included the youth’s name, date of review, required attendees, any comments from
treatment team members or any other team members, a brief synopsis of the youth’s progress
in the program, performance plan revisions, progress on performance plan goals, positive and
negative behaviors, behaviors resulting in physical interventions, and treatment progress. A
review of documentation confirmed two of the nine youth’s formal treatment review meetings
included the Residential Assessment for Youth (RAY) Reassessment results, the other seven
youth records were not applicable. Reviewed documentation for each of the informal treatment
team meetings confirmed reviews were held bi-weekly each month. Bi-weekly informal meetings
were alternating formal treatment team meetings. Reviewed documentation for each of the
informal treatment team meetings included the youth’s name, date of review, required
attendees, any comments from treatment team members or others, brief synopsis of the youth’s
progress in the program, performance plan revisions, progress on performance plan goals,
positive and negative behaviors, behaviors resulting in physical interventions, and treatment
progress. Two of the nine reviewed case management records were applicable for RAY
Reassessment results, and the other seven were not applicable. All informal treatment team
meeting documentation was contained in each youth’s record. Each youth’s assigned juvenile
probation officer (JPO), parent/guardian, and other pertinent parties were invited and
encouraged through advance notification to participate and if participation could not be
arranged, the opportunity to provide input was provided. During the week of the annual
compliance review, an observation was conducted of a treatment team meeting which revealed
all required staff were present. An interview with nine youth indicated staff talk about the youth’s
performance to include progress on performance plan goals, positive and negative behavior,
and treatment progress.
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,
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as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program maintains a written policy and procedures regarding the transition planning
conference, and Community Re-Entry Team (CRT) meetings. A review of three closed youth
case management records confirmed a transition conference was held at least sixty days, prior
to the youth’s targeted release date. A review of documentation showed the youth, treatment
team leader, program director (PD) or designee, and other team members attended the
transition conference. Documentation confirmed the treatment team leader invited and
encouraged participation of the youth’s juvenile probation officer (JPO), parent/guardian,
education staff, and any other pertinent parties through advance notification. A review of
documentation confirmed during the transition conference, the participants reviewed transition
activities on the youth’s performance plan, revised performance plans, if necessary, identified
additional transition activities as needed, identified target completion dates, and identified
persons responsible for completion. The treatment team lead obtained attendees’ dated
signatures representing their acknowledgment of the transition goals, and accountability for
completion. A copy of the plan was sent with a request for return with signature to anyone not in
attendance who had a responsibility for completion of transition goals. If the plan was
transmitted electronically to the JPO, the return email acknowledgment receipt was printed and
filed with the plan. Documentation revealed a Community Re-Entry Team (CRT) meeting was
conducted prior to the youth’s release with youth’s and case manager’s participation and
evidence of an invitation to participate in the CRT meeting was shown.
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 requirements for each
youth’s exit portfolio. A review of three closed youth case management records revealed the exit
portfolio was discussed and initiated for the youth during the transition conference. Each youth’s
exit portfolio was discussed during the exit conference and documentation indicated the exit
portfolio was completed and given to the youth upon release. One of the three closed case
management records did not contain a state-issued identification card. An interview with the
case manager and reviewed documentation showed the program continuously asked the
parent/guardian of the youth for a copy; however, the program was not successful in obtaining
the card. Each of the three closed youth case management records showed documentation of
the youth’s Social Security card, birth certificate, educational and/or vocational certificates
earned in the program, all educational records/documents, school transcripts, résumé, and
sample employment application. Each of the three youth’s exit portfolios were verified during the
exit conference and reviewed documentation indicated the exit portfolio was completed and
given to the youth upon release. Reviewed documentation showed the program’s case
management staff forwarded the exit portfolio information to the youth’s juvenile probation
officer (JPO). The program’s contract does not include any additional requirements for the exit
portfolio.
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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 regarding completion of an exit
conference. A review of three closed youth case management records revealed an exit
conference was conducted after the program notified the juvenile probation officer (JPO) of the
release. Each conference was conducted at least fourteen days prior to release. Reviewed
documentation indicated the date of the conference, signatures, and a summary of pending
transition goals were documented. Reviewed documentation confirmed the youth’s date of
admission and date of termination correlated with the Department’s Juvenile Justice Information
System (JJIS). The status of transition activities established at the transition conference and
plans were finalized for the youth’s release. Reviewed documentation confirmed provisions for
continuation of education and/or employment. Documentation showed the youth, the youth’s
parent/guardian, case manager, and JPO were aware of the vocational plan for the youth,
documents, and post-release discharge plans. A review of documentation showed the
intervention and treatment team leader, parent/guardian, education representative, JPO, youth,
and other pertinent parties all participated in the exit conference. Reviewed documentation
indicated the exit conference was held separately from the transition conference and the
Community Re-Entry Team (CRT) meeting.
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 regarding written provisions for youth
input. The program’s formal process to promote constructive input from youth is conducted
through youth surveys, community meetings, informal and formal treatment team, one to one's,
and Request to Speak and grievance forms, if necessary. A review of the program’s efforts to
solicit input from youth through avenues such as youth advisory board minutes, program
surveys, and suggestion forms, were available in the youth advisory council board binder. The
advisory board meetings are held at least every ninety to 120 days. A review of the program’s
sign-in sheets, agendas, and meeting minutes confirmed the meetings are being held as
required. An interview with nine youth indicated they can voice their input on their progress
and/or concerns as needed. The youth will speak with a supervisor or inform a staff of an idea or
concern. An interview with the program director (PD) reported the program solicits input from
youth by providing each youth with a Request to Speak form and formally addresses any issues
or concerns with their case manager and therapist.
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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 maintains a written policy and procedures requiring a designated mental health
clinician authority (DMHCA). The program has a clinical director who serves as the program’s
DMHCA. The program’s DMHCA works full-time and is on-site at least forty hours each week as
required by the program’s contract to ensure appropriate coordination and implementation of
mental health and substance abuse services in the program. As a part of their assigned
responsibilities, the DMHCA ensures consistent and appropriate services in addition to being
on-call twenty-four hours a day, seven days each week for emergency consultation. The
program’s DMHCA is a licensed mental health counselor. The reviewed license reflected it was
free and clear in the State of Florida with an expiration date of March 31, 2025. The program’s
back-up DMHCA is the regional clinical director who has a free and clear license in the State of
Florida with an expiration date of March 31, 2027. The DMHCA indicated their role in
coordination and implementation of mental health and substance abuse includes ensuring each
youth is assessed and participates in services which align with outcomes of assessments
rendered, and clinical supervision of non-licensed mental health therapists. Additionally, they
facilitate individual, family, and group therapy services.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program’s
designated mental health clinician authority (DMHCA) serves as the program’s supervisor for all
on-site clinical staff. The program’s clinical staffing based on the contract requires one DMHCA,
one recreation therapist, two licensed therapists, and three non-licensed mental health
clinicians. The program had one position for a licensed therapist which has been vacant since
December 20, 2024.The program had one licensed staff vacancy; however, the second licensed
staff had a clear and active license with an expiration date of March 31, 2025. Additionally, the
program’s regional clinical director is a licensed clinical social worker. The regional clinical
director’s license was free and clear in the State of Florida with an expiration date of March 31,
2027. The regional clinical director provides support and supervisory services to the DMHCA
and clinical staff. The program is licensed under Chapter 397 by the Department of Children and
Families (DCF) to provide substance abuse services to adolescents. The Chapter 397 license
expires March 22, 2025.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and procedures regarding non-licensed clinical staff.
The designated mental health clinician authority (DMHCA) confirmed their responsibility for
ensuring non-licensed clinical staff are working under their supervision and performing services
they are qualified for based on education, training, and experience. The program’s practice is to
complete group and/or individual clinical supervision for non-licensed clinicians and the
recreation therapist. A review of clinical supervision logs since the last annual compliance
review was conducted. The clinical supervision was documented on the program’s form and
included all elements of the Department’s Direct Supervision Log form. Reviewed
documentation confirmed each non-licensed clinical staff received clinical supervision for each
week they provided services. The program is licensed under Chapter 397 through the
Department of Children and Families (DCF) to provide substance abuse services to
adolescents. The license was displayed in the lobby with the program’s physical address listed.
The reviewed license expires on March 22, 2025. The program’s contract requires a recreation
therapist. Education documentation for each clinician supported requirements were in
accordance with the contractual requirements. One licensed therapist position has been vacant
since December 20, 2024. The program had five non-licensed mental health clinicians providing
therapeutic services during the annual compliance review period. Three non-licensed staff’s
education documentation reflected each held a master’s-level degree from an accredited
university or college in the field of counseling, social work, psychology, or a related human
services field. Two non-licensed staff’s education documentation reflected both held a
bachelor’s-level degree from an accredited university or college in the field of counseling, social
work, psychology, or related human services field. Each bachelor’s-level degree staff had fifty-
two hours of pre-service training prior to working with youth, to include sixteen hours of training
in their duties and responsibilities. Each of the five non-licensed clinical staff received training in
the administration of the Assessment of Suicide Risk.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program maintains a written policy and procedures for mental health and substance abuse
services which address a standardized intake and mental health and substance abuse
screening process. This process includes a review of commitment packet information, reports
and records, and administering the Massachusetts Youth Screening Instrument, Second
Version (MAYSI-2) in the Department’s Juvenile Justice Information System (JJIS). A review of
nine mental health and substance abuse records indicated the program completed a MAYSI-2
on the day of admission. The program documented the review of information to include the
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commitment packet, reports, and records for existing documentation of mental health or
substance abuse problems or history of human trafficking. Each reviewed MAYSI-2 was
completed in full in JJIS and included the date of completion and name of staff who completed
the screening. Screenings were completed by trained staff. Four of the nine reviewed MAYSI-2s
indicated further assessment was required; however, it is the program’s practice to refer all
youth for further evaluation regardless of screening results. None of the reviewed youth records
were applicable for emergency procedures or the youth being in crisis. No reviewed youth
records were applicable for suicidal ideation. The reviewed screening policy and procedures
indicated the program director (PD) is responsible for the implementation of a standardized
admission and intake mental health and substance abuse screening process. The policy
addresses the review of available information, administration of the MAYSI-2, staff training in
administration of the MAYSI-2, and a process for youth in crisis requiring immediate attention.
The interviewed PD reported a MAYSI-2, Assessment of Suicide Risk, Clinical Health and
Substance Abuse screening form, and the Substance Abuse Subtle Screening Inventory
(SASSI) is completed upon intake to identify suicidal risk factors.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a written policy and procedures to establish an assessment and
evaluation process to guide the development of each youth’s individualized treatment plan. The
program ensures the mental health and substance abuse needs of the youth are identified
through a comprehensive mental health and substance abuse evaluation process. Each youth
receives an in-depth assessment within the first thirty days of residential placement. All
assessments are to be completed by a licensed mental health professional or mental health
clinical staff working under the direct supervision of the licensed mental health professional.
Each of the nine reviewed records indicated a new combined mental health and substance
abuse evaluation was completed for the youth. Each of the nine evaluations were completed
within thirty days of admission and each youth consented to substance abuse services prior to
the evaluation. Each reviewed assessment was completed and signed by a licensed staff within
ten days. Each evaluation included the date of referral/admission, date of the evaluation,
identifying information, the reason for the evaluation, relevant background information,
behavioral observations, a Mental Status Examination, procedures administered, discussion of
findings, diagnostic impressions, patterns of alcohol and/or drug abuse, impact of use on major
life areas, risk factors for continued use, and recommendations. None of the reviewed mental
health and substance abuse records had an updated evaluation.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
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The program maintains a written policy and procedures outlining the program’s mental health
and substance abuse treatment services. A review of nine youth records indicated each
contained an initial mental health and substance abuse treatment plan within seven days of
admission. Each initial treatment plan was documented on the program’s form which included
all elements of the Department’s Initial Mental Health and Substance Abuse Treatment Plan
form. Three of the youth were applicable for psychotropic medications and the plan included the
medication details. Each of the nine initial plans were completed by the mental health clinical
staff. Five of the nine initial treatment plans were completed by a non-licensed mental health
clinical staff and were signed by the designated mental health clinician authority (DMHCA),
within ten days of completion. The remaining four initial plans were completed and signed by the
DMHCA. Each plan was signed by the youth, parent/guardian, juvenile probation officer (JPO),
treatment team leader, program administration, and a living unit staff. Each plan documented
the participation of the JPO and parent/guardian by telephone. Each of the nine records were
applicable for an individualized treatment plan to be completed within thirty days and treatment
plan reviews to be completed at thirty-day intervals. Three of the individualized treatment plans
were for youth prescribed psychotropic medications and the plans included the medication
monitoring schedule. Each of the nine reviewed records documented thirty-nine treatment plan
reviews. Each review was completed at least every thirty days as required. Individualized
treatment plans and reviews documented signatures of the youth, parent/guardian, JPO,
treatment team leader, program administration, living unit staff, and education staff. Each plan
was signed by the DMHCA on the day of completion. Each applicable youth’s treatment plan
documented prescribed services, goals, and objectives which were individualized for each
youth. The plans included individual counseling, group counseling, family counseling, and
applicable psychotherapy. A comparison of video to the logbooks and sign-in sheets for groups
indicated they were occurring as scheduled and as documented.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program has a written policy and procedures addressing treatment and discharge planning.
A review of nine youth records indicated each youth was assigned to a treatment team upon
arrival to the program. Reviewed treatment team documentation and treatment team
assignment forms for each reviewed record confirmed the treatment team members were
comprised of the youth, program administration, residential living unit, education, medical staff,
mental health and substance abuse staff, and parents/guardians. Each youth with mental health
and substance abuse treatment goals received treatment by a qualified professional. The
program is licensed under Chapter 397 to provide substance abuse services to adolescents.
Each youth record contained the Department’s Authority for Evaluation and Treatment
(AET)form and a signed Youth Consent for Substance Abuse Treatment. Reviewed progress
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notes were documented on the program’s form and contained all elements of the Department’s
Counseling/Therapy Progress Notes form. Reviewed progress notes verified treatment included
individual psychotherapy and psychosocial skills. Each record verified services were provided
as stipulated in the youth’s treatment plan. A review of three youth records was completed for
discharge plans. Each youth of the three reviewed discharge summaries were documented on
the Department’s Mental Health and Substance Abuse Treatment Discharge Summary form.
None of the closed records were applicable for the youth being released while on suicide
alert/precautions. Each of the three reviewed summaries documented the future services
needed. Reviewed documentation supported the plans were discussed during the exit
conference with the youth, parent/guardian, and assigned juvenile probation officer (JPO). Each
record documented the youth and parent/guardian signed the plan and the plan was sent to the
assigned JPO.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program maintains a written policy and procedures to establish a delivery protocol for
Substance Abuse Treatment Overlay Services (SAOS) and Mental Health Overlay Services
(MHOS) programming. Substance abuse and mental health treatment is provided on-site
through the provisions of SAOS and MHOS. Required clinical treatment groups include life skills
training, Coping with Stress, Living in Balance (LIB), Adolescent Coping with Depression, and
Skillstreaming the Adolescent. Nine interviewed youth stated they participate in family and
individual counseling at the program. Nine interviewed staff indicated direct care staff do not
facilitate any mental health or substance abuse groups. An interview with the designated mental
health clinician authority (DMHCA) indicated the program provides individualized treatment
through evidence-based curriculum and individual, family, and group therapy services. The
interviewed program director (PD) confirmed the required clinical groups at the program.
Documentation confirmed the DMHCA was on-site for forty-hours each week and licensed staff
were on-site at least five days each week. The required counselor to youth ratio is not to exceed
one counselor to sixteen youth. A review of caseload assignments indicated they were between
ten and fifteen youth. The program was providing individual therapy once every two weeks,
family therapy at least monthly, applicable psychiatric services every two weeks, and mental
health/substance abuse groups four times each week as required. This was verified by the
programs group schedule. The program has an independent contract with a licensed
psychiatrist who provides services as needed.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program maintains a written policy and procedures for the provision of psychiatric services
within the program. The program’s contracted psychiatrist is responsible for psychiatric
evaluations, consultation, medication management, and medical supportive counseling. A
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review of the psychiatrist’s license indicated they held a medical doctor license which was free
and clear in the State of Florida with an expiration date of January 31, 2026. The psychiatrist is
available for emergency consultation twenty-four hours a day, seven days a week. The
psychiatrist provided psychiatric services briefly as a representative of treatment team and
psychiatric recommendations for youth are incorporated into evaluations and planning at the
program. The program did not utilize a back-up psychiatrist during the annual compliance
review period. The program does not use a psychiatric advanced practice registered nurse. A
review of the psychiatric sign-in logs verified the psychiatrist was on-site weekly. Reviewed
documentation indicated the psychiatrist actively participated in, managed, and supervised
psychotropic medication services in the program. The program does not utilize tele-psychiatry
services. The psychiatrist reported they are providing the Initial Diagnostic Psychiatric Interview
for new admissions and follow-ups for medication management and referrals as needed. The
interviewed psychiatrist reported they are on-site weekly and on call twenty-four hours daily as
needed. The psychiatrist reported they have no concerns with services provided at the program.
During an informal interview the designated mental health clinician authority (DMHCA) reported
they meet with the psychiatrist to discuss youth receiving psychiatric services weekly when they
are on-site. A review of nine records indicated one was applicable for psychiatric services;
therefore, an additional two records were requested and reviewed. Each of the three applicable
youth entered the program with prescribed psychotropic medications. Each youth was referred
for a psychiatric interview, and each of the three applicable youth received a diagnostic
interview within fourteen days of admission. Each of the three applicable youth’s reviewed Initial
Diagnostic Psychiatric Interviews included history, a Mental Status Examination, a Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, treatment
recommendations, prescribed medications, explanation for the need of medications, target
symptoms, initial treatment goals, potential side effects, and frequency of medication
management. Each youth was referred for a psychiatric interview upon admission. Each
interview was documented on the Department’s Clinical Psychotropic Progress Note (CPPN)
form and included page three when medication was prescribed and/or continued. The three
youth were applicable for twenty-two psychiatric medication reviews to be completed at least
every thirty days. All were completed as required. None of the reviewed records were applicable
for a psychiatric evaluation update. Each instance where page three of the CPPN was used, the
psychiatrist documented the identifying data, diagnosis, target symptoms of each medication,
effects of the medication, medication dosage, dosage range, frequency, route of administration,
side effects, adherence to the medication regime, and whether there was telephone contact with
the youth’s parent/guardian. Each was signed and dated by the psychiatrist. Three youth
records documented monitoring for Tardive Dyskinesia monthly as indicated on the CPPN.
None of the reviewed records were applicable for the use of 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 policy and procedures regarding the implementation of a Suicide Prevention
Plan. The plan shall provide guidelines for the identification, management, and assessment of
potentially suicidal youth. The program maintains a Suicide Prevention Plan which was last
signed and reviewed by the program director (PD), and director of operations on January 10,
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2025. A review of the plan reflected it included identification and assessment, staff training,
suicide precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, and a review process. The review process for suicide attempts and
mortality review included circumstances surrounding the event, procedures relevant to the
incident, all relevant training received by involved staff, pertinent medical and mental health
services involving the victim, possible precipitating factors, and recommendations.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
The program maintains a written Suicide Prevention Plan which serves as the program’s suicide
prevention procedures. The Suicide Prevention Plan addresses the program’s suicide
prevention services, suicide precautions and observation logs, as well as suicide prevention
training. A review of nine youth records indicated each was applicable for an Assessment of
Suicide Risk (ASR) to be completed upon admission as part of the program’s standardized
practice. The program reported they had one youth who was identified as being actively suicidal
and requiring interventions during the annual compliance review period. A review of the nine
ASRs completed as part of the admission process indicated each was completed in full and
each youth was transitioned to standard supervision after a conference was documented with
the designated mental health clinician authority (DMHCA) and the program director (PD). All
were completed by licensed staff. One youth requiring suicide interventions was referred for an
ASR after admission screenings. The ASR was completed and signed within twenty-four hours
by a licensed staff. The ASR documented a conference between the assessor, which was the
DMHCA, and the PD regarding the decision to continue the youth on precautionary observation.
A Follow-Up ASR was needed and completed for the youth prior to the removal of the youth
from precautionary observation. The Follow-Up ASR was documented on the Department’s
Follow-Up Assessment of Suicide Risk form. The youth was maintained on suicide precautions
and 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. Close supervision was maintained until it was determined no
longer necessary by the DMHCA for the youth. Reviewed documentation indicated a conference
was held by the PD and licensed DMHCA to reduce the youth’s level of supervision.
Discontinuation of close supervision was documented in accordance with the program’s Suicide
Prevention Plan and included the date and time the youth was stepped down. The Department’s
Juvenile Justice Information System (JJIS) suicide alerts were initiated for the youth placed on
suicide precautions, and accurately closed following the recommendations of the Follow-Up
ASRs. There was evidence in the program’s logbook indicating administration or supervisory
staff provided instructions related to the suicide risk assessment findings and suicide precaution
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decisions. There were no video observations to verify precautionary observations during the
annual compliance review due to program only storing thirty days of video footage.
3.12 Secure Observation (Critical) Non-applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a written policy and procedures requiring staff to always maintain at
least constant supervision of the youth on precautionary observation (PO) and document their
observations of the youth on the Suicide Precautions Observation Log in intervals which do not
exceed thirty minutes. A review of nine youth records indicated none were applicable for being
placed on PO. The program had one youth applicable for placement on suicide precautions
during the annual compliance review period. The Suicide Precautions Observation Logs were
maintained for the duration the youth was under suicide precautions. The appropriate level of
supervision and observations of the youth’s behavior was documented in real time and not
exceeding thirty-minute intervals. For the reviewed youth record warning signs were observed,
and notification to the program director (PD) and mental health clinical staff was documented on
the Suicide Precautions Observation Log. The Suicide Precautions Observation Log was
reviewed and signed by the shift supervisor and mental health clinical staff. The Suicide
Precautions Observation Log documented safe housing requirements.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a written Suicide Prevention Plan which details suicide prevention
training requirements. The program’s Suicide Prevention Plan requires six hours of annual
training which includes suicide training in the Department’s Learning Management System
(SkillPro). A review of nine pre-service and nine in-service training records documented
program staff completed the required six hours of suicide training. The program is required to
complete one mock suicide drill for each shift at least quarterly. A review of suicide drills showed
the program conducted the necessary drills on each shift, as required since the program opened
in May 2024. Reviewed drills consistently included the use of lifesaving measures to include the
use of cardiopulmonary resuscitation (CPR), suicide kits, first-aid kits, and an automated
external defibrillator (AED). All drills were simulated, and the program youth were not utilized in
the simulated drills. In addition, a review of video confirmed mock suicide drills were simulated
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and staff acted out scenarios. Reviewed documentation confirmed applicable staff participated
in at least one drill which involved the use of CPR. The program’s practice is to review the drills
during the monthly all staff meetings. An interview with the program director (PD) confirmed this
practice. The program has four suicide response kits which are co-located with first-aid kits in
master control, medical, and both sub-control rooms. Nine staff were interviewed regarding
suicide drill participation. Six staff reported drills are conducted two to three times a month.
Three staff reported drills are conducted once a month.
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 maintains a written policy and procedures to outline operation procedures for crisis
intervention. The program’s Crisis Intervention Plan addresses mental health crisis intervention
services and Crisis Assessments. A review of the plan verified it included notification and alert
systems, 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.
The program’s Crisis Intervention Plan addresses mental health crisis intervention services and
Crisis Assessments. A review of nine mental health records indicated none were applicable for
a Crisis Assessment. The program had no youth applicable for a Crisis Assessment during the
annual compliance review period.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written policy and procedures outlining the mental health and
substance abuse procedures for youth who are believed to be in imminent danger to
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themselves or others because of mental illness or substance abuse impairment. The
Emergency Response Plan for mental health and substance abuse services includes immediate
staff response, notifications, communication, supervision, authorization to transport for
emergency mental health and substance abuse services, transport for emergency Baker Act,
transport for emergency Marchman Act, documentation, training, and review.
3.18 Baker and Marchman Acts (Critical) Satisfactory Compliance
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 maintains a written Emergency Response Plan for mental health and substance
abuse emergencies to serve as the program’s emergency response procedures. The plan
outlines procedures for emergency mental health and substance abuse services and Baker and
Marchman Acts. The program had one Baker Act during the annual compliance review period.
The reviewed record indicated the staff immediately referred the youth for an assessment and
place the youth on precautionary observation (PO) once warning signs presented. The
program’s clinical staff assessed the youth within two hours and referred the youth for an
evaluation at a Baker Act facility. The youth was transported by law enforcement and returned
to the program on precautionary observation until assessed by mental health staff. The youth
was maintained on precautionary observation until an Assessment of Suicide Risk (ASR) and a
Mental Status Examination were completed. The ASR was completed by a licensed staff.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a written policy and procedures for an ongoing safety planning process
for each admitted youth. Safety planning is designed to identify stimuli which have both positive
and negative effects on the youth. Within fourteen days of admission, the intervention and
treatment team shall meet with each youth to develop the safety plan. A review of nine youth
records indicated each had a safety plan created within fourteen days of admission and
reviewed every thirty days. Each plan documented warning signs, youth baseline behavior,
crisis recognition, jointly developed coping strategies, preferred intervention strategies, and a
debriefing process. Each plan was jointly prepared with the youth, parent/guardian, and mental
health staff. Each plan incorporated information from previous assessments and interviews.
None of the plans required an update due to significant behavioral or mental health events.
Each of the nine reviewed records contained fifty-one safety plan reviews. The plans are
accessible to staff and located in the administration office. Nine interviewed youth reported they
contributed to the development of their safety plans. The interviewed program director (PD)
reported safety plans are reviewed and updated monthly.
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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 maintains a written policy and procedures requiring a contracted health authority
to provide on-site medical services to youth in the program. The program maintains a contract
with a designated health authority (DHA) who is a licensed physician (MD). The DHA holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
the State of Florida. The DHA has a clear and active license in the State of Florida, which
expires on January 31, 2026, with specialty training in family practice. A review of the Florida
Department of Health records confirmed the DHA had no disciplinary cases and/or public
complaints on record. The program does not utilize an advanced practice registered nurse
(APRN) or physician’s assistant (PA) for clinical duties. Reviewed documentation confirmed the
DHA was on-site at least once a week, with a week defined as the seven-day period beginning
on Sunday and ending on Saturday. Reviewed documentation confirmed at no time did more
than nine days pass between on-site visits. A review of DHA sign-in sheets since the last annual
compliance review confirmed the DHA was on-site for a minimum of two hours a week. The
program has a back-up DHA who can be utilized. The back-up DHA is a licensed physician with
a clear and active license in the State of Florida expiring on January 31, 2026. An informal
interview with the DHA confirmed the back-up DHA was not utilized during the annual
compliance review period. A review of the program’s policy confirmed tele-medicine/tele-health
is not provided by the program.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program’s contract with the Department outlines the requirements for a health service
administrator (HSA) and additional coverage by a registered nurse (RN). The program has one
HSA who is a full time RN, three full-time RNs, one part-time RN, and one full-time licensed
practical nurse (LPN) on-site. A review of nurse licensure credentials for nurses who provided
services during the annual compliance review confirmed licenses were clear and active. Each
held a current certification in cardiopulmonary resuscitation (CPR). The contractually required
on-site hours for the nursing staff was sixty hours for RNs and forty hours for the HSA weekly. A
review of the nursing schedule confirmed the HSA and full time RNs were both on-site as
required.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The designated health authority (DHA) is responsible for an
annual review of all health-related policies, procedures, and protocols. The reviewed policies
and procedures confirmed the DHA signed on January 8, 2025, the program director (PD)
signed on January 6, 2025, and the psychiatrist signed on January 12, 2025. Reviewed
documentation confirmed the nursing staff reviewed, signed, and dated the cover page of all
FOPs, healthcare protocols, and other procedures listed on January 2, 2025. This was the same
time the annual review of medical FOPs and protocols was conducted. Reviewed
documentation confirmed all newly employed healthcare personnel received a comprehensive
clinical orientation to the Department’s healthcare policies and procedures, given by a
registered nurse or designated healthcare professional. All approval of treatment protocols or
standing procedures were written and were authorized by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program maintains a written policy and procedures ensuring the completion of the Authority
for Evaluation and Treatment (AET) form for all youth admitted into the program. Eight out of
nine youth were applicable for an AET, and one youth was over the age of eighteen upon
admission. A review of each applicable Individual Healthcare Record (IHCR) confirmed the
original AET form was filed in the youth’s IHCR with a legible copy, or the word “COPY”’ clearly
stamped on each AET. Each applicable reviewed AET form was signed by the youth’s
parent/guardian. Reviewed youth IHCRs confirmed there were no parents/guardians who
refused to sign the AET. One of nine reviewed youth IHCRs confirmed an additional court order
was filed. Each AET form was signed by a Department representative. Each reviewed AET was
valid. Three of nine reviewed IHCRs confirmed the youth was currently eighteen years of age or
older and contained a signed release of information. One of nine youth was currently in the care
of the Department of Children and Families (DCF). An interview with the nurse reported the
policy for obtaining a new or current AET is for the nurses to review all projected intakes in the
Department’s Juvenile Justice Information System (JJIS) and validate the AET. All new
admissions are discussed with case management prior to the youth’s arrival and if the youth
need an updated AET, the staff member shall immediately contact the juvenile probation officer
(JPO) to request one. The nurse reported, upon intake or when the youth turn eighteen-years-
old while in the program, a release of information is completed, and filed on top of the AET in
each youth’s IHCR.
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 maintains a written policy and procedures to inform the parent/guardian of
significant changes in the youth’s condition and obtain consent when new medications and
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treatments are prescribed. Nine youth Individual Healthcare Records (IHCRs) were reviewed for
parental/guardian notifications. Seven of nine reviewed IHCRs were applicable and confirmed
documentation of parental/guardian notification for over-the-counter (OTC) medications beyond
those covered by the Authority for Evaluation and Treatment (AET). Consent was provided by
the parent/guardian and written notifications were sent utilizing the Department’s Parental
Notification of Health-Related Care form. There was no new medication ordered at the time of
intake. Three of nine youth were applicable for taking psychotropic medication at admission.
Each reviewed IHCR confirmed staff witnessed all telephone call attempts and conversations for
psychotropic medications. One youth was in the care of the Department of Children and
Families (DCF), where there has been a termination of parental/guardian rights, and the court
authorized all treatment and procedures and indicated all treatments were approved by a court
order. Each of the nine reviewed IHCRs confirmed vaccinations were verified within thirty days
of the youth’s admission. The program reported they did not have any youth applicable for
religious exemptions for immunizations. An interview with the nurse reported parents/guardians
are notified within twenty-four hours with a written parental/guardian notification form, and verbal
consent is obtained as soon as possible after an order is written by the physician. It was
reported the process for documenting parental/guardian exemption for immunization is for the
parent/guardian to provide the appropriate form to the Department of Health (DOH) and then a
copy is provided to the program. The exemption form is filed in the youth’s IHCR.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a written policy and procedures regarding youth healthcare admission
screenings and rescreening each time the physical custody of the youth changes. A review of
nine youth Individual Healthcare Records (IHCRs) confirmed each youth had a Facility Entry
Physical Health Screening (FEPHS) completed on the date of admission by a registered nurse
(RN). None of the FEPHS forms were completed by a direct care staff. Three youth were
applicable for a change in physical custody and the program nurse completed a FEPHS
rescreening on the day the youth returned. An interview with the RN confirmed the program’s
practice.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program maintains a written policy and procedures ensuring each youth admitted into the
program receives a healthcare orientation. Nine youth Individual Healthcare Records (IHCRs)
were reviewed, with each documenting a general healthcare admission orientation was
provided. reviewed documentation confirmed the youth’s orientation topics included access to
medical care, sick call, what constitutes an “emergency” and when to notify staff, medication
process to include side effect monitoring, the right to refuse care and how it is documented,
what to do in the case of a sexual assault or attempted sexual assault, the non-disciplinary role
of the healthcare providers, and standard universal precautions. The program’s Health
Education Orientation Package form listed all reviewed topics to include seatbelt usage, alcohol
and drug related problems, sexually transmitted disease/infections, tobacco products, including
smoking cessation, dental hygiene and dental care, basic personal hygiene, immunizations,
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infection control, prevention of sexual and other physical violence, nutrition, physical fitness, and
breast and testicular self-examinations, which was signed and dated by the youth. The Health
Education Orientation Package form addressed parenting skills, and prenatal, postpartum, and
parenting education. The frequency for education services is weekly for forty-five minutes.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program maintains a written policy and procedures requiring the designated health authority
(DHA) to be notified by telephone, or verbally if on-site, of all youth admitted into the program.
Six of nine reviewed youth Individual Healthcare Records (IHCRs) confirmed the youth were
known or suspected with a chronic condition upon admission and confirmed a referral to the
physician was made. None of the youth were identified as in need of emergency care upon
admission. Reviewed documentation confirmed notification to the DHA/designee was
documented in the youth’s chronological progress notes within the IHCR, and the DHA was
notified within twelve hours of admission, and no later than noon the day following admission.
Three of nine youth were taking psychotropic medication upon admission and the psychiatrist
was notified. An interview with the nurse reported the staff who conducts the intake notifies the
DHA by telephone for all admissions regarding youth history and chronic conditions, and this
notification occurs the same day of admission.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a written policy and procedures to address the completion of the Health-
Related History (HRH) form prior to the completion of the Comprehensive Physical Assessment
(CPA) upon each youth’s admission to the program. A review of nine youth Individual
Healthcare Records (IHCRs) found each youth had a new HRH completed on the day of
admission prior to the CPA being completed. Each reviewed HRH was completed by a
registered nurse (RN). Each HRH was reviewed by the designated health authority (DHA) as
indicated by a checkbox on the CPA. An interview with the nurse confirmed the practice of
completion the HRH at the time of admission by the admitting nurse.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a written policy and procedures ensuring the completion of the Department’s
standardized Comprehensive Physical Assessment (CPA) form for all youth admitted into the
program. Nine youth Individual Healthcare Records (IHCRs) were reviewed, and each included
a new CPA completed by the designated health authority (DHA) within seven days of admission
on the Department’s form. Each of the CPAs documented the appropriate Medical Grade for the
reviewed youth. There was no indication of any missing or incomplete elements on any of the
reviewed CPAs. All nine youth refused part of the examination, and each CPA documented the
refusal and included the youth’s signature by the applicable portion of the CPA examination.
Each reviewed CPA had all sections complete in full utilizing “O” and/or “X” markings except for
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sections numbered nineteen through twenty-two, as those sections were not applicable to the
male program. The results of each youth’s Tuberculosis Skin Test (TST) were documented on
the CPA and the Department’s Infectious and Communicable Disease (ICD) form and on the
program’s TST/Purified Protein Derivative (PPD) form. Reviewed documentation confirmed the
Department’s Problem List was updated as needed. An interview with the program’s nurse
confirmed the CPA is completed by the DHA during admission and updated as needed
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 maintains a written policy and procedures requiring all youth admitted to be
clinically screened and medically evaluated for sexually transmitted infections (STIs). The policy
states the program shall routinely offer counseling, testing, and referrals for medical treatment to
all youth at risk of human immunodeficiency virus (HIV) infection. Confidential HIV testing shall
be conducted for all youth recommended for testing based upon the clinician assessment, risk
assessment, or upon youth request. Nine youth Individual Healthcare Records (IHCRs) were
reviewed, and each youth was clinically screened and evaluated for STIs. Each youth required
further evaluation and was referred to the medical doctor (MD). Each referral was documented
on the STI screening tool and testing was ordered; however, the testing was not
performed/completed due to each youth refusing. The program maintains a written policy and
procedures reflecting HIV test results are only disclosed to the youth and the youth’s legally
authorized representative, healthcare providers during the course of consultation, diagnosis, or
treatment of the individual, the Department of Health for purposes of reporting and control of
spread of disease, health facility staff committees conducting program monitoring, evaluation,
and service reviews, medical personnel who have been subject to a significant exposure, and
healthcare facility personnel or agents for the healthcare provider who have a need to know in
the course of patient care activities or administrative operations. The local health department
provides pre and post-test counseling services. All nine youth refused to consent to HIV testing.
Nine youth were asked if they can ask for an HIV test, and each stated yes. An interview with
the nurse reported youth are interviewed during the initial nursing assessment and all youth are
screened for STIs regardless of their risk. Additionally, youth are referred for an off-site
evaluation, if needed. The STIs are documented in the infectious and communicable disease
information section of the youth’s chart.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program maintains a written policy and procedures ensuring all youth in the program are
able to make sick call requests and have their complaints treated appropriately through the sick
call system. Sick call care, including dental complaints, shall be available to all youth two times
a day, seven days each week. Sick call care shall be provided by licensed healthcare
professionals, pursuant to their scope of practice and according to protocols approved by the
designated health authority (DHA). When a licensed healthcare professional is not on-site, the
shift supervisor shall review all sick call requests as soon as possible, and within two hours after
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the request is submitted. Any complaint of severe pain, including dental pain, shall be treated as
an emergency with immediate referral to the program’s healthcare staff or DHA. Emergency
dental care services, to include complaints of severe pain, shall be provided by a licensed
dentist. Nine youth Individual Healthcare Records (IHCRs) were reviewed, and one was
applicable for similar sick call complaints three or more times within a two-week period. A
referral was made to the DHA and the situation was treated as an emergency and a referral was
made to a licensed healthcare professional. Six of nine youth completed a Sick Call Request
form, and the forms were completed by a registered nurse (RN). If sick call care is conducted by
a licensed practical nurse (LPN) it is reviewed by the RN. Each Sick Call Request form was filed
in the youth’s IHCR in reverse chronological order. No youth were in restricted housing of any
kind. Each Sick Call Request form and/or progress notes were documented in accordance with
Florida Administrative Code and on the Sick Call Index. Each of the youth’s sick calls were
documented on the program’s Sick Call Referral Log and the dates listed on the Sick Call Index
corresponded to the completed Sick Call Request forms located in the IHCR. A review of the
daily schedule, posted schedule, and nurse interview confirm sick call was conducted daily. Sick
call care is provided twice daily Monday through Friday at 8:15 a.m. and 4:00 p.m. The program
conducts sick calls on Saturday and Sunday at 7:00 a.m. and 5:00 p.m. The sick call hours are
posted in each living unit and only licensed nurses conduct sick call requests; however, in the
event the nurse is not available the program has a procedure where a trained non-licensed
staff/supervisor can conduct the sick call. The shift supervisor reviews all sick call requests as
soon as possible and within four hours after the request is submitted when there is not a
licensed nurse on-site. All Sick Call Request forms are available to youth at any time. The
program has an exam table and equipment to perform sick calls. Nine youth were asked how
quickly they can see a nurse once youth make a sick call request. One reported immediately,
seven reported within one day, and one reported they never requested a sick call; however,
they knew the process. An interview with the nurse reported a youth can submit a sick call at
any time by placing the form in the sick call box. The box is monitored by the nurse at a
minimum of once a day and youth are assessed within twenty-four hours. The nurse reported
the program does not use room restriction and if a youth is placed in medical isolation,
healthcare staff document this on a nursing progress note daily regarding the youth’s health
status. If a youth has submitted a Sick Call Request form or is prescribed medication and is in
restricted housing during the scheduled sick call hours and/or medication administration times,
the healthcare staff will address the Sick Call Request and/or administer medication at the end
of each scheduled activity. During the annual compliance review week, observations of a youth
sick call was conducted. The youth was escorted to the medical office by a direct care staff. The
medical provider identified themselves and stated why the youth was there. The youth was seen
in a private area with no other youth present to hear or see the examination by the licensed
staff.
4.13 Episodic/First-Aid and Emergency Care Limited Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program maintains a written policy and procedures ensuring the provision of episodic care
and first-aid care. The program will provide twenty-four-hour emergency medical, mental health,
substance abuse, and dental care to all youth. All staff who have direct contact with or provide
supervision to youth, including transporters, shall be trained in sick call complaints which are
emergency complaints and proper emergency on-site emergency notification procedures and
care, to include transfer procedures to facilitate the immediate transfer of youth who require
emergency medical, mental health, and dental care services. The program director (PD) shall
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ensure all telephones within the program have access to outside lines to ensure unimpeded
access to the emergency use of 9-1-1. Nine youth Individual Healthcare Records (IHCRs) were
reviewed for on-site first-aid or episodic care. Six youth were not applicable and three were. All
reviewed first-aid/episodic care was provided by a licensed healthcare staff, documented in the
progress notes under the notation of episodic, and completed in subjective, observation,
assessment, and plan (SOAP) format. None of the episodic or first-aid care was provided by
non-healthcare staff. The program has seven first-aid kits located in master control, medical, the
kitchen, and each of the two living units. The program has a process for ensuring contents are
maintained and stored in accordance with guidelines, to prevent expiration or deterioration, and
replenished as needed. The nurse checks kits monthly. Observations of three first-aid kits found
each was fully stocked with designated health authority-approved contents. A review of the first-
aid kit binder confirmed the first-aid kits were being monitored as required. The program has two
automated external defibrillators (AEDs) located in master control and the medical office. The
AED procedures are located in both areas. Nurses check to ensure the AED batteries and pads
are operable. During the annual compliance review week, the nurse conducted a self-test of the
AED in front of the regional monitor. There were no issues observed. Reviewed documentation
confirmed the AED batteries expire in December 2032, and March 2031. The pads expire on
July 2, 2027, and May 4, 2026. The batteries and pads were last changed in September 2022. A
list of emergency numbers including the Poison Control Center was posted and accessible for
non-licensed and licensed staff and inaccessible to youth. Reviewed documentation confirmed
the authorized direct care staff were appropriately trained on the administration of the
epinephrine auto-injector. A review of nine staff training records confirmed they met episodic,
first-aid, and emergency care training requirements. The program has two operational shifts. A
review of the program’s mock emergency medical drills reflected announced and unannounced
drills were conducted on each shift as required since the program opened in May 2024.
Emergency medical drills included the demonstration of cardiopulmonary resuscitation (CPR),
first-aid, and the AED, as required. Reviewed documentation confirmed direct care staff
participated in at least one emergency “man down” drill within the annual compliance review
period. During an interview, the PD reported medical emergency drills are reviewed during all
staff meetings. In addition, reviewed documentation found staff signed drill review sign-in sheets
to confirm they were provided the opportunity to review the scenario. Video observations on two
separate occasions found drills did not simulate episodic care events. During the annual
compliance review week, there was no observation of an episodic care event. The program has
a policy and procedures on the use, access, and inventory of NARCAN®. NARCAN® is to be
stored in the medical cart and staff are trained on how it is administered. Medical staff and
supervisors are the only ones who have access to NARCAN®. The program documents the
inventory of NARCAN® in the over-the-counter binder. Nine staff were interviewed, and three
reported they are personally allowed to call 9-1-1, one staff stated no, one staff reported they
would radio master control to call, and four reported they would notify the supervisor and let
them make the call. Nine youth were interviewed, and each reported they cand see a doctor and
dentist if needed. An interview with the nurse reported the program has seven first-aid kits
located in the kitchen, medical, phase one, phase two, for the two transport vans, and master
control. The nurse reported youth who are sent off-site for emergency care are tracked through
a transport log. The informally interviewed nurse reported the medical staff checks to ensure the
AED batteries and pads are operable. The nurse reported emergency drills are conducted each
shift monthly, with CPR/first-aid drills conducted quarterly. Drills are held for each shift, at a
minimum on a quarterly basis. It was reported the process for documenting on-site episodic
care is to document the care on a progress note in SOAP format and then document the event
on the Episodic Care Log. Non-healthcare staff can complete the form to notify nursing staff
upon their return to assess youth who received episodic treatment after hours.
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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 maintains a written policy and procedures ensuring timely referrals, coordination,
and documentation of medical services to off-site health providers for youth with emergent or
non-emergent needs. Nine youth were reviewed, and one youth was applicable for off-site care.
Additional records were requested, and the program reported they only had one youth for off-
site medical care since the last annual compliance review. Reviewed documentation confirmed
the Summary of Off-Site Care Consultation Report form was utilized and filed in the IHCR and
documented on the Episodic Care Log. The youth was over the age of eighteen; therefore, the
parent/guardian was not notified. The DHA did review and sign/initial the off-site care findings,
instructions, and information. The youth required a follow-up appointment, which was completed
on November 8, 2024. An interview with the nurse reported youth who are sent off-site for first-
aid or emergency care needs are tracked on the episodic log, and on the transport log and a
planner. It was reported all hospital orders are noted and reviewed by medical staff and the
designated health authority (DHA) to ensure tracking. The informally interviewed nurse reported
medical staff track follow-up testing, referrals, and appointments on the DHA internal healthcare
tracker. It was reported, in order to ensure the DHA is reviewing and initialing all off-site care
findings, orders are reviewed upon the youth’s return with the DHA by nursing staff. A checklist
is followed to ensure all steps are completed. The DHA folder is used for weekly review on the
next scheduled visit.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program maintains a written policy and procedures ensuring youth who have chronic
conditions receive regularly scheduled evaluations with the required follow-up. All youth
identified with chronic medical conditions shall have treatment plans/physician progress notes
which specify a youth’s particular course of therapy, identify the role of the qualified health
professionals in carrying it out, and are updated as indicated. The program shall ensure youth
who have chronic illnesses receive regularly scheduled evaluations and necessary follow-up. A
review of nine youth Individual Healthcare Records (IHCRs) confirmed five youth were identified
on the Facility Entry Physical Health Screening Form (FEPHS) with a chronic condition during
intake admission. None of the youth were identified as having a communicable disease and
taking prescribed medication on an-ongoing basis for any reason. Each youth was classified
with an appropriate Medical Grade. Each youth was placed on a chronic illness list and received
periodic evaluations at least every ninety-days. None of the applicable youth were taking anti-
tuberculosis medications. An interview with the program director (PD) reported the formalized
procedures in place to review the important youth medical issues with the healthcare staff is
conducted during the daily management meetings, where staff review important youth medical
issues and health service recommendations. An interview with the nurse reported, once youth
are identified upon intake the youth is placed on the medical tracker for monitoring due dates.
The nurse notifies the DHA for all admissions regarding youth history and chronic conditions.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program maintains a written policy and procedures which outline the process of how
medications are to be received, stored, inventoried, and administered in a safe and effective
manner. Medications shall be provided pursuant to a physician order written in the Individual
Healthcare Record (IHCR). Parenteral medications shall only be administered by a licensed
healthcare staff who has experience in the administration of such medications unless the youth
has routinely administered their own medication prior to admission to the program, and if
individually approved by the nursing manager and the program director (PD). Five of nine
reviewed youth IHCRs confirmed youth were admitted with medication, which was verified prior
to being accepted into the program. Each applicable youth’s prescription verification was
included in the chronological progress note. Documentation confirmed the designated health
authority (DHA)/designee and psychiatrist were contacted to obtain the order to resume the
specified medications prescribed prior to admission. The DHA placed an order on the
Practitioner Order form for all continued medications. Each Medication Administration Record
(MAR) clearly indicated medication start and stop dates. It was confirmed staff initialed each
administered medication entry. There were no undocumented explanations for a lapse or errors
in medication administration. Reviewed documentation confirmed nursing staff documented
weekly side-effect monitoring on the MAR. One youth was applicable and signed the Refusal of
Treatment form indicating the refusal of medication. Each applicable MAR clearly documented
the refusals. Each reviewed MAR documented all required elements to include youth name,
Department identification number (DJJID), date of birth, youth allergies, precautions, Medical
Grade, medical alerts, current picture of the youth, and youth’s initials. Five of nine youth
reviewed were prescribed psychotropic medications upon admission. The program’s practice is
to notify the DHA upon admission and for the youth to receive an Initial Diagnostic Psychiatric
Interview within fourteen days of admission. Reviewed documentation confirmed each youth
received a medication monitoring/review every thirty days as required and confirmed there were
no standing orders for psychotropic medications, no emergency treatment orders for
psychotropic medication, and no pro re nata (PRN) orders for psychotropic medications. During
the annual compliance review week, one medication administration was observed with no
issues noted. The youth was escorted to medical by direct care staff. The Six Rights of
Medication Administration were verified by the registered nurse (RN). The RN administered the
medication as required and did not pre-pour any of the medications. Nine youth were
interviewed, and seven reported the nurse gives them medication and two responded they do
not take any medication; however, they know the nurse conducts medication administration. An
interview with the nurse reported the program’s process to verify a youth’s medication is through
the records sent from the juvenile detention center. Additionally, medication is verified with the
parent/guardian during intake.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program maintains a written policy and procedures specifying the requirements for storage
and inventory of medications and sharps and safeguarding all medication, which is inaccessible
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to youth at the program. Observations of all medical equipment classified as sharps to include
syringes, needles, scissors, and suture removal kits confirmed they were secured and
inventoried utilizing a routine perpetual inventory descending count as each sharp was utilized
and disposed. All medications were identified and secured in the locked area designated for
storage of medications. The medication cart was clean and organized with stock items separate
from youth-specific medications. All controlled substances had a perpetual inventory and were
stored separately from other medications. Each medication was stored in a separate, secured
area which was inaccessible to youth. Observations of the medication storage area confirmed
the program’s practice to store narcotics in the secured medication cart behind two locks.
Medications which require refrigeration were stored in a secured refrigerator, which is used for
medication only. The program’s process for the destruction and disposal or return of expired or
discontinued medications is for the pharmacy consultant to destroy the medication or
discontinue the medications and return them to the pharmacy for credit. Perpetual and weekly
inventories of all sharps and stock over-the-counter (OTC) medications were completed as
required. Perpetual inventories with running balances were maintained on all controlled
substances with a shift-to-shift inventory conducted by the registered nurses (RN). Reviewed
documentation confirmed supervisory-level, non-healthcare staff were trained in the delivery
and oversight of medication self-administration. All trainings were delivered by a registered
nurse (RN). During the week of the annual compliance review, three OTC medications, three
controlled medications, and three sharps were reviewed, and the inventories were accurate.
The program’s policy when there are count discrepancies is for the nurse to notify the
designated health authority and the program director (PD) when any discrepancies are found in
the weekly inventory counts. An interview with the nurse reported staff conduct counts twice
daily before shift and at the end of the shift. Additionally, when a discrepancy is found the DHA
and the PD are notified.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program maintains a written policy and procedures ensuring infection control which
includes an Exposure Control Plan. The plan is in compliance with the guidelines established by
the Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control
and Prevention (CDC). The infection control policy was last reviewed and signed by the
designated health authority (DHA) on January 8, 2025, and the program director (PD) on
January 6, 2025.The plan covers common infectious diseases of childhood, self-limiting,
episodic contagious illnesses, viral or bacterial infectious diseases, tuberculosis, Hepatitis A, B,
and C, human immunodeficiency virus (HIV), infectious diseases caused by blood-borne
pathogens, other outbreaks or epidemics caused by any other infectious agent, outbreaks of lice
or scabies, Methicillin-Resistant Staphylococcus Aureus (MRSA) and other anti-biotic resistant
micro-organisms, food-borne illnesses, bio-terrorist agents, and chemical exposures. The
program provides staff with the opportunity for Hepatitis B immunizations and access to
protective equipment. The plan includes a process for needle stick post-exposure evaluation. In
the event of an incident, the PD has a process in place to establish a separate file containing all
documents for youth and staff who experienced a facility or occupational exposure. The nurse
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reported a copy of the program’s Exposure Control and Infection Control Plans are maintained
in the medical office and master control. The nurse and the PD reported the program has not
had any instances which required notification to the local county health department, CDC,
and/or the Department’s Central Communications Center (CCC) since the program begin in
May of 2024. Licensed healthcare staff conduct infection control training for the program. The
program has not had any reportable infectious diseases since the last annual compliance
review.
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’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. The program staff are required to account for the
whereabouts of youth under their supervision and ensure staff-to-youth ratios are in compliance
with contract requirements. A program tour verified the daily youth activity schedule was posted
throughout the program and is designed to keep youth engaged in a full schedule of activities.
Observations of staff supervision for four days during the annual compliance review week
included classrooms, line movement, school breaks, youth head counts, mental health groups,
work details, youth searches, and outdoor/indoor recreation activities. The observations ensured
staff-to youth ratios were maintained, as required. A tour of the program verified the program
and living units were clean, well maintained, and graffiti free. A perimeter check was conducted,
and fencing appeared to be in good repair. Staff and youth were appropriately attired. During
outdoor activities and/or movement, observations verified staff were strategically positioned to
ensure proper supervision of youth and to ensure there were no physical obstructions in their
view of the youth. Observations of interactions between program staff and youth reflected the
interactions were positive and consistent with the program’s BMS. An informal interview with
several staff confirmed each staff knew how many youth they were supervising. The program’s
policy states 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, and consistently applying the BMS. Program staff shall be able to
always account for the whereabouts of youth under their supervision. Video observations of
youth were conducted during awake and sleep hours. The observations confirmed youth to staff
ratios were in compliance during awake and sleep hours, staff were awake and alert, and staff
conducted ten-minute checks with some minor exceptions.
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 behavior management system (BMS) which has not changed since the
program started on May 15, 2024. The program’s BMS is used to promote appropriate behavior,
monitor, recognize, and reward a youth’s progress. It is a program of incentives and
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consequences which promotes individualized skill building, appropriate behavior, and
accountability. Staff use the level system to monitor how well the youth are progressing in the
program. Youth earn increased levels daily for complying with the program rules. At the end of
the day and week, the youth are rewarded in relation to the level earned. Each youth enters the
program on an orientation level prior to starting the BMS and progresses their way up the four
levels. The four levels of the BMS include orientation, rookie, intern, and ram levels. Youth learn
about the BMS during the orientation process. Each youth is provided a program handbook
which describes the BMS. A review of the youth handbook indicated the BMS is designed to
promote safety, respect, and fairness. The BMS promotes and protects youth rights and has
opportunities for positive reinforcement. The BMS includes positive and negative consequences
and uses constructive disciplinary actions. The BMS promotes socially acceptable means for
youth to meet their needs, includes a process for explaining to youth the reasons sanctions are
being imposed, youth have the opportunity to explain their behavior, there are opportunities for
staff and youth to discuss the impact of behavior to others, includes reasonable reparations for
harm caused by others, there are discussions of alternative behaviors, promotes positive
dialogue, and minimizes separation of the youth from the population. A review of the BMS
confirmed it is not used solely to increase a youth’s length of stay, deny basic rights or services,
promote the use of group punishment, allow youth to punish other youth, or include disciplinary
confinement. A review of nine staff training records indicated staff were trained on the BMS by
the staff development coordinator. A review of nine position descriptions confirmed the job
functions included the implementation of the BMS. A review of nine youth case management
records indicated each youth participated in an orientation upon arrival to the program and
received a copy of the youth handbook. Observations found the BMS was posted throughout
the program. Observations of staff and youth interactions confirmed staff were adhering to the
BMS by utilizing a ratio of four-to-one positive to negative consequences when redirecting the
youth as indicated in the program’s policy. The incentives for youth include using their level to
earn daily canteen, weekly canteen, monthly canteen, participating in off-campus activities,
monthly birthday events, restaurant meals, extra hygiene products, and receiving extra snacks.
Nine staff were interviewed, and each reported the BMS consists of a level system and consists
of incentives and consequences. Each of the interviewed staff verified youth receive incentives
which include canteen items, receiving extra snacks, outings, games, sports tournaments, and
outside activities. Nine interviewed staff stated nothing can be taken away from a youth as a
consequence. Each interviewed staff stated youth are informed of the consequences and they
are able to explain their behavior during the review of the program’s behavior reports. Nine
youth were interviewed, each stated the consequences for negative behaviors included not
earning their level, special treatment meetings, minor and major reports, and receiving a
behavior report. Nine youth were interviewed and each youth stated they receive incentives
such as special meals, extra snacks, canteen items, a daily progress note, and participate in
outings. Nine interviewed youth stated staff are consistent in what behaviors they give rewards
and consequences to. All nine youth were able to explain the difference between each level and
how they move from level to level. All nine youth verified youth are never allowed to punish
other youth. An interview with the program director (PD) confirmed the program utilizes a level
BMS. The BMS promotes safety, respect, fairness and protection of rights within the community,
provides for constructive discipline, and a system of positive and negative logical consequences
to encourage youth in meeting expectations for behavior, provides for positive reinforcement
and recognition for accomplishments and positive behaviors at a minimum ratio of four-to-one
positive to negative consequences, promotes socially acceptable means for youth to meet their
needs, which includes processes addressing the needs, and cognitive capacity of youth. The
PD stated the monitoring of staff implementation of the BMS to ensure consistency is conducted
through a daily/weekly review of the program’s documentation system to ensure staff are
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current in daily progress note (DPN) entries, and discussions during daily 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.
This program does not use room restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program maintains a written policy and procedures to conduct and document ten-minute
checks during sleep hours or at other times, such as during an illness or room restriction. The
program has a total of 122 video cameras capable of recording thirty-days of video footage.
During the annual compliance review week, the program reported all cameras were operational;
however, several of the program cameras times were an hour different than the real time and
administration staff were aware of the problem. Documentation supported staff completed the
checks and initialed the ten-minute check sheets. A video review of nine-day samples of thirty-
minute increments for ten-minute checks from each living unit, for various times, to include
overnight shifts and other times, was conducted. Observations of ten-minute checks reflected
checks were conducted between eight and ten-minutes and documented in real time, and the
checks were met with fidelity, with the exception of one day where youth were in their rooms
during shower time and the full ten-minute checks were not conducted. Observations indicated
staff were conducting the ten-minute checks; however, staff only checked if each youth door
was locked. The program administrators conducted a retraining of ten-minute checks for all staff
and provided documentation prior to the completion of the annual compliance review. Nine
interviewed staff verified room checks were conducted between eight and ten-minutes when a
youth is placed in their room for sleeping or non-punishment reasons.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
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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 requires staff to conduct formal head counts each hour and after outdoor
activities. In addition, the policy indicates counts are conducted during power outages, escapes,
program disturbances, or any other disruptions which may occur. A review of the Continuity of
Operations Plan (COOP) verified program staff must always account for the whereabouts of the
youth under the care and custody of the program. This includes the need for continual head
counts to be conducted minimally, at the beginning and end of each shift, during any emergency
situation, and at regular intervals. Nine randomly selected dates and times in the program’s
logbook were reviewed for census counts since the program started on May 15, 2024.
Documentation validated head counts and movements were conducted at the beginning of each
shift, after outdoor activities, during emergency situations, such as program disturbances, and
during actual and/or simulated drills. In addition, the program logbooks included documentation
of new admissions, releases, daily census counts, youth movements, transfers, and youth
temporarily away from the program. Observations made during the annual compliance review
week indicated it is the program’s practice to conduct hourly program headcounts of the youth in
the program. Nine interviewed staff verified formal counts are conducted every hour. Each staff
reported if a count cannot be reconciled, all movement is stopped, and an emergency
headcount is conducted until the count is reconciled. Each staff stated emergency counts are
conducted if a count is wrong, during power outages, when a youth is unaccounted for, if a
youth is missing, and during fire drills.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a written policy and procedures to ensure the maintenance of a
chronological record of events, incidents, and activities in a central logbook is maintained in
master control. The program maintains a bound logbook with numbered pages for each month.
Observations and a review of logbooks since the program started on May 15, 2024, found
logbook entries were documented in ink with no erasures or white-out areas. Errors were
typically struck through with a single line, and dated and initialed by the staff correcting the
error. Reviewed documentation of nine randomly selected dates within the logbooks reflected
each entry included the date and time of the event, the name of the staff and youth involved, a
brief description, the name, and signature of the staff making the entry. A review of shift reports
since the program started on May 15, 2024, verified each report was completed on a daily
basis. Each staff signs the shift briefing sign-in sheet to acknowledge receiving the information.
Documentation supported the shift report was maintained at each living area for forty-eight
hours. Logbooks included entries for emergency situations, incidents, special instructions for
monitoring youth, population counts, law enforcement access to youth, perimeter checks, and
youth movement. In addition, admissions and releases were documented as well as transports
away from the program. Reviewed documentation and a review of the Department’s Central
Communications Center (CCC) reports indicated there were no instances of escapes or
attempted escapes during the annual compliance review period. Reviewed logbooks reflected
the program documented internal incidents reported to the Florida Abuse Hotline and/or the
Department’s CCC.
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5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a written policy and procedures for assignment, inventory, tracking, and
storage of program keys. Keys are bound on a tamper resistant ring which includes a brass-
colored tag with the number of keys and a tracking number. Program keys are maintained in
master control on a board with the corresponding tracking number. The program has a daily key
log to track keys. The log indicates the name of staff and what type of key they are to be
assigned according to their position. The program maintains a master inventory list of program
keys. A random check of five different sets of program keys compared to the inventory list
indicated the keys were accounted for and the master control staff knew which area each key
was assigned to. At the time of the annual compliance review, several staff keys, which included
two administration staff’s keys, were unable to open the youth rooms and shower doors. In
addition, one key in the key box in master control has no key ring and staff were not sure the
use for the key. Administration staff removed the unknown key from master control. Active keys
are assigned to direct care staff while restricted keys are designated for medical staff, teachers,
case managers, and therapists. An informal interview with master control staff indicated the
program’s practice is when direct care staff arrive to the program, personal keys are collected
by master control and placed in the key box in master control. Visitor keys are collected by
master control and placed on a board in master control. Medical staff, teachers, case managers,
and therapists receive their respective restricted keys from master control after their personal
keys are collected. Both the master control operator and the staff receiving shift exchange keys
were documented at the beginning, and again at the end of the shift when the keys are
returned. A review of the key logs and logbooks since the program started on May 15, 2024,
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 random check of three staff verified the
number of keys on the key ring matched the inventory and each staff knew their function. A
review of the Department’s Central Communications Center (CCC) reports since the program
started on May 15, 2024, indicated there were no incidents related to key control. Nine staff
were interviewed and were able to explain the program’s key control process for personal and
program keys.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
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non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a written policy and procedures to identify materials considered to be
contraband, to prevent contraband from entering the program, and consequences when found
in the possession of youth 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 are oriented to the program rules including the list of items considered to be
contraband. The program’s policy and youth handbook included all items considered
contraband as outlined in Florida Administrative Code. The list of contraband items included
sharps, escape paraphernalia, tobacco products, lighters or matches, electronic or vaporless
cigarettes, unauthorized food or clothing, any intoxicating beverages, any controlled substance,
any prescription or non-prescription drug, any firearm or weapon, any explosive substance, non-
program issued keys, unauthorized currency, non-program issued cellular telephones and/or
equipment, electronic devices capable of taking pictures or video recordings, as well as smart
watches. In addition, the program’s policy and youth handbook include consequences if found
with contraband, search procedures of the physical plant, searching the program grounds, youth
searches, and searches of incoming and outgoing mail. The program’s policy 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.
The program’s policy specifies the manner in which any unauthorized or contraband item is to
be disposed, to include return to original owner, mailed to the youth’s home, stored at the
program and returned to youth upon release, or, in the case of illegal contraband, turned over to
law enforcement. Unannounced room searches are conducted at least daily at irregular and
unpredictable times and common area searches are conducted daily. During the program tour,
several randomly selected rooms were checked, and no contraband was observed. The
program’s policy and procedures, and orientation training provided to all new staff, stipulate
staff, including supervisors and administrators, found in possession of contraband will be
subject to disciplinary action up to and including dismissal. A review of the visitor’s sign-in log
verified it included an attestation statement. There was a total of fifty new staff hired during the
annual compliance review period. A review of fifty staff records found each included a signed
contraband attestation form. A review of the Department’s Central Communications Center
(CCC) reports since the program started on May 15, 2024, indicated there were no instances of
contraband found at the program. The interviewed program director (PD) reported contraband
items which may be used as evidence shall be secured by the discovering staff and hand-
delivered to the PD or designee and subsequently secured under lock and key. The program
staff shall document the chain of custody for the items and give the information to the
responding law enforcement officer. In all instances involving the confiscation of illegal
contraband, the confiscated item(s) shall be turned over to law enforcement authorities and a
report will be filed. Nine staff were interviewed, and each stated room checks are conducted
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randomly throughout the day as long as youth are not in their room, during shower time, and
randomly while youth are in school, and randomly twice or three times throughout the day.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a written policy and procedures to ensure searches and full body visual
searches are conducted according to Florida Administrative Code at the time of admission, after
off-campus activities, and visitation. Parent(s)/guardian(s) are notified of searches during
visitation by letter and the youth handbook, which is mailed at the time of each youth’s
admission. Youth are searched before entering and prior to leaving the classroom, after outdoor
recreation activities, after work detail, and during all movement. Youth who are a new
admission, re-admission, returning from visitation, returning from off-campus activities and/or
appointments, suspected of contraband, or are a security risk are full body searched.
Observations made throughout the annual compliance review week validated youth are
provided instruction regarding the search, youth searches were conducted by staff of the same
gender as the youth, were conducted in a manner so as not to degrade the youth, and were
based on the Right Interactions (RI) training manuals. Searches observed during the annual
compliance review week verified youth were searched after every movement and after
participating in work detail projects. During the annual compliance review week there were no
scheduled transports, no new admissions, no visitation, and no youth returning from off-campus
activities; therefore, searches could not be observed. In person observations and a video
footage review of five random dates and forty-one separate searches indicated searches were
conducted, with the exception of two instances where video footage indicated one contractor
staff was not searched prior to entering the program, and two male staff were not searched prior
to the start of their shift. Nine staff were interviewed, and each stated youth are searched after
every movement. Nine youth were interviewed, and all indicated searches occur during all
movement, four stated after visitation, two stated after outdoor activities, two stated after
returning from off campus, two stated after meals, and one stated when items are missing.
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 for transportation, operation, and
maintenance of each vehicle used to transport youth. The program has a total of three vehicles
and two are used to transport youth and one is for program use. Each vehicle used to transport
youth had a quarterly safety inspection conducted by a certified automobile mechanic.
Observations of the two program vehicles verified each was locked when not in use. An
observation of both vehicles used to transport youth found it had the appropriate number of
seatbelts, a seatbelt cutter, a window punch, up-to-date fire extinguisher, and a first-aid kit with
approved items by the nursing staff. Documentation indicated weekly visual vehicle inspection
checks are conducted on all vehicles as required and documented on the vehicle maintenance
check sheets. Both observed vehicles used to transport youth had passenger doors which could
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not be opened from the inside. A random check of fourteen staff personal vehicles and two
program vehicles during the annual compliance review week found all of the vehicles were
locked and secured when not in use.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a written policy and procedures to ensure the safety and security of
youth and the community when youth are transported outside of the program. The program’s
human resources staff obtain monthly driving record information from the Department of
Highway Safety and Motor Vehicles for all staff designated to transport youth. The program
assigns a ratio of one staff to five youth during transport, not including the driver. There were no
transportations scheduled during the annual compliance review week; therefore, a
transportation could not be observed. The program’s policy states youth are not permitted to
drive program or staff vehicles. Nine staff were interviewed, and each stated prior to transport
the youth and vehicles are searched for contraband, and youth are secured in the vehicle. The
youth sit in the back, wearing a seatbelt, handcuffed, and one staff sits in the back with them.
Seven of nine interviewed staff stated they use the program’s cellular telephone, radio, and/or
their approved personal telephone during transports, and two staff stated they have not
conducted a transport. A follow-up with the staff who reported they use their personal telephone
indicated the staff were on an approved list to have their telephone. All nine staff confirmed they
are not allowed to use personal vehicles to transport youth. All nine interviewed staff stated the
safety equipment in the transport vehicles included a first-aid kit, emergency kit, a knife-for-life,
and fire extinguisher. All interviewed staff stated the transport vehicles are searched for
contraband prior to and after each use. The interviewed staff stated they would contact the
program if an emergency response arose during vehicle transport and then call roadside
assistance. Each interviewed staff knew the staff-to-youth ratio during transport. Nine
interviewed youth stated while on a transport they have never been handcuffed to any part of
the vehicle. Nine interviewed youth stated they never witnessed anyone placing contraband in a
transport vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a written policy and procedures to ensure safety and security is
maintained. The policy addressed who is responsible for conducting the audits, procedures to
implement corrective actions for deficiencies, and an internal system to verify deficiencies are
corrected. Weekly safety and security audits are conducted by the physical plant manager or
designee and documented on the Safety and Security Audit Inspection form. Any deficiencies
are addressed on the form and a work order is submitted to the appropriate staff for corrections.
A review of the safety and security inspection forms since the program started on May 15, 2024,
indicated inspections were completed as required. Supervisors conduct perimeter checks on
each shift and checks are documented in the program’s logbook. A review of the program’s
logbooks verified this practice. A review of deficiencies entered in the Department’s Juvenile
Justice Information System (JJIS) verified there were no deficiencies assigned in regard to
safety and security audits during the annual compliance review period. An interview with the
program director (PD) reported daily walk throughs and security checks are conducted on each
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shift daily. In addition, outcomes are documented and discussed during the morning
management meeting.
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 written policy and procedures to have a tool management system
which ensures youth do not use tools or equipment as weapons or for security breaches. The
policy addresses the issuance, inventory, and control of equipment and tools. The policy states
prohibited tools at the program include machetes, bowie knives, and other long bladed knives. A
review of inventory logs and observations verified tools are securely stored when not in use,
easily marked for identification, and inventoried prior to and following work activities. All sharp
edged and pointed tools are inventoried daily when in use. The maintenance staff are
responsible for conducting the inventories and securely maintaining all Class A tools and
equipment. The maintenance staff completes a tool inventory list which documents each tool in
the inventory. All maintenance tools were inaccessible to youth and were observed to be
secured in the maintenance office. Observations of the tool storage area found it was organized
and secure. Class B tools including mops, brooms, and buckets are maintained in a locked
office in the hallway by the sub-control which are inaccessible to the youth. The items are used
by staff and youth when performing daily cleanup activities. Staff are required to complete a
sign-out and sign-in log when items are taken and are returned to the designated storage room.
Kitchen staff are responsible for securing, maintaining an inventory log, and maintaining a sign-
out/sign-in log for kitchen utensils and sharps. A random review of ten unique kitchen utensils
and sharps and unique tools in the maintenance office verified the tool inventory in the logs
were accurate. Reviewed documentation and the Department’s Central Communications Center
(CCC) reports verified there were no instances of missing or lost tools since the program started
on May 15, 2024. If a tool is broken or inoperable, the physical plant manager is responsible for
disposal the broken tool and administration and the physical plant manager will work together to
replace the broken tool. An informal interviewed with the physical plant manager reported if a
tool is missing, staff will notify administration, fill out an incident report, document the incident in
the logbook, call the CCC, and the program will be searched until the tool is found.
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 written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. The program’s policy and procedures include
supervision requirements when youth are using tools, the issuing of tools to youth and staff, a
youth assessment to determine the youth’s risk, and established ratios, which include one staff
to five youth during work detail or vocational training. A review of the program’s procedures
verified staff are required to complete a sign-out and sign-in log when Class B tools are taken
and are returned to the designated storage room. A Youth Risk Assessment is completed by the
case manager for youth to use Class A and Class B tools. Nine youth case management
records were reviewed, and each youth had a Youth Risk Assessment completed by the case
manager prior to the youth using tools. Nine youth case management records included
documentation each youth was trained on the intended and safe use of Class B tools. An
observation of three youth completing work detail and helping to taking trash outside to the
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dumpster was conducted. The youth were properly supervised and followed safety protocols.
Nine youth were interviewed, and each stated they use mops and brooms and three youth
reported they used a dustpan; however, it depends on youth levels. Nine staff were interviewed,
and each indicated youth are allowed to use mops and brooms.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a written policy and procedures establishing guidelines for outside contractors
who come on-site to complete repairs. When a contractor or vendor enters the program, they
sign the Outside Contractor On-Site Work Project Log and visitor log which lists unauthorized
items. The program’s policy states personal cellular telephones, and electronic devices capable
of taking pictures and/or audio/video recording, including smart watches, are prohibited in the
secure area. The physical plant manager or designee inspects all tools upon the arrival of
outside contractors and is responsible for providing approval if such tools are required. The
physical plant manager is with the contractor during the time of the project/repair. The program’s
guidelines for external workers include checking of tools upon arrival and departure, searching
of all vendors prior to entering the program, tool restriction while in the program, missing tool
follow-up, and restriction of youth from the work area. The outside contractor completes the
program’s Outside Contractor form upon entrance to the program, where they list what tools are
needed to complete the work order. Maintenance staff will review the form and sign once the
tools are inventoried and approved. Upon exiting the program, the Outside Contractor form is
reviewed, all tools are verified, then the form is signed. Any tools required to be used within the
program are inventoried and recorded on the contractor’s agreement form before and after the
repair is completed. Reviewed documentation for three project invoices showed two of the three
vendors signed and completed contractor agreements, and all requirements were met. For one
vendor there was no documentation of the outside contractor agreement and tool inventory. The
program was only able to provide the visitor sign-in log for the contractor’s visit.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a written Continuity of Operations Plan (COOP) which addresses the
completion of fire, safety, and evacuation drills. A review of the program’s COOP revealed the
program conducts monthly fire drills and COOP drills on each shift. The program has two shifts
and reviewed documentation validated fire drills were conducted for both shifts each month
since the opening of the program. In addition, the program conducted COOP drills which
included riots, disturbances, active shooter, chemical spills, medical situations, and severe
weather. Each drill contained the type of drill, date and time, participants, brief scenario, and
findings and recommendations. The program director (PD) reported drills are reviewed at all
staff meetings and are conducted monthly. During the annual compliance review, observations
found fire evacuation routes and egress plans were posted throughout the program. At the time
of the annual compliance review, the program had twenty-six fire extinguishers and reviewed
documentation reflected the last inspection was conducted in January 2025. Nine interviewed
staff reported participating in fire drills monthly. Six staff reported participating in COOP drills.
Additionally, staff mentioned participating in other required drills. Nine youth were interviewed
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regarding drill participation. Seven youth reported participating in monthly fire drills. Two youth
reported they recently arrived at the program and were not sure about the drills.
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 the Department approved Continuity of Operations Plan (COOP)
available for all staff to review. The COOP was reviewed and submitted to the Department on
April 5, 2024. The Department approved the COOP on April 15, 2024. The COOP provides for
basic care and custody of youth in the event of an emergency or disaster. A review of the
COOP indicated alternative relocation sites approved by the Department’s regional
director/designee should the program require evacuation due to an emergency or disaster.
The COOP addresses the program’s Emergency Disaster Preparedness Plan and is one
combined plan. The COOP is readily available to all staff and is located in master control and
the program director’s (PD’s) office. The program has provisions of equipment and supplies
maintained in the intake office area and master control to ensure a continuous operation of
services during emergency or disaster situations. The program maintains identifying information
on each youth in the program which is in a youth emergency binder. In the event the program
has to evacuate, the youth emergency binder accompanies the youth to the temporary location.
A review of identifying information for nine youth on the youth emergency binder indicated each
has the youth’s name, Department of Juvenile Justice identification number, admission date,
gender, race, contact information, emergency contact, assigned juvenile probation officer (JPO),
committing judge, victim information, physical description, health status, and a photograph. The
interviewed PD reported staff have full access to the COOP. The COOP is located in the
trainer’s office, master control, and the PD’s office.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a written policy and procedures addressing storage and inventory, to ensure
all youth and staff are safe from the effects of the unauthorized use of flammable, poisonous,
toxic items, and materials. The program’s flammable, poisonous, and toxic materials are stored
in a flame-resistant locked cabinet within the locked maintenance office. Kitchen staff are
authorized to use chemicals, are responsible for securing all chemicals in the storage cabinet,
and maintaining an inventory log and sign-out/sign-in log for kitchen chemicals. A review of ten
flammable, poisonous, and the toxic items verified the items were securely stored and
inventories were accurate. A Safety Data Sheet (SDS) binder is located inside the storage area
with a picture of each material and a number corresponding to the SDS for each chemical. A
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perpetual chemical inventory list is maintained, and the chemicals are checked daily. The
program has a Chemical Daily Usage Log used to track all toxic items when in use by
authorized staff. Observations of the storage area indicated it is clearly marked as hazardous
chemicals and securely locked. Flammable items are stored in a metal cabinet clearly marked
as flammable items. Chemicals used to clean the program are stored in a locked closet located
in the main hallway of the program and in a secured closet in the kitchen. An inventory sheet is
maintained which documents the daily use. A review of the storage closet verified the number
and type of chemicals were maintained on the inventory list. A tour of the program and
observations found the program stores all toxic items and poisonous materials in the cabinets
within the maintenance office and other cleaning agents are stored within a secure locked
cabinet in the kitchen office area, inaccessible to youth. A random sample of ten chemicals
verified the actual count matched the inventory logs, the chemicals were secured, and the SDSs
were present for the items reviewed. The program maintains a written policy and procedures to
ensure all flammable, toxic, caustic, and poisonous items are disposed of appropriately through
waste management. The maintenance staff are responsible for the control and accountability of
all caustic, toxic, poisonous, flammable, hazardous fluids, substances, or chemicals used in the
program. An informal interview with the physical plant manager stated the program makes every
effort to use up all chemicals, used kitchen grease and waste is stored in a large gallon, and any
unused chemicals are taken to the local waste management facility. All liquid waste from work
details is disposed of down plumbing drains. The program’s policy states all chemical spills are
reported to master control, the shift supervisor, and maintenance staff immediately.
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 maintains a written policy and procedures prohibiting youth from handling any
flammable, poisonous, and/or toxic items or materials. Youth are not to clean, handle, or
dispose of any toxic, bio-hazardous bodily fluids, or human waste. Youth are strictly prohibited
from the maintenance area where toxic items and chemicals are stored. Observations confirmed
all chemicals were maintained behind at least one locked door and cabinet, and youth do not
have access to areas where items are being stored. An observation of three youth completing
work detail was conducted. None of the observed youth were handling chemicals or cleaning
products. Eight of the nine interviewed youth stated they did not use any chemicals or cleaning
products. One youth reported using paint and has a Class A certification.
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
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activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
This program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures to allow youth to have visitation and communication
with family members while in the program. The program assists youth and families in
maintaining connections in a visitation environment which provides monitoring, control of
movement, and security practices to ensure visitor, youth, staff, and program safety. The
program’s policy provides each youth opportunities to promote communication and engagement
which fosters family reunification and community connections. The program maintains a list of
approved visitors; however, attorneys, representatives of the court, juvenile probation officers
(JPO), other agency representatives, and clergy are authorized to visit at any time. Searches of
visitors will be conducted upon entry and all youth are to be searched following visitation
sessions. The program’s visitation policy indicated considerations for requests of alternative
visitation arrangements with parents/guardians, if needed. Youth are informed about visitation
upon their admission to the program during the orientation process. The visitation and
communication procedures are covered in the youth handbook and addressed on the
orientation checklist. The visitation procedures are posted in the lobby. Visitation is held one day
a week on Sundays from 1:00 p.m. to 3:00 p.m. Youth are given opportunities to communicate
with their family in person, by telephone, and by mail. The program maintains a correspondence
log for each youth which documents incoming and outgoing mail, which is inspected by staff.
The correspondence logs are maintained in each youth’s case management record. Youth are
permitted weekly telephone calls. Each youth’s use of the telephone is documented in each
youth’s case management chronological and telephone log. A review of the telephone logs
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verified youth have consistent telephone communication with family members. Youth can write
to the parents/guardians at any time and are encouraged to correspond with family members by
mail. All outgoing and incoming mail is searched by the case manager. A review of the
logbooks, visitation sign-in logs, and outgoing and incoming mail logs verified the program
allows visitation and mail only for approved immediate family members to include
parents/guardians, stepparents, siblings, and grandparents. It is the program’s practice for the
assigned case manager to follow-up with the JPO regarding human trafficking victims to
determine whether the parent/guardian should be permitted to communicate with the youth;
however, there were no youth applicable for a history of human trafficking since the program
started on May 15, 2024. Nine youth were interviewed, and each confirmed they can call and/or
send letters to their parent(s)/guardian(s). The interviewed program director (PD) stated for
youth who do not speak English as their primary language, the program uses contracted
translation services.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a written policy and procedures to ensure each youth has a variety of
recreation and leisure activities. A review of the staff roster confirmed the program has a
recreation therapist, who met all requirements for the position. An informal interview with the
recreation therapist and reviewed documentation of nine youth records verified recreational
therapy is part of each youth’s Individualized Performance Plan (IPP). The recreation therapist
stated there is a discussion with the youth on goals they can work on, then progress of goals is
measured during treatment team meetings. The program’s recreation calendar designates an
activity for the youth to participate in during outdoor recreation each day, as well as a calendar
of alternative activities if recreation is indoors. The program’s activity schedule is posted
throughout the living units and common areas of the program. All activities promote social and
cognitive skill development, creativity, teamwork, healthy competition, mental stimulation, and
physical fitness. Youth are provided with at least one hour of large muscle activity daily.
Reviewed documentation of the logbook and daily activity schedule confirmed the program has
a range of supervised and structured indoor and outdoor recreation and leisure activities for the
youth, for at least one hour daily. Observations made throughout the annual compliance review
week validated youth are provided with at least one hour of indoor or outdoor recreation and
leisure time. Nine youth were interviewed, and each youth stated they are provided at least one
hour of physical activity which includes playing basketball, football, and doing activities with the
program’s recreation therapist. Nine staff indicated the program provides youth with at least one
hour of recreation each day. Each staff indicated the outdoor activities consist of basketball,
football, board games, card games, watching television, playing video games, and using big and
small recreation areas.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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Standard 6: Safety and Security
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The career and technical education services are being provided as required with Florida Ready
to Work Soft Skills, Occupational Safety and Health Administration (OSHA)-10, and first-
aid/cardiopulmonary resuscitation (CPR). The risk level of this program was recently lowered to
moderate-risk and the residential provider changed. The program is intently working to continue
providing the contracted services for food handling and Microsoft Word under the new provider.
The Microsoft Word certification can lead to the Microsoft Fundamentals and/or Microsoft Office
Specialist certifications on the Master Credentials List (MCL). The food handling certification can
lead to the Food Safety and Science certification on the MCL. Direct care staff provide career
and technical education services through the facilitation of first-aid/CPR, Florida Ready to Work
Soft Skills, and OSHA-10. The staff are certified in first-aid/CPR facilitation. Certification is not
required to facilitate Florida Ready to Work Soft Skills and OSHA-10, as those are certified by
each organization upon youth passing the web-based modules and assessments. During the
annual compliance review week, there were twenty-seven youth enrolled in coursework towards
earning an industry certification. Five reviewed youth records confirmed each youth was on
track to complete the required Florida Ready to Work Soft Skills, OSHA-10, and first-aid/CPR
courses within the contracted time frame. Nine interviewed youth reported the program is
preparing them for high school, their high school equivalency diploma (GED), vocational school,
employment, and/or college.
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 maintains a written policy and procedures regarding educational access. The
program provides education services through a contract with Florida Virtual School (FLVS). The
daily school schedule is incorporated into the program’s activity schedule, with no major
discrepancies. Nine interviewed youth all reported there were no interruptions during the school
day. A logbook review of randomly selected days monthly, since June 2024, indicated education
classes started and ended on time, according to the school schedule. Observations of the
program’s video on December 17, 2024, January 8, and January 13, 2025, showed youth were
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moved to and from the classrooms according to the school schedule, with an hour deviation on
January 8, 2025. There was no teacher in the classroom, so the youth were moved back to the
living unit an hour before dismissal time.
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 by Florida Scholars Academy/Florida Virtual School
(FSA/FLVS). This indicator was reviewed; however, will not be rated until the 25/26 review
cycle. The contracted educational provider shall deliver educational instruction ensuring the
required instructional times are met. Education services are provided through a contract with
Florida Virtual School (FLVS) who maintains a 250-day calendar which is distributed over twelve
months and includes twenty days for teacher training and planning. This calendar was approved
on April 29, 2024. A review of the daily school schedule revealed education provides six fifty-
minute classes from 8:30 a.m. through 2:45 p.m., with a sixty-minute lunch break, fulfilling the
weekly requirement of twenty-five hours of instructional time. Nine interviewed youth all reported
there are no interruptions during the school day. The interviewed lead educator confirmed the
school schedule was being followed. A review of randomly selected monthly logbook entries
since June 2024, disclosed education classes started and ended on time. Observations of the
program video on December 17, 2024, January 8, and January 13, 2025, indicated classes
started and ended on time as scheduled; however, not all classrooms had instructional staff
present during the school hours. The video revealed on January 8, 2024, one classroom had no
teacher present all day and those youth were dismissed at 1:45 p.m. Another classroom had no
teacher after 11:01 a.m. on the same date. On January 13, 2025, there was no teacher present
for the entire day in the same classroom as on January 8, 2025; however, all youth stayed until
the end of the scheduled school day. It was reported on January 14, 2025, during the program
tour, there were two classrooms with no instructional personnel present. Upon further
discussions with program staff, it was revealed it is a common practice for the program to move
the youth to the classrooms daily, while following the school schedule; however, there is not
always a teacher provided in all classrooms.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
Education services are provided by Florida Scholars Academy/Florida Virtual School
(FSA/FLVS). This indicator was reviewed; however, will not be rated until the 25/26 review
cycle. The education contracted provider is responsible for developing a career education
program appropriate for the educational abilities and goals of youth in the program and
appropriate for the length of stay and classification of youth in the program. The career
education program does include Type 1 through Life Management Skills, Personal Finance, and
Money Management courses. The career education program does include Type 2 through
course offerings which provide exploration and knowledge of occupations within specific
careers. The career education program does include Type 3 through course offerings which
provide content and competencies for specific careers. There was no indication of a personal
career aptitude given by the education provider. The residential provider does give youth a
personal career aptitude assessment. The education contracted provider is responsible for
providing Career and Professional Education (CAPE) courses leading to pre-apprentice
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Office of Accountability and Program Support Page 66 of 68 (Revised September 2022)
certifications and industry certifications. Youth at this program are enrolled in Digital Information
Technology and Foundations of Programming which are courses which lead to the CAPE
industry certification. During an interview with the regional director of Florida Scholars Academy,
it was reported career education services and assessments provided to youth include the
Microsoft Office Specialist (MOS) certification documented through the youth’s Digital
Technology and Life Skills elective courses. It was reported information is shared with the multi-
disciplinary treatment team members and the paraprofessional staff during treatment team
meetings, by progress monitoring of the courses and youth completion of the course
requirements.
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.
Education services are provided by Florida Scholars Academy/Florida Virtual School
(FSA/FLVS). This indicator was reviewed; however, will not be rated until the 25/26 review
cycle. The contracted educational provider maintains a written policy and procedures requiring
an education transition plan to be developed upon each youth’s admission. A review of five
closed records confirmed none contained an education transition plan. Youth who entered the
program before July 1, 2024, when FLVS began their contract, would not have had the
education transition plan developed by the provider. During an interview with the lead educator,
it was confirmed each youth is assisted with their education transition plan by the educational
staff on-site. During the annual compliance review week, a request for alternative plans for
youth entered after July 1, 2024, revealed education transition plans had not been created for
any youth before the beginning of December 2024.
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.
Education services are provided by Florida Scholars Academy/Florida Virtual School
(FSA/FLVS). This indicator was reviewed; however, will not be rated until the 25/26 review
cycle. The contracted educational provider has procedures in place to provide qualified
instructional personnel. A review of five educational instructional staff and one flex teacher who
provides virtual education at the program confirmed all had a current teaching certification. This
was verified by using the Florida Department of Education website. Each of the reviewed
teachers were teaching some out of field classes, as well as in field classes, according to youth
schedules and their current certifications, which were all non-renewable temporary certificates.
The parent/guardian notifications for out of field teachers were not provided so the out of field
subject areas could not be confirmed. During the annual compliance review week, it was
reported due to the closure of headquarters, verification of the school board approval of out of
field teaching for this provider could not be confirmed.
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Office of Accountability and Program Support Page 67 of 68 (Revised September 2022)
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.
Education services are provided by Florida Scholars Academy/Florida Virtual School
(FSA/FLVS). This indicator was reviewed; however, will not be rated until the 25/26 review
cycle. The education contract provider is responsible for referring all youth who receive their
high school diploma or equivalent to Florida Youth College so they can work with a career
navigator on postsecondary courses and/or enrollment in a state or technical college. A review
of five youth records confirmed none of the youth were referred to Florida Youth College.
Further review of the youth records revealed each youth was still working towards earning their
high school diploma at the time of their release; therefore, they did not meet the eligibility criteria
for a referral to Florida Youth College. An additional youth record was reviewed for a youth who
did meet the eligibility criteria and was referred to Florida Youth College.
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Each referral received by Florida Youth College from the education contract provider is
assigned a career navigator. The career navigator then connects with youth through the
residential contract provider to schedule an orientation session. During orientation, the youth
and career navigator develop a career pathway plan to include postsecondary courses and/or
enrollment in a state or technical college. The career navigator continues to assist youth on their
career pathway plan and have incremental follow-up sessions scheduled through the residential
contract provider. A review of five youth records confirmed there were no referrals made to
Florida Youth College, therefore, a career navigator was not assigned to the youth. An
additional record was requested for review. There was documentation to support the date of
orientation and the occurrence of a thirty-day, sixty-day, ninety-day, and 180-day follow-up.
Reviewed documentation confirmed the youth’s career interests were assessed. A copy of an
admission to a postsecondary program was not included, as it was stated the youth would enter
employment directly after release; therefore, they did not apply to a postsecondary program.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 68 (Revised September 2022)

report_type: QI Residential

program_name_raw: Palm Beach Youth Academy

rule: Indicator 4.13

excerpt: Episodic/First-Aid and Emergency Care

rating: Limited Compliance