state: FL

facility_name: Everglades Youth Academy

summary: QI Residential - FY24-25 - 2 findings

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Everglades Youth Academy- Sex Offender Program
Youth Opportunity Investments, LLC
(Contract Provider )
5050 NE 168th St.
Okeechobee, Florida 34972
Review Date(s): October 22-25, 2024
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:
Serena Brown, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Nicos Antonakos, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Rondarrell George, Office of Accountability and Program Support, Regional Monitor (Standard
2)
Danielle Penn, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Acasha Pressley, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Sharon Wong, Office of Accountability and Program Support, Regional Monitor (Interviews)
Program Name: Everglades Youth Academy- Sex Offender Program
MQI Program Code: 1481
Provider Name: Youth Opportunity Investments, LLC. Contract Number: 10289
Location: Okeechobee County / Circuit 19 Number of Beds: 16
Review Date(s): October 22-25,2024 Lead Reviewer Code: 226
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
3.08 Specialized Treatment Services*
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 71 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Non-Applicable
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Non-Applicable
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth 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 Contract Specific Career and Technical Education Services Satisfactory
1.19 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 71 (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 Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 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 71 (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* Limited
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 71 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 71 (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 Satisfactory
5.24 Controlled Observation Satisfactory
5.25 Controlled Observation Safety Checks and Release Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 71 (Revised September 2022)
Program Overview
The Everglades Youth Academy - Sex Offender Program (SOP) is a sixteen-bed program, for
thirteen to twenty-one-year-old males, located in Okeechobee, Florida. The program is operated
by Youth Opportunity Investments, LLC., through a contract with the Department. The program
provides Juvenile Sexual Offender Treatment Services. In addition, the program is co-located
with the Everglades Youth Academy - Maximum and High-Risk program under the same
contract on the same campus. The program fosters each youth by providing Skillstreaming the
Adolescent, Pathways, Impact of Crime, Thinking for a Change, and Living in Balance curricula.
Additional treatment services provided include individual, family, recreational, and group
therapy. The program administration is comprised of one facility administrator (FA), three
assistant facility administrators (AFAs), one human resources manager, and one administrative
assistant. Case management services are provided by one director of case management, five
case managers, and two transition services managers. Medical services are accessible twenty-
four hours a day, seven days a week and are provided by a registered nurse (RN) serving as
the health services administrator, one additional RN, two licensed practical nurses (LPNs), a
contracted physician, a contracted optometrist, a contracted dentist, and a contracted
psychiatrist. Educational services are overseen by the Florida Scholars Academy and provided
by Florida Virtual School. The building is designed with two wings, each containing three
separate living units. Everglades Youth Academy - SOP occupies one living unit on the east
wing. The living unit has sixteen individual sleeping rooms, a case management office, an open-
concept day room, and an adjoining classroom. The program has one main master control and
two sub-control stations, seven therapist offices, education offices, program administration
offices, a maintenance office and storage areas, one large recreation field, six small recreation
courts, a kitchen, a medical clinic, two medication pass rooms, and an automotive sally port.
The program has 113 video security cameras monitored by master control staff and six cameras
were inoperable at the time of the annual compliance review. The video surveillance system is
capable of recording over thirty days of video footage. At the time of the annual compliance
review, the program had ten vacancies consisting of three therapists, three master control
technicians, two shift supervisors, one staff development position, and one AFA position.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 71 (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 to ensure all newly hired staff and
volunteers receive an initial background screening. The program had fifty newly hired staff since
the last annual compliance review. A review of the staff records found forty-nine received a
background screening prior to contact with youth and confidential records and one staff record
showed an initial background screening was in progress and the staff had not had contact with
youth at the time of the annual compliance review. Documentation reflected a criminal history
report was reviewed and the Department’s Staff Verification System (SVS) module was updated
for each of the forty-nine staff. None of the reviewed records were applicable for obtaining an
exemption prior to working with youth. Two of the reviewed staff had a break in service as
indicated in SVS, and documentation supported the staff had a new background screening
completed prior to working with youth. The program utilizes a pre-employment assessment tool
for all direct care staff. Reviewed documentation reflected each of the applicable newly hired
staff received a passing score on the pre-employment assessment tool prior to hire. There were
no volunteers, contracted staff, and/or interns applicable for an initial background screening
since the last annual compliance review. The Annual Affidavit of Compliance with Level 2
Screening Standards was submitted to the Department’s Background Screening Unit (BSU) on
January 22, 2024, meeting the annual requirement.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program maintains a written policy and procedures to ensure all staff and volunteers
receive a background rescreening every five years from their initial date of hire. The program’s
administrator tracks each staff’s hire date and volunteer start dates to determine when the five-
year rescreening’s should be submitted. The program had two staff applicable for a five-year
rescreening since the last annual compliance review. Each staff’s rescreening was completed
and submitted to the Department’s Background Screening Unit prior to their anniversary date.
Each rescreening was completed at least ten business days prior to each staff’s five-year
anniversary. There were no volunteers or interns applicable for a five-year rescreening since the
last annual compliance review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 71 (Revised September 2022)
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 which provide an environment for staff,
youth, and others to feel safe and secure from any form of abuse or harassment. The program’s
policy requires the Florida Abuse Hotline and the Department's Central Communications Center
(CCC) telephone numbers to be posted and accessible to all. A tour of the program confirmed
the Florida Abuse Hotline and CCC numbers were posted throughout the program. The program
allows unhindered access for youth and staff to report allegations of abuse. The program had no
CCC allegations or incidents related to physical, psychological, and/or emotional abuse during
the annual compliance review period. Five reviewed staff records indicated staff signed the code
of conduct documentation in the staff handbook. The program’s steps to report abuse is for a
youth to request to make a call. Staff will provide the youth with telephone access in a controlled
observation area to make a confidential call. The shift supervisor is notified and a call to the
CCC is made within two hours of the program learning of the incident. The program will provide
basic information at the time of the report. Staff will document any incident number generated by
other agencies. The program began the Trauma Responsive and Caring Environment (TRACE)
self-assessment on June 21 and completed it on July 1, 2024, for the Mental Health Overlay
Services program under the same contract number on the same campus; however, the results
of the self-assessment were cancelled on October 8, 2024, due to inclement weather. All staff
completed the TRACE training during the pre-service orientation and annual training. Five youth
were interviewed, four reported never being stopped from reporting abuse to the Florida Abuse
Hotline or CCC, and one youth reported they have never had to call. All youth responded yes to
feeling safe at the program. Youth knew where to locate the telephone numbers for contacting
the Florida Abuse Hotline and CCC. Four of five interviewed youth agreed staff would speak
respectfully toward the youth at the program. One youth reported sometimes staff would speak
respectfully toward the youth. Three youth stated they never heard staff using profanity. One
youth stated they occasionally heard profanity and one youth stated it depends on the staff and
profanity was not directed at youth. Interview results were shared with the facility administrator
(FA). Four youth stated they never exchanged telephone numbers or social media contact
information with staff. One youth stated contact information was exchanged with a former staff
and former youth; however, the names were undisclosed. Five interviewed staff were asked
about allowing a youth to call in an abuse report and the responses included the youth are
allowed to make calls if needed, staff will notify the supervisor, staff follow chain of command to
have either the shift supervisor, case manager, or facility administrator (FA)/assistant facility
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 71 (Revised September 2022)
administrator (AFA) give the youth the call. All staff are mandated reporters and can make a call
as well. All five staff stated they have not observed a youth being denied an abuse call. All staff
agreed they never observed other staff using profanity toward youth. The FA was interviewed
and stated staff are always expected to maintain ethical and professional behavior.
Expectations are for staff to interact with youth in a manner promoting their emotional and
physical safety. In an event safety for the youth is compromised, an internal investigation would
immediately be conducted.
1.04 Management Response to Allegations (Critical) Non-Applicable
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had no allegations of physical, psychological, or emotional abuse in the program
during the annual compliance review period; therefore, this indicator is rated non-applicable.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program maintains a written policy and procedures for documenting and reporting incidents.
The program’s policy and procedures require the program to notify the Department's Central
Communications Center (CCC) within two hours of gaining knowledge of the incident. The
program had five CCC incidents reported during the annual compliance review period, and each
was reviewed. One of the five incidents was reported twenty-four minutes late. Two incidents
were documented as medical. The other three incidents reported were documented as
behavior, mental health, and falsification. A review of the master control logbook confirmed all
five incidents were documented. The program did not experience any increase in reportable
incidents to the CCC since the last annual compliance review, which had eleven documented
incidents.
1.06 Right Interactions (RI) and Physical Intervention Rate Non-Applicable
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.
There have been no Right Interactions (RI) incidents during the annual compliance review
period; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 71 (Revised September 2022)
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program maintains a written policy and procedures which state the residential contracted
provider staff will satisfy pre-service/certification requirements as outlined by Florida
Administrative Code within 180 days of hire. The program’s policy requires supervisors to
complete sixteen additional hours of supervisor specific pre-service training. Additional staff who
supervise the youth are the case managers, therapists, assistant facility administrator, and
operations managers. All of the instructors providing Right Interactions (RI), first-aid, and
cardiopulmonary resuscitation (CPR) were qualified trainers. The program submitted a pre-
service training plan and calendar approved by the facility administrator, assistant secretary for
residential services, and the director of the Department’s Office of Talent, Leadership, and
Culture. A review of five staff training records provided evidence all five staff completed training
within 180 days of hire. Staff trainings were documented in the Department’s Learning
Management System (SkillPro). Trainings required to be completed prior to any contact with
youth were child abuse recognition, reporting and prevention, CPR, first-aid, automated external
defibrillator (AED), program operating procedures, Prison Rape Elimination Act (PREA),
emergency procedures, RI, professionalism, interpersonal communication and ethics, and
suicide awareness and prevention. Additional trainings completed within the 180 days of hire
were active shooter preparedness, adolescent development and behavior, balanced approach
to restorative justice, the Department’s Central Communications Center (CCC) incident
reporting, civil rights, communication, confidentiality/Health Insurance Portability and
Accountability Act (HIPAA), Department of Juvenile Justice (DJJ) legacy/history, equal
employment opportunity, gang awareness, human trafficking, infection control, information
security awareness, the Department’s Juvenile Justice Information System (JJIS), mental health
and substance abuse, Motivational Interviewing, quality report writing, safety, security, and
supervision of youth, sexual harassment, effective and respectful treatment of youth, and
trauma responsive practices. Three out of five staff completed an additional training provided by
the program for electronic vape products. All five staff completed training in the grievance
process, infection control, Exposure Control Plan, behavior management system, the intent and
safe use of tools as required by the program’s manual, and specialized services training.
Training also included Mental Health Overlay Services, Substance Abuse Treatment Overlay
Services, and Juvenile Sex Offender Treatment Services. There was one supervisory record
applicable for pre-service training. The reviewed record for a shift supervisor indicated thirty-
three training hours were completed in the areas of coaching, leadership, and personal
accountability.
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 regarding in-service training for all staff.
The program’s policy requires all full time and part time staff to complete a minimum of twenty-
four hours of in-service training and supervisory staff will complete an additional eight hours of
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 71 (Revised September 2022)
training in the areas of coaching, leadership, or personal accountability annually. Five staff
training records were reviewed for in-service training. All five reviewed staff training records
documented each staff exceeded the twenty-four hours of annual in-service training
requirements. All five staff had current certifications in Right Interactions (RI). Each staff had
certification in first-aid, automatic external defibrillator (AED), and cardiopulmonary resuscitation
(CPR). Each of the two applicable staff exceeded the eight hours of management/supervisory
training in the areas of coaching, leadership, and personal accountability. The program has a
training calendar which is updated as changes occur. All trainings were delivered by qualified
trainers and were documented in the Department’s Learning Management System (SkillPro).
The program maintains a written in-service training plan which was submitted and approved by
the facility administrator, assistant secretary for residential services and the director of the
Department’s Office of Talent, Leadership, and Culture prior to implementation. One record was
applicable and indicated staff completed job specific specialty services training in Mental Health
Overlay Services, Substance Abuse Treatment Overlay Services, Comprehensive Services for
Major Disorders, Developmental Disabilities Treatment Services, Intensive Mental Health
Treatment Services, Juvenile Sex Offender Treatment Services, and Specialized Mental Health
Services. One staff was applicable for key position training in Outcome Based Corrective Action
Plans and specific, measurable, achievable, relevant, and time-bound (SMART) performance
management training, which was completed.
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 on the youth grievance process. The
program’s policy requires each youth to be treated fairly and not discriminated against by the
program staff for exercising their right to grieve. The program’s grievance process includes
three phases, which include an informal, formal, and appeal process. Grievance forms were
observed on the living unit during the program tour. The grievance boxes were observed in the
west and east wing hallways. The first way youth will express concerns and/or complaints is to
address the direct care staff on the living unit. The informal phase process includes youth
utilizing the Request to Speak form to communicate with their case manager and/or the
assistant facility administrator (AFA) assigned to the living unit. Another way youth will informally
discuss any concerns and/or complaints is during the monthly town hall meeting. The program’s
practice correlates with their process and copies of the grievances for the past twelve months
were maintained. During the annual compliance review period the program had one grievance
for safety dated on September 12, 2024. No appeal phase was needed, and the grievance was
completed according to the program’s policy and procedures. Five interviewed youth stated they
never had a reason to file a grievance. All five youth were aware of the grievance process. Each
youth stated the grievance would be addressed within twenty-four hours by the facility
administrator (FA). Five interviewed staff agreed youth have a right to complete a grievance.
Staff stated they are informed about grievances in the staff meetings. Staff explained the
grievance process included youth having access to the forms, filling out the forms, and placing
the forms into the grievance box. The supervisor and FA/AFA collect the forms to review. The
FA was interviewed on the programs formal grievance process and was able to explain the
steps for the youth completing a grievance and the appeals process.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 71 (Revised September 2022)
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program maintains a written policy and procedures for requirements for facilitator staff
training for the delinquency intervention models and evidence-based practices. The program’s
policy requires staff to be trained on the specific delinquency intervention models, strategy, and
evidence-based practices curriculum. The program’s non-clinical and non-primary delinquency
intervention model offered at the program is Thinking for a Change (T4C). The T4C group is an
identified supplemental services group. The program had one case manager trained to facilitate
T4C for the annual compliance review period, who resigned in October 2024. The trained case
manager’s education and work experience was considered by the program when determining
staff delivery for the delinquency intervention model. The supplemental group T4C was not
provided during the annual compliance review period. The program’s activity schedule was
reviewed and determined at least sixty percent of youths’ awake hours include structured,
planned programming, or activities. The facility administrator’s interview confirmed Living in
Balance (LIB) and Skillstreaming the Adolescent were the curricula used to address the
specialized needs of the population.
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 providing life skills training to the
program youth. The program’s policy requires treatment curriculum focusing on developmental
and social skills. Life and social skills are provided to the youth through the Living in Balance
(LIB) and Skillstreaming the Adolescent groups. Both groups provided communication,
interpersonal relationships and interactions, non-violent conflict resolution, anger management,
critical thinking, problems-solving, and decision-making. The program addresses the needs of
the program’s target gender group. A review of the sign-in sheets from January 31 to October
16, 2024, for the Skillstreaming the Adolescent groups confirmed youth were provided life skill
training three times a week on Mondays, Wednesdays, and Fridays. A review of the sign-in
sheets from December 22, 2023, to October 16, 2024, for LIB confirmed the group was held
once a week. The groups provided the youth life and social skills services/activities as required.
No additional life skill intervention services were provided at the program. The designated
mental health clinician authority (DHMCA) was interviewed and stated the specialized groups
included Pathways, Skillstreaming the Adolescent, and LIB. Five interviewed youth stated they
participated in Pathways, Skillstreaming the Adolescent, and LIB groups and were learning skills
on problem-solving and how to express their feelings. The facility administrator interview
confirmed LIB and Skillstreaming the Adolescent are the current curricula used to address the
specialized needs of the population.
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1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s contract requires the youth to participate in activities to increase their awareness
of crime victims. The program provides Impact of Crime (IOC) and additional restorative justice
awareness activities. In December, program youth participated in making holiday cards for the
local senior assisted living home. The youth participated in raising chickens for egg collections
and growing vegetables to donate to the local abuse shelter each quarter. The program
provided pictures and a program article documenting the donations to the local abuse shelter.
An interview with the facility administrator explained the different donation activities including the
vegetable garden and chicken coop donation of food, and the donation of holiday gifts. Five
interviewed youth stated they participate in IOC. Youth also stated they are learning to become
more open and change their ways through donating to the community.
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 for updating the internal alert systems
and the Department's Juvenile Justice Information System (JJIS) for easy access to alerts for
program staff. The program’s policy requires risk factors or special needs identified during the
admission process to be updated in the program’s internal alert system and/or JJIS. The
process of updating alerts is for the direct care, case manager, and/or clinician to place a youth
on alert status if youth meet the criteria for a new alert. A review of the program's internal alerts
binder confirmed it correlated with JJIS for updated youth alerts. Staff are informed about youth
alert information or changes to alerts during shift briefings, on the alert board in the conference
room, and from postings in the kitchen and the medical offices. A review of the five youth
records showed youth were identified with alert risks and were place in the alert system. None
of the alerts observed were entered late. All documented alerts were observed in the alert
logbook and shift reports. During the program nurse’s interview, it was reported medical staff
update alerts and non-licensed staff do not update alerts. The interviewed facility administrator
(FA) explained the process for updating the youth alerts in JJIS and which program staff were
responsible for updating the alerts. The FA stated all JJIS alerts must be consistent with internal
alerts. Five interviewed staff confirmed they are advised of any changes with youth alerts from
passed on information by the assistant facility administrator and shift supervisor during briefings,
managers meeting each morning, reviewing the JJIS alerts, the alert board in the conference
room, and the alerts posted in the medical office and master control.
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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 maintains a written policy and procedures for maintaining all the program’s youth
healthcare and case management records. The program’s policy requires the program to
protect and store the youth records in a secure cabinet. Based on observation during the
program tour, the Individual Healthcare Records, mental health and substance abuse records,
and individual case management records were stored in to separate binders in a secure records
cabinet labeled confidential. The individual case management records contained the youth’s
name, Department identification number, date of birth, county of residence, and committing
offense. The individual case management records contained sections for the legal information,
demographics and chronological information, correspondence, miscellaneous, case
management, and treatment team activities. All records were labeled confidential and/or
securely maintained electronically.
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 maintains a written policy and procedures to ensure the program has a community
advisory board. The program’s policy requires the program to have meetings at least every
ninety to 120 days with the community support groups and other community partnerships to
serve as support to the program. The program’s community support and advisory board
quarterly meetings were held in person on March 26, May 28, and September 30, 2024. The
ninety to 120 days were not met between the May 28 and September 30, 2024 dates. The
meeting was held five days late. A review of the sign-in sheets, agendas, and meeting minutes
confirmed the program maintained documentation of their email and mailed recruitment efforts
for involvement from a law enforcement representative, a school board representative, a faith-
based community member, a community business member, a member of the judiciary, a
representative from the LGBTQIA+ community, and other community partners. The advisory
board included a parent/guardian of a former youth involved with the juvenile justice system and
a victim services community representative. The interviewed facility administrator (FA) reported
the advisory board meets quarterly, and meetings are documented with sign-in sheets, meeting
agendas, and meeting minutes of the participation from the community members. A telephone
call was made during the annual compliance review week to a local community partner who
serves as a board member. A message was left with the board member’s secretary and there
was no return call.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program’s written policy and procedures detail the system for evaluating staff. The program
conducts quarterly performance evaluations for newly hired staff and annual evaluations for all
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staff thereafter. The administrative staff provide coaching sessions as needed. The program
maintains a detailed position description for all staff and a written agreement outlining duties for
all contracted staff. Five staff personnel records were reviewed, of which three contained an
annual performance evaluation, and two contained a ninety-day performance evaluation. Each
staff had an evaluation which was based upon a set of established performance standards
which aligned with the duties outlined on the staff’s position description. The evaluations rated
the staff’s quality of work, modeling of appropriate behavior, a positive reinforcement in a four-
to-one ratio, and each evaluation included ratings on the staff’s job-specific responsibilities. Five
staff were interviewed, and each staff had knowledge of how often they receive an evaluation.
Staff reported yearly, every six-months, and during their job probation period. An interview with
the facility administrator (FA) reported staff are evaluated after their first ninety days and
annually, thereafter, on their job performance.
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 is required to implement all items and services either negotiated or outlined in the
contract which are considered special contract conditions or listed within the scope of services
attachment. These may be referenced as the Memorandum of Negotiation (MON), summary of
negotiated points, special conditions, or simply listed in contract. These items typically exceed
the minimum requirements outlined in Florida Statute and Florida Administrative Code. The
program tracks measurable contract conditions through outcome measures entered into the
Department’s Juvenile Justice Information System (JJIS), which are administratively monitored
by the assigned contract manager annually. The program’s contract contains site-specific
requirements to include diverse media, faith-based opportunities, restorative justice and
community service offerings, parenting education, motivation, achievements, and reward
activities. A review of documentation, on-site observations, and an interview with the facility
administrator (FA) validated the program was providing special contract conditions, as required.
The program has a partnership with a community prison ministry representative who leads
religious activities for youth desiring to participate. The program offers restorative justice and
community service opportunities for all youth, which allows youth to complete community
service through canteen points, assisting in the kitchen, assisting maintenance, assisting with
the animal husbandry program, making posters and cards, food collection and can drives, and
participation with the greenhouse. The program has an animal husbandry program with
chickens on-site. Youth have built, maintained, and provide regular care for the chickens. The
program’s greenhouse has been updated and repaired and has been functional since the last
annual compliance review. Approximately seven youth have been participating in the animal
husbandry program. The program provides education and support for youth expecting a child
during the youth’s transition phase. There were approximately four youth who were fathers and
received parent education and/or resources while in the program since the last annual
compliance review. The program’s registered nurse provides instruction on developmental
milestones, shaken baby syndrome, car seats, and water safety to confirmed fathers. Youth
coordinate with their therapists regarding specific family therapy. Expectant fathers are provided
additional materials such as books, brochures, and mentoring opportunities during their stay.
Special visitations are coordinated, when appropriate. An informal interview with the compliance
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manager confirmed the program had a total of four applicable youth who received parental
resources and education. Observations in the youth’s living units showed books and other
publications were provided and the program has a youth library. The library has educational and
fictional reading materials for youth to sign-out. Specific requests are accommodated as
appropriate. Materials are screened and vetted through the lead teacher for appropriateness.
Media donations are encouraged by parent/guardians and community stakeholders. On-site
observations and informal interviews confirmed the youth have access to a variety of reading
materials in addition to tablet access. Youth tablets have pre-loaded educational games, access
to religious materials, and books. The program participates with drives for the donation of
clothing, shoes, hygiene items, food and engage in holiday celebrations with the program youth.
The next community activity scheduled is for a food and can drive which will be held for
Thanksgiving and is scheduled for November 5, 2024. All eligible youth completed all of their
community service hours while at the program. Youth with community service requirements
coordinate with the assigned case manager to ensure performance planning reflects the need
and community service. Hours are tracked on logs and provided to the assigned juvenile
probation officer. The program utilizes trained volunteers, mentors, and other members from the
community to provide positive modeling and experiences with the youth. The program has a
partnership with the community and local church volunteers, nonprofit agencies, to include a
domestic violence shelter, professional athletes, the local sheriff’s office, and staff mentors to
speak and model experiences with youth. On-site observations reflected the youth were wearing
their assigned uniform and were observed to be appropriately dressed. The program has a
barber chair, and it is utilized as part of the incentivized barbershop program. The program
participates in additional activities with community partnered programs. The program’s activities
include sport competitions, training camps, and other achievement celebrations. Incentives and
celebrations for positive behavior and youth success include honor roll, graduations, student of
the month, classroom of the week, daily, weekly, and monthly incentives, a football team, inter-
program sports tournaments, movie nights, music studio access, canteen, gym access,
quarterly dinners with administration, academic competitions, cook-off competitions, student
council, carnival/field days, family days, holiday celebrations, and pizza parties. Informally
interviewed youth and the interviewed assistant FA confirmed the program held incentive
celebrations in addition to the daily and weekly incentives for academic and behavioral
achievements.
1.18 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program maintains a written policy and procedures which address data trend analysis
components. The program’s administration and management policy addresses research efforts
to enhance operations and contribute to the base knowledge of juvenile justice. The program’s
quality assurance and program planning policy detailed a formal process for monitoring and
evaluating quality, compliance, fidelity, appropriateness, safety, and effectiveness of all program
services utilizing a framework for measurement and evaluation of outcomes and process
measures. The program conducts weekly security audits. The report identifies any deficiencies
and potential issues within the program and anticipated resolution dates. A review of the weekly
security audits confirmed the audits were conducted and completed on a weekly basis as
required. An interview with the program’s compliance manager explained the program’s efforts
to collect and analyze data. Additionally, the program participates in monthly compliance
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reviews to discuss accomplishments, the facility administrator’s (FA’s) plan of action, any
corrective actions put in place, monthly staff and youth survey responses relating to perceptions
of program safety, living environment, treatment environment, whether youth community
meetings are occurring, and monthly incidents. The program conducts interviews with families
and youth on a quarterly basis, tracks outcome measures, monitors incident reports, conducts
internal fidelity monitoring, tracks evidence-based services, incidents, and quality improvement
audits. The program discusses scores, results, and findings in the morning management
meetings, monthly management meetings, community advisory board meetings, and during the
program’s all-staff meetings.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a written policy and procedures regarding initial contact to each youth’s
parent/guardian and court notification upon each youth’s admission. A review of five youth case
management records reflected the program notified each parent/guardian by telephone within
twenty-four hours of admission and notified each parent/guardian in writing within forty-eight
hours of admission. Each case management record reflected the court and juvenile probation
officer (JPO) 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 has a written policy and procedures regarding youth orientation. A review of five
youth case management records reflected the program provided each youth an orientation on
the day of admission. The program did not have an admission during the annual compliance
review week; therefore, a youth admission was not observed. Reviewed documentation verified
the youth orientation included all the necessary elements. Five youth were interviewed, and
each reported the orientation process provided all the required information. One youth stated
the program took them to the medical office first, then to the therapist, and lastly to the case
management office to complete the orientation. One youth stated a black folder was given to
them with everything the program expects of them. One youth reported during the orientation
phase, which is comprised of the first twenty-one days, there is no visitation or mail until
orientation is over. The youth reported the beginner phase has more privileges like receiving
mail and visitation. The next step in the process is the intermediate phase, then the veteran
phase, and then expert phase. One youth stated they were given a youth handbook which
included rules, level system information, procedures, and all basic needs.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a written policy and procedures regarding written consent of youth eighteen
years of age or older. A review of five youth case management records reflected four were
applicable for the program to obtain written consent since the youth were over the age of
eighteen before providing or discussing information with the parent/guardian. One youth was
under the age of eighteen. Each applicable case management record had a signed consent
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form allowing the program to discuss information related to the youth’s physical or mental health
screening, assessment, or treatment.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a written policy and procedures regarding a classification system, in
accordance with Florida Administrative Code, which promotes safety and security, as well as
effective delivery of treatment services. The program’s policy requires the initial classification to
be used for the purposes of assigning each newly admitted youth to a living unit, sleeping room,
and youth group or staff advisor. Each youth admitted 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. A
review of the program’s classification form indicated it included the 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. A review of five youth case management records reflected each
classification form included, the youth’s physical characteristics, gender, height, weight, general
physical stature, age, maturity level, identified special needs including medical, mental health,
escape risk, security risk, development, intellectual, and physical disabilities, history of violence,
gang affiliation, and criminal behavior. Each youth’s applicable risk factors were marked on the
form along with a review of the Department's Juvenile Justice Information System (JJIS) alert
list to assist in assigning the youth to living, sleeping, and advisor arrangements. Each of the
five youth did not have suicide risk or escape risk factors. None of the five youth warranted a
reclassification for an increase in the youth’s privileges or freedom of movement, and/or
participation in a work project. None of the reviewed youth were applicable for off-campus
activities. The interviewed facility administrator reported the program’s case manager or
designee will facilitate an admission classification meeting for all admitted youth immediately
following the initial intake screening process. Meeting outcomes will be documented and a
justification for room placement will be identified on the Admission Classification form.
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2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a written policy and procedures regarding gang identification and notification
to law enforcement. The program’s policy requires staff to review each youth’s Department Face
Sheet prior to arrival at the program to identify alerts, including gang involvement, if known. If a
youth comes in without proper prior identification as a gang member and discloses during intake
they are a gang member, the case manager notifies the facility administrator (FA) and the
program’s gang specialist. Five youth case management records were reviewed, and one was
identified as being potentially involved in gang activity. Two additional records were provided for
review. Each reviewed record indicated local law enforcement, law enforcement in the youth’s
home county, the educational provider, and the youth’s juvenile probation officer (JPO) were all
provided notification of the suspected gang involvement. Each youth had the appropriate gang
alerts entered in the program’s internal alert system and the Department's Juvenile Justice
Information System (JJIS).
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a written policy and procedures regarding gang prevention and intervention
strategies. The program’s policy requires gang prevention and intervention activities to be
implemented when youth are identified as being a criminal street gang member, affiliated with a
criminal street gang, or are at high-risk of involvement, through the Impact of Crime curriculum.
Each youth’s performance plan shall include goals and objectives relating to gang activities and,
if the youth desire, a plan to disaffiliate prior to the youth’s release from the program. Five youth
case management records were reviewed, and one was applicable for gang identification
prevention and intervention activities. Two additional records were requested for review. In each
reviewed record the youth was identified as a gang member or affiliated gang member. Each
reviewed record had sign-in sheets which confirmed the youth participated in gang prevention
and intervention strategies. A review of each youth’s performance plan showed each included
relevant goals and objectives related to gang intervention strategies for the youth to complete
prior to release from the program. The program utilizes the ARISE Foundation’s Life Skills
Gangs: 50+ Stories of Fractured Lives as the selected gang prevention and awareness
curriculum. A review of the gang intervention group sign-in sheets confirmed the groups were
provided as required. An interview with the facility administrator (FA) indicated gang intervention
and prevention strategies are provided to the youth monthly.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
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team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a written policy and procedures to ensure the individualized needs of each
admitted youth are identified and prioritized through a comprehensive assessment process
completed by a multidisciplinary intervention and treatment team. As a part of the needs
assessment process, the intervention and treatment team identify the youth’s criminogenic risk
and protective factors, prioritize needs, and determine the youth’s risk to reoffend. The
program’s policy requires the Residential Assessment for Youth (RAY) to be completed within
thirty days of the youth’s admission to the program. The program shall ensure reassessments
are completed for each youth at least every ninety days from the initial assessment. A review of
five youth case management records were reviewed and confirmed each initial RAY was
complete within thirty days of admission and maintained in Department's Juvenile Justice
Information System (JJIS). Two of the reviewed records were applicable for a RAY
Reassessment and three youth had not been in the program for ninety days at the time of the
annual compliance review. All initial RAYs and completed reassessments were maintained in
each youth’s case management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a written policy and procedures ensuring the Youth Needs Assessment
Summary (YNAS) process is completed within thirty days of each youth’s admission. A review
of five youth case management records showed each contained a YNAS which was completed
within thirty days of the youth’s admission to the program. Each YNAS was documented in the
Department's Juvenile Justice Information System (JJIS), included the signature of each
treatment team member, and a copy was maintained in each youth’s case management record.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a written policy and procedures ensuring performance plan development,
goals, and transmittal are completed properly. Reviewed documentation of five applicable
performance plans confirmed the Individualized Performance Plan (IPP) was developed within
thirty days of the youth’s admission. The program’s policy requires each plan to be developed
after the initial Residential Assessment for Youth (RAY) and Youth Needs Assessment
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Summary (YNAS). Each reviewed IPP was developed and signed by the treatment team leader,
youth, administrative representative, living unit representative, treatment staff, education staff,
and other parties with a significant responsibility in goal completion. There were no applicable
youth for current involvement with the Department of Children and Families (DCF) or the
Agency for Persons with Disabilities (APD). Each signature sheet was attached to the original
performance plan in the youth’s official case record. There was documentation indicating the
signature sheet was sent to each parent/guardian to obtain their signature; however, none of the
signature sheets were returned during the annual compliance review period. Each reviewed IPP
included goals based upon the prioritized needs for each youth, reflecting the risk and protective
factors identified during the initial assessment process. Each plan had the youth’s three top
criminogenic needs. Each plan detailed transition activities and set target dates for the youth’s
final sixty days in the program. The plans specified the youth’s responsibilities for achieving
goals, along with the program staff’s responsibilities in supporting them. Every goal had a
designated target date for completion. Within ten working days of the completion of each plan,
the program sent a transmittal letter and a copy of the plan to each youth’s committing court,
juvenile probation officer (JPO), and parent/guardian. There were no applicable youth for
current involvement with the Department of Children and Families (DCF). Five youth were
interviewed, and each stated they participated in the development of the performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a written policy and procedures requiring each youth’s Individualized
Performance Plan (IPP) to be revised as needed for completion of the program. Five youth
records were reviewed, and four were applicable for performance plan revisions based on the
Residential Assessment for Youth (RAY) Reassessment results, newly acquired information
which warranted a change, and demonstrated progress towards goal completion. None of the
five reviewed records were applicable for youth in transition; therefore, they did not contain
information needed to facilitate transition activities for the last sixty days of the youth’s stay in
the program. Each reviewed performance plan indicated and referenced academic and
treatment goals which were incorporated into the youth’s plan. There were no applicable youth
for current involvement with the Department of Children and Families (DCF) or the Agency for
Persons with Disabilities (APD).
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a written policy and procedures regarding Performance Summaries and
transmittals. The program’s policy states the intervention and treatment team shall complete a
Performance Summary on each youth every ninety days after the development of the
Individualized Performance Plan, unless the committing court request for every thirty days.
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A review of five youth case management records revealed two were applicable for Performance
Summaries to be complete every ninety calendar days and the other three youth were not in the
program for ninety days during the annual compliance review week. There were no youth
applicable for Performance Summaries prepared prior to the youth’s release, discharge, or
transfer from the program. Each reviewed summary included goals, overall treatment progress,
academic status, behavior, level of motivation and readiness to change, interaction with peers
and staff, overall behavior adjustment to the program, and significant positive and negative
events. Reviewed documentation reflected each youth was allowed to read and add comments
prior to signing and received a copy of the summary, and the original summary was filed in the
youth’s case management record. Each Performance Summary was signed and dated by the
treatment team leader, staff preparing the summary, facility administrator or designee, and the
youth. Reviewed documentation indicated a copy of each summary was sent to the youth’s
committing court, juvenile probation officer (JPO), and parent/guardian within ten working days
of the completion of the summary. Three closed records were reviewed for a release summary.
Each release summary included the original summary, justification for release, and a Pre-
Release Notification (PRN) sent to the JPO. Each release summary and PRN were sent within
seventy-two hours of planned release. Each record included a signed copy of the summary.
None of the records indicated the court objected to the youth’s release. Each closed record
documented notification to the youth’s parent/guardian of the youth’s release date once the
program obtained the approved PRN from the youth’s committing court. Each reviewed release
record contained a Residential Assessment for Youth (RAY) exit assessment. Three youth were
applicable for referral to the Sexually Violent Predator Program (SVPP). Each youth’s JPO was
notified by email of release; however, none of the reviewed youth were deemed eligible for the
SVPP. One youth was applicable for victim notification, and the program mailed the Victim
Notification of Release letter to the victim or designee at least ten days prior to the youth’s
release. The other two youth’s victims lived with the youth.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a written policy and procedures to ensure parental/guardian involvement in
case management services. Documentation supported the program makes efforts to include the
parent/guardian in the assessment process, participation in the development of the youth’s
performance plan, progress reviews, formal treatment team meetings, and transition planning. If
a parent/guardian is unable to attend the meetings in person, they are afforded the opportunity
to participate by telephone or are able to provide verbal or written input prior to the meeting. At
the time of the annual compliance review the program did not have any scheduled treatment
team meetings; therefore, the reviewer did not complete an observation. A review of the youth’s
progress notes revealed the program reaches out to parents/guardians to facilitate involvement
by telephone, email, and/or a letter will be sent to the residence. An interview was conducted
with the facility administrator (FA), and it was indicated all parents/guardians are provided a
handbook upon admission. The parents/guardians are encouraged to participate in monthly
treatment teams and family sessions as well. Five youth were interviewed, and three stated their
parents/guardians are involved during monthly treatment meetings. One youth stated their
family resided out of state, so they provided information by telephone.
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2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a written policy and procedures regarding the requirements for formal and
informal treatment team meetings. Five youth case management records were reviewed, and
each record contained documentation the formal reviews were held at least every thirty days.
Reviewed documentation confirmed the formal treatment team meeting documentation included
the youth’s name, date of the review, all required attendees, comments, a brief synopsis of the
youth’s progress at the program, any performance plan revisions, and positive and negative
behaviors. Each youth was provided an opportunity to demonstrate skills acquired in the
program and comment on their progress. All Residential Assessment for Youth (RAY)
Reassessment results were discussed, and each formal treatment team’s documentation was
maintained in the youth’s record. Each informal review was held bi-weekly, alternating formal
treatment team meetings. Documentation supported informal treatment team documentation
included the youth’s name, date of the review, all required attendees, comments, a brief
synopsis of the youth’s progress at the program, any performance plan revisions, progress on
performance plan goals, and positive and negative behaviors. Each youth was provided an
opportunity to demonstrate skills acquired in the program and comment on progress. All RAY
Reassessment results were discussed, and all informal treatment team documentation was
contained in each youth’s record. Documentation confirmed the youth’s juvenile probation
officer (JPO), parent/guardian, and other pertinent parties were invited and encouraged to
attend the meetings or to provide verbal or written input. The program did not conduct a
treatment team meeting during the annual compliance review week; therefore, no treatment
team meeting was observed. Five youth were interviewed, and each stated they are a part of
the treatment team meeting, and they are allowed to demonstrate skills acquired in the program.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a written policy and procedures regarding the transition planning conference
and the Community Re-Entry Team (CRT) meeting to plan for each youth’s successful transition
to the community upon release from the program. The policy outlines the process for transition
planning, conferences, and the CRT meeting. A review of three closed youth case management
records indicated each youth had a transition conference held at least ninety days prior to their
targeted release date. Documentation confirmed the youth, treatment team leader, facility
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administrator or designee, and other team members attended the transition conference. The
program documented attempts to facilitate involvement from the juvenile probation officer (JPO),
parent/guardian, education staff, and other pertinent parties and noted their input in the
transition conference documentation. Reviewed documentation supported during the transition
conference, participants reviewed transition activities on the youth’s performance plan, revised
the performance plan as necessary, identified additional transition activities as needed,
identified target completion dates, and the persons responsible for completion. The treatment
team leader obtained all attendees’ dated signatures and noted those who participated over the
telephone, virtually, or through writing. The plan was sent to those who couldn’t attend in person
and the email acknowledgments were filed with the plan. Each reviewed CRT confirmed the
meeting was conducted prior to the youth’s release and all parties participated. Each youth case
management record provided evidence of an email invitation to participate in the CRT meeting.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a written policy and procedures regarding exit portfolios for youth released
back into the community. Three closed youth case management records were reviewed, and
each documented the exit portfolios were discussed and initiated for the youth’s transition
conference. One out of the three exit portfolios did not have a state issued identification, Social
Security card, and birth certificate. The program reported the youth lived out of state and the
information was requested prior to the youth’s release. The other two exit portfolios contained
all the required items. There was documentation to support the exit portfolio was verified during
the exit conference and was provided to the youth and juvenile probation officer (JPO) upon
release for all three youth. Each youth was provided with completed forms and clear instructions
as to how to obtain information necessary for employment. During the transition conference, a
plan documenting the persons responsible for working with the youth to obtain the needed
information was created.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a written policy and procedures regarding exit conferences. The program’s
policy requires the exit conference to be conducted to review the status of goals developed at
the transition conference and to finalize release plans. A review of three closed youth case
management records was completed. Each reviewed record documented an exit conference
was held after the program notified the assigned juvenile probation officer (JPO) of the youth’s
release and at least fourteen days prior to release. The reviewed documentation indicated the
date of the conference, signatures, and a summary of pending transition goals. Each youth’s
date of admission and date of termination documented in the case record correlated with the
Department's Juvenile Justice Information System (JJIS). Reviewed documentation confirmed
the status of transition activities established at the transition conference, a review of plans
finalized for the youth’s release, and provisions for continuation of education or employment.
Documentation supported the youth’s parent/guardian and JPO were aware of the vocational
plan for the youth. Each exit conference included the intervention and treatment team leader,
parent/guardian, education representative, JPO, the youth, and all other pertinent parties. All
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three youth records documented the exit conference was conducted separately from the
transition conference and 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 has a policy and procedures regarding youth input. The program has a formal
process to promote constructive input by youth, giving them a Request to Speak form, which will
be filled out and submitted. This form is located on each living unit at the program. Additionally,
the program hosts town hall meetings and student advisory board meetings, which are held
monthly for each living unit. There was a review of the program’s sign-in sheets, agendas, and
meeting minutes to confirm the meetings were being held as required. The student advisory
board meetings were conducted once each month and the town hall meetings were conducted
twice each month. An interview with five youth indicated youth may submit a grievance form
about a concern or can request to speak to a supervisor or the facility administrator (FA), if
needed. Additionally, a youth my request to speak with a therapist to convey concerns or issues
at the program. An interview with the FA indicated monthly surveys are completed by youth, bi-
weekly town hall meetings are conducted, and monthly student advisory council meetings are
conducted to allow youth to provide input and communicate their concerns, as well as address
any systemic issues they may have.
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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 regarding the designated mental health
clinician authority (DMHCA). The program employs a clinical director who serves as the
program’s DMHCA. The program’s DMHCA is a full-time staff who is on-site at least forty hours
each week and is responsible for the coordination and implementation of mental health services
in the program. As a part of the assigned responsibilities, the DMHCA shall ensure consistent
and appropriate mental health services and shall be available on-call twenty-four hours a day,
seven days each week to provide consultation in the event of emergencies. The program’s
assistant clinical director shall coordinate licensed clinician coverage as needed and assist in
DMHCA responsibilities in their absence. The program’s DMHCA is a licensed clinical social
worker. A review of the license determined it was free and clear in the State of Florida with an
expiration date of March 31, 2025. The interviewed DMHCA confirmed their on-site schedule of
at least forty hours each week and being on-call for emergencies. The program’s licensed
assistant clinical director provides back-up DMHCA coverage and is a licensed mental health
counselor. A review of the assistant clinical director’s license reflected it was free and clear in
the State of Florida with an expiration date of March 31, 2025. The interviewed DMHCA
indicated their role in the coordination and implementation of mental health services at the
program includes the provision of clinical supervision, fidelity monitoring, oversight of service
tracking, and the facilitation of group, family, and individual counseling.
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 regarding licensed mental health and
substance abuse staff to establish requirements for qualified professionals in the delivery of
mental health and substance abuse services. The program’s policy requires all licensed and
non-licensed mental health and substance abuse staff to be hired in accordance with contract,
Department Rule, and mandated guidelines. Treatment shall be provided by individuals meeting
qualifications. The program’s designated mental health clinician authority (DMHCA) is
responsible for ensuring staff working under their supervision are qualified to provide services
based on education, training, and experience. The mental health staff include a licensed
DMHCA, a licensed assistant clinical director, one licensed therapist, and a licensed
psychologist. Each reviewed license was free and clear in the State of Florida and available on-
site as required.
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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 program’s policy requires all mental health and substance abuse services to be provided by
licensed or non-licensed clinical staff members who are qualified to provide such services based
upon education, training, experience, and who are working under the direct supervision of a
licensed mental health professional. The program’s designated mental health clinician authority
(DMHCA) holds an active and clear license and serves as the program’s supervisor for all on-
site clinical staff. The program’s contract requires one licensed DMHCA, one licensed assistant
clinical director, and eight therapists. At the time of the annual compliance review the program’s
non licensed staff included five full-time therapists and one part time therapist. The program
reported having one vacancy. The non-licensed position has been vacant since August 2024. A
review of direct supervision logs for non-licensed staff since the last annual compliance review
reflected each staff received face-to face clinical supervision for the weeks in which services
were provided without exception. Supervision was documented on the program’s form and
included all elements of the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. The program is
licensed under Florida Chapter 397 with the Department of Children and Families to provide
adolescent substance abuse services. The license was displayed in the lobby and expires April
1, 2025. A review of the non-licensed staff’s experience and education indicated two staff held a
master’s-level degree and three held a bachelor’s-level degree. All three staff with bachelor’s-
level degrees had fifty-two hours of specialized pre-service training to include sixteen hours of
training on duties and responsibilities prior to working with youth. Each of the non-licensed staff
had twenty hours of training in the administration of the Department’s Assessment of Suicide
Risk and Crisis Assessments.
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 identifying each youth’s mental health
and substance abuse needs through a required comprehensive screening process to ensure
necessary referrals are made for at-risk youth. The program’s policy requires the screening to
include a review of relevant information including the commitment packet, reports, and/or
records for existing documentation of mental health or substance abuse problems, and/or
history of human trafficking. The program’s practice is to complete a Massachusetts Youth
Screening Instrument, Second Version (MAYSI-2) and an Assessment of Suicide Risk (ASR) for
all youth regardless of the screening results. The facility administrator (FA) is responsible for
developing a written policy and procedures for the implementation of a standardized
admission/intake mental health and substance abuse screening process. The policy included a
standardized screening process, incorporated a review of commitment packet information,
reports, and records, administration of the MAYSI-2 on the Department’s Juvenile Justice
Information System (JJIS) by a qualified professional, referral of juvenile offenders identified by
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screenings as in need of further evaluation or immediate action, staff training in mental health
and substance abuse issues, and a standardized process for referral of youth identified as in
need of further mental health and/or substance abuse evaluation to an appropriate service
provider/professional or, when immediate attention is needed, to a hospital or Baker Act or
Marchman Act receiving facility as required. The FA’s interview confirmed all youth are
evaluated by a licensed mental health counselor (LMHC) during intake and those determined to
be at risk for suicide are referred as necessary. A review of five youth records confirmed a
MAYSI-2 was completed during admission for each youth. Each reviewed record confirmed
screenings were completed by trained staff and put into JJIS on the date of admission. All
MAYSI-2 screenings were completed in full and staff conducting the screening reviewed each
youth’s commitment packet information and records for existing mental health and substance
abuse problems as required. The program generates a referral, if necessary, for further
evaluation or immediate attention including the reason and utilization of a MAYSI-2 tracking log
for further assessment requirements. Four of five youth needed additional referrals due to
substance abuse, anger, traumatic thoughts, somatic complaints, depression, and disturbing
thoughts. The program’s practice is to refer all youth for further evaluation regardless of MAYSI-
2 results. No youth were applicable for an immediate assessment, crisis intervention, or
emergency services.
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 documenting the specification of mental
health and substance assessment/evaluations. Youth are identified by screenings, staff
observations, or behaviors post-admission. Referrals are made for a comprehensive mental
health evaluation and/or comprehensive substance abuse evaluation if necessary. The
program’s practice is to complete a new comprehensive mental health and substance
evaluation within thirty days of each youth’s admission. A review of five youth records verified
the program completed a combined mental health and substance abuse evaluation referral at
admission. All five youth records contained a new mental health evaluation completed within
thirty calendar days of admission and a youth consent for substance abuse services. A non-
licensed mental health or substance abuse clinician completed the evaluations; however, a
licensed mental health clinician reviewed and signed each evaluation within ten calendar days.
The evaluations consisted of demographics, reason for evaluation, relevant background
information such as home environment and family functioning, history of physical abuse, sexual
abuse, neglect, witnessing violence and other forms of trauma, behavioral functioning, physical
health, mental health, and substance abuse history, and education functioning. In addition, the
evaluations included behavioral observations, a Mental Status Examination, interview or
procedures administered, discussion of findings, diagnostic impression/formulation, including
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, patterns
of alcohol and other drug abuse, impact of alcohol and other drug abuse on major life areas, risk
factors, other drug abuse, and recommendations.
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3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a written policy and procedures requiring the mental health treatment
team to ensure each youth’s treatment plan to be individualized and relevant to their specific
needs. The treatment team shall consist of the designated mental health clinician authority
(DMHCA), mental health and substance abuse clinical staff, and other applicable members
assisting in the youth’s mental health needs. Each youth determined to have a mental disorder
or substance abuse impairment who is receiving substance abuse treatment in the program
requires 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 must be completed. Five youth records were reviewed
confirming each initial treatment plan’s completion within seven days of initiation of treatment,
date of development, and an initial treatment note. Each plan was documented on the
program’s form and contained all required elements of the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. One of five reviewed plans included the
prescription of psychotropic medication, the Initial Psychiatric Diagnostic Interview completion
within seven days, and the youth’s psychiatric needs including medication and frequency of
monitoring by the psychiatrist. Each initial plan was signed by a licensed mental health clinical
staff and all treatment team members who assisted in creating the plan. Additionally, the plan
was signed by, or indicated participation of, the youth, parent/guardian, when applicable,
juvenile probation officer, treatment team leader, program management, living unit
representative, education representative, and any other applicable treatment team members.
The individualized treatment plans and reviews included the dates of reviews. All reviews were
completed at least every thirty days as required. The individualized treatment plans included all
prescribed services and included all required signatures. Each individualized plan included
personalized goals and objectives for each youth. Four of five youth were recommended
individual counseling four times a month, group therapy five times a month, and family therapy
once a month. One youth was prescribed individual counseling twice a month. One youth also
had medication management once a month. Video surveillance confirmed group therapy
sessions were conducted for the required time and length 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.
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The program maintains a written policy, procedures, and requirements for mental health and
substance abuse treatment and discharge planning. Mental health and substance abuse
treatment planning focuses on providing mental health and/or substance abuse interventions
and treatment to reduce or alleviate the youth’s symptoms of mental 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 and/or substance abuse
treatment plans. All youth who receive mental health and/or substance abuse treatment while in
the 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 the youth’s release from the program. Treatment teams consist of the youth,
administration, residential living unit representative, and other staff responsible for delinquency
intervention and treatment services for the youth. Five youth records were reviewed and
confirmed each youth was assigned a treatment team at program arrival. Documentation
confirmed the assigned team members were in attendance during each meeting. Each youth
record indicated the mental health and substance abuse treatment services included individual,
group, and/or family counseling provided by a qualified professional or non-licensed substance
abuse clinical staff in accordance with the youth’s initial or individualized substance abuse
treatment plan. Four of five youth were eighteen years of age, and one youth had a court order
authorizing treatment; therefore, none were applicable for the Department’s Authority for
Evaluation and Treatment (AET) form. The four youth records did contain the Department’s
consent for youth eighteen or older, and the remaining record contained a court order. All five
youth records contained a Youth Consent for Substance Abuse Treatment form. All mental
health treatment notes or substance abuse treatment notes were documented on a form
containing all necessary elements. Each of the five youth records indicated individual
counseling, psychosocial skills training, and progress notes determined each youth received
services as stipulated on the treatment plan. None of the five records were applicable for a
discharge plan; therefore, a review of three additional records was completed. A discharge plan
was completed and documented on the appropriate form for each reviewed record. None of the
three youth were released on suicide alert/precautions. Future mental health or substance
abuse treatment recommendations were documented on the discharge plan and discussed with
each youth, parent/guardian and juvenile probation officer (JPO). The program’s practice is to
send a hard copy of the Mental Health/Substance Abuse Treatment Discharge Summary to the
youth’s JPO for their records.
3.08 Specialized Treatment Services (Critical) Limited 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 involving specialized treatment services.
According to the program’s contract, required primary clinical groups are Pathways and
Skillstreaming the Adolescent. The designated mental health clinician authority worked on-site
for forty hours a week and was on call for emergencies. The clinical staff worked on-site seven
days a week and on-call as needed. The identified non-primary group is Living in Balance (LIB).
All five interviewed youth confirmed attending groups as scheduled on a consistent weekly
basis. Additionally, five interviewed staff also confirmed groups were occurring as scheduled.
Each group was in ratio according to the contract. The designated mental health clinician
authority (DMHCA) confirmed the mental health and substance abuse groups were provided.
The program’s practice is to provide individual counseling once every two weeks, sex offender
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counseling two times each week, family therapy once a month, and psychiatric services
monthly, or as needed. A contract amendment stipulated family therapy should be provided
once every two weeks as of July 1, 2024, and three juvenile sex offender counseling groups
shall be provided weekly. A review of documentation indicated services were not being provided
in accordance with the amendment. A licensed psychologist was on-site as needed, which was
confirmed by documentation and interviews with the facility administrator and designated mental
health clinician authority (DMHCA).
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 regarding the psychiatric services
provided to the program’s youth. Psychiatric services include psychiatric evaluation, psychiatric
consultation, medication management, and medical supportive counseling provided to youth
with a diagnosed Diagnostics 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
Department Rule. Reviewed documentation confirmed the program’s utilization of a licensed
psychiatrist with a clear and active license expiring January 31, 2026. The psychiatrist is
contracted to be on-site bi-weekly and on-call for emergency consultation twenty-four hours a
day, seven days a week. A review of logbooks confirmed the psychiatrist’s visits were
conducted on a bi-weekly basis, with active supervision of medication services and ongoing
evaluations. An interview with both the psychiatrist and the designated mental health clinician
authority (DMHCA) confirmed meetings with the facility administrator to discuss youth receiving
psychiatric services were occurring once each month, and psychiatric services were occurring
bi-weekly. A review of five youth records revealed none entered the program on psychotropic
medications. An additional two youth records were reviewed; however, the youth were not
admitted on psychotropic medications either. The two records reviewed were prescribed
psychotropic medications after entering the program. An interview with the program’s nurse
indicated there were no additional youth admitted on psychotropic medication. Documentation
confirmed the program’s practice to refer all youth entering the program for psychiatric
interviews. Both reviewed records indicated the Initial Diagnostic Psychiatric Interviews included
the youth’s history, medical, mental health and substance abuse history, a Mental Status
Examination, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
diagnosis, treatment recommendations, initial treatment goals, potential side effects,
risks/benefits, and frequency of medication. The initial interview was completed on the
Department’s Clinical Psychotropic Progress (CPPN) form, with each identified as the Initial
Diagnostic Psychiatric Interview. The two youth were receiving medication reviews every thirty
days and documentation supported this practice. The CPPN was completed accurately
documenting the prescription of psychotropic medication after the evaluation. Both reviewed
records confirmed page three of the CPPN included identifying data, diagnosis, target
symptoms of each medication, evaluation and description of effects, prescribed psychotropic
medications, and side effects. The documentation supported each parent/guardian was
contacted by telephone to discuss the evaluation and medication, and each evaluation was
signed by the psychiatrist. The program does not utilize tele-psychiatry.
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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 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 Florida Administrative
Code. The program maintains a written plan detailing suicide prevention procedures for any
youth identified as a risk in the program. The plan outlines guidelines for identification and
assessment of at-risk youth. The plan involves staff trainings, suicide precautions, levels of
supervision, referrals, communication, notification, documentation, immediate staff response,
and review processes. The review process for suicide attempts and mortality review included
circumstances surrounding the event, procedures relevant to the incident, all relevant training
received by staff involved, pertinent medical and mental health services involving the victim,
possible precipitating factors, and recommendations for changes in policy, training, physical
plant, medical or mental health services, and/or operational procedures. The Suicide Prevention
Plan was reviewed and approved by the facility administrator on October 21, 2024.
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 policy and procedures for the Suicide Prevention Plan which
provides necessary directives for identifying, managing, and accessing potentially suicidal
youth. 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. The program’s practice is to complete an admission screening
determining youth at-risk for suicide and to complete an Assessment of Suicide Risk (ASR). Any
youth identified as at-risk is placed on precautionary observation. None of the five youth records
were applicable for suicide risk. Additional records were requested; however, only one record
was applicable for suicide risk since the last annual compliance review. The youth was identified
as being at-risk through staff observations. The youth exhibited signs of suicide risk and was
placed on constant supervision. The juvenile probation officer and parent/guardian were
notified, and notification was documented on the ASR. Mental health staff did provide supportive
services and the designated mental health clinician authority (DMHCA) completed the suicide
risk assessment and the youth was placed in secure observation placement. The youth was
placed on secure supervision from December 5, 2024, until January 18, 2024. The documented
ASR was completed within twenty-four hours by the DMHCA. Follow-Up ASRs were completed
resulting in a Baker Act for the youth after a conference was completed with the facility
administrator and DMHCA. An alert was initiated in the Department’s Juvenile Justice
Information System (JJIS) and accurately closed after the youth was removed from secure
observation. The logbooks and video surveillance confirmed active supervision of youth while
on secure observation and verified supervision practices.
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3.12 Secure Observation (Critical) Satisfactory Compliance
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program maintains a written policy and procedures for the Suicide Prevention Plan which
defines specific instructions for any youth placed on suicide precautions. Youth placed on
suicide precautions should be maintained on secure observation or less restrictive placement
when possible. The staff assigned to observe the youth are required to provide the essential
level of supervision and document each interaction with youth, at a minimum of thirty-minute
intervals. The five youth records reviewed were not applicable for secure observation. An
additional record was requested, and the program had only one applicable youth since the last
annual compliance review. The youth’s secure observation placement was authorized by the
designated mental health clinician authority (DMHCA) and designated in writing. The Health
Status Checklist form was completed and was included in the reviewed youth record. The
assigned staff member of the same gender conducted visual checks of the youth and recorded
an inspection of the room before placement. The logbook was updated accordingly. A Follow-
Up Assessment of Suicide Risk (ASR) was completed within eight hours of secure placement.
Mental health staff provided supportive services as necessary. A conference with the facility
administrator and DMHCA determined the youth’s removal from secure observation and
documentation reflected agreeance. The logbooks and video surveillance confirmed active
supervision of youth while on secure observation and verified supervision practices.
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 regarding Suicide Precaution
Observation Logs. The five reviewed records were not applicable for suicide precautions;
therefore, additional records were requested. At the time of the annual compliance review, only
one additional youth record was applicable. The suicide precaution logs were accurately
maintained and documented the appropriate level of supervision and observation of the youth’s
behavior. The designated mental health clinician authority (DMHCA) was notified when
warnings signs were observed. The shift supervisor reviewed and signed each observation log.
The reviewed Suicide Precaution Observation Logs 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 policy and procedures requiring all staff who work with youth to
receive six hours of annual training on suicide prevention and implementation of suicide
precautions. The program’s policy requires all staff working with youth to be trained in suicide
precautions and emergency response procedures and participate in mock suicide drills
quarterly, on each of the three shifts. The drills facilitate practice responses to a suicide attempt
or incident of serious self-injury and will include methods for contacting other program staff for
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back-up support, medical personnel, and emergency medical services. Drills include the
provision of life saving measures such as cardiopulmonary resuscitation (CPR) and the use of a
suicide response kit. A review of five staff training records verified each received the required
six hours of training. The program has three suicide response kits which are co-located with
first-aid kits in master control, east sub-control, and west sub-control. A review of mock suicide
drills indicated the program completed at least one drill on each shift quarterly. Drills included
the provision of life-saving measures for acutely suicidal youth or youth in crisis. A review of a
mock suicide drill video confirmed drills were simulated and staff acted out and then debriefed
scenarios. The program does not use program youth in drill simulations and staff who are not
present for a drill receive a verbal review during the program’s mandatory monthly all-staff
meeting. The interviewed facility administrator reported drills occur monthly. Five interviewed
staff reported when a youth is suicidal, they are responsible for notifying mental health staff,
searching youth for sharp objects, maintaining constant sight and sound supervision,
documenting supervision, and notifying the supervisor. The interviewed staff reported the
suicide kits are co-located with first-aid kits in medical, master control, and sub-controls. All five
interviewed staff reported drills are conducted at least monthly.
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 regarding crisis intervention. The
program’s policy states crisis intervention shall be provided to youth in crisis in the least
restrictive means possible to protect the safety of the youth, staff, and others, while maintaining
control and safety of the program. The program has developed a Crisis Intervention Plan to
ensure the protection of youth, to the greatest extent possible, and to differentiate a youth who
has an acute emotional problem or serious psychological distress from one who requires
emergency services. A review of the program’s Crisis Intervention Plan indicated it contained all
required elements.
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 maintains a written policy and procedures and a Crisis Intervention Plan
addressing mental health crisis intervention services and Crisis Assessments. A review of five
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youth records indicated none of the youth records were applicable for a Crisis Assessment. An
informal interview with the regional compliance manager verified there were 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 for the Emergency Response Plan. The
program’s policy requirement for mental health and substance abuse emergencies is to ensure
the highest quality of care, safety, and management of the youth. The plan is maintained and
annually reviewed by the facility administrator (FA) and designated mental health clinician
authority (DMHCA). A review of the plan verified it contained all required elements and was last
signed on October 21, 2024, by the DMHCA and the FA.
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 policy and procedures for youth considered to be at risk for
suicide. 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 five reviewed youth records were not applicable for Baker and
Marchman Acts. The program reported there was one applicable youth since the last annual
compliance review and provided the record for review. After identifying the youth’s need of
emergency care, the designated mental health clinician authority (DMHCA) made the
authorization to Baker Act the youth. A review of the youth’s record verified the youth was
placed on one-to-one supervision at the time of discovery. Mental health staff were involved in
the Baker Act process and law enforcement transported the youth to the appropriate facility.
After returning to the program, the youth was placed on constant supervision. A referral was
completed indicating a Mental Status Examination was needed. A licensed mental health
professional completed the Assessment of Suicide Risk, and the youth was maintained on the
appropriate supervision level until assessments were completed.
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 to ensure on-going safety planning
processes for each youth. The safety plan shall be designed to identify stimuli which have both
positive and negative effects on the youth. Five reviewed safety plans did include warning signs,
baseline behaviors, crisis recognition, jointly developed coping strategies, intervention strategies
preferred by youth, and the debriefing process. Safety plans were completed within fourteen
days after admission and were jointly prepared by the youth, parent/guardian, and the
program’s clinical staff. The five reviewed safety plans incorporated any recommendations from
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previous clinical assessments and were reviewed every thirty days as required. Staff with youth
contact reviewed the safety plans and all five interviewed youth confirmed discussing plans
during treatment teams. All safety plans were maintained in east and west sub-controls and
were updated every thirty days and as needed. The facility administrator confirmed safety plans
are updated and reviewed at a minimum of every thirty days or as needed.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a written policy and procedures for the designated health authority (DHA). The
DHA is clinically responsible for all youth and provides on-site medical services. The DHA is a
licensed medical doctor (MD) with a specialty in pediatrics and family practice. The DHA at the
program does not have any disciplinary cases or complaints on record. The DHA’s license was
clear, active, and expires on January 31, 2026. The program has a back-up DHA. The back-up
DHA’s license was clear, active, and expires on January 31, 2025. The program is not
applicable in reference to the DHA designating a physician assistant (PA) or advance practice
registered nurse (APRN) for clinical duties. A review of the sign-in/out logs indicated 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. The number of hours required by contract for the DHA is up to
eight hours weekly. The program has a policy and procedures for the back-up DHA to be
utilized when the DHA is on vacation or has a scheduled absence. The back-up DHA was used
on July 13, 2024, and July 20, 2024, when the DHA was not on-site. A review of the medical
policy and procedures indicated there was no inclusion or approval from the Department’s
Office of Health Services for telemedicine/telehealth services. The interviewed DHA reported
medical policies and procedures are reviewed annually. The DHA stated their role is to
complete Comprehensive Physical Assessments (CPAs) within seven days of intake, to
complete follow-up appointments as needed, and to complete Health-Related History reviews
and periodic evaluations every ninety days.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a written policy and procedures in place for licensed medical staff. The
licensed medical staff policy was reviewed and reflected the program’s daily clinical care such
as intake evaluations, assessments, health education, medication management, and other
assigned duties are performed by licensed medical staff. The designated health authority (DHA)
is clinically responsible for all healthcare services provided to the youth. The program’s
operating procedures and nursing protocols are approved by the DHA. The licensed medical
staff at the program are registered nurses (RNs) and licensed practical nurses (LPNs). The
program has a total of two RNs, one who serves as the health service administrator (HSA). The
RN’s license was clear and active with an expiration date of April 30, 2024. The program has
two LPNs, and both of their licenses were clear and active with an expiration date July 31, 2025.
The program’s HSA’s license was clear and active with an expiration date of July 31, 2026. The
program’s nursing staff was in compliance with the contracted requirements. The required on-
site hours for the nursing staff according to contract indicated one RN shall work three twelve-
hour shifts each week with alternating weekends, and two LPNs shall work three twelve hours
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shifts each week with alternating weekends. The HSA shall work forty hours each week and
cover weekends when needed.
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 a written policy and procedures in place for medical facility operating
procedures (FOPs). The FOPs are used for all health-related procedures and protocols. The
designated health authority (DHA) and the facility administrator (FA) review, sign, and date all
respective treatment FOPs. The FA signed the FOPs on January 11, 2024. The DHA signed the
FOPs on February 14, 2024. The psychiatrist signed the FOPs on February 8, 2024. The
nursing staff reviewed, signed, and dated the cover page on all FOPs, healthcare protocols, and
other procedures. One registered nurse (RN) and one licensed practical nurse (LPN) signed on
January 11, 2024, one LPN signed on September 19, 2024, and one RN signed October 7,
2024. There were no new policies or changes in policies made during the annual compliance
review period. Reviewed documentation confirmed all newly hired healthcare personnel
received a comprehensive clinical orientation to the Department’s healthcare policies and
procedures by a RN. The approval of treatment protocols or standing procedures was written
and authorized by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a written policy and procedures in place for the Department’s Authority for
Evaluation and Treatment (AET). The AET is a form authorizing specific treatment for youth in
the custody of the Department and is required prior to providing services except for emergency
care and routine medical and mental health intake screenings. Five youth Individual Healthcare
Records (IHCRs) were reviewed. Three youth records indicated the youth were eighteen years
of age or older, and each youth signed the Department’s consent for youth eighteen or older.
Only two youth records were applicable for an AET, which included signatures, dates, and their
original AET was filed in their IHCR. One youth’s AET was a limited AET due to the youth being
under the care of the Department of Children and Families (DCF). The two records applicable
for an AET form being signed by a Department representative were signed as required. Both
applicable AETs were valid. The interviewed nursing staff reported the program has a policy and
procedures for obtaining a new or current AET. The medical staff and case management staff
will reach out to the juvenile probation officer (JPO) and parent/guardian to obtain the AET if
needed. The program has a policy and procedures for documenting consent for youth who are
eighteen years of age or older. The youth over the age of eighteen can consent without
parental/guardian notification.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a written policy and procedures in place for parental/guardian notification and
consent. The program must inform the parent/guardian of significant changes in the youth’s
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condition and obtain consent when new medications and treatments are prescribed. A review of
five Individual Healthcare Records (IHCRs) indicated three records had documentation of
parental/guardian notification for over-the-counter (OTC) medications. Parental/guardian
consent was provided for the three applicable youth. None of the reviewed youth records were
applicable for any new medication being ordered. One youth record was applicable for the youth
taking psychotropic medications and the written notification was sent utilizing the Department’s
form and the form was in the record. The applicable record documented a staff witnessed a
telephone call/attempts and conversations for psychotropic medications. Five youth records
were reviewed for vaccinations verified within thirty days of the youth’s admission and only four
records were applicable. One youth was eighteen years old and did not consent to
immunizations. The youth was from another country, did not having any immunization records
with the State of Florida shot website, or by their school, and refused all immunizations. The
program attempted to verify immunizations for the undocumented youth; however, no
immunization records were able to be verified for this youth. Four youth records were applicable
for having vaccinations verified within thirty days of admission with the State of Florida shot
website or by their school. Each applicable immunization verification was completed within thirty
days as required. The interviewed nursing staff reported the program has a policy and
procedures in place for parental/guardian notifications. Parental/guardian notifications are made
either verbally or in writing for youth under the age of eighteen for medication and treatment
ordered. The parent/guardian is notified by email. To ensure timely parental/guardian
notifications are made, the notifications are completed in real time and a follow-up call is made
and documented. The program has a policy and procedures in place regarding informing the
parent/guardian when obtaining consent for new psychotropic medications, discontinuances, or
psychotropic medication adjustments. A call is placed by the psychiatrist for any new orders,
changes, and/or discontinuations which are witnessed by medical staff and the acknowledgment
form is sent to the parent/guardian along with the Clinical Psychotropic Progress Note (CPPN).
The interviewed nursing staff reported the program has a policy and procedures in place for
obtaining immunization records. The records are obtained upon admission into the program.
The records are obtained from the Florida Shots website and through school records. Flu
vaccines are provided on-site at the program. The program has a process for documenting
parental/guardian exemption from immunizations. Upon admission, an exemption form is
requested and completed by the parent/guardian when applicable.
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 in place for healthcare admission screenings
and rescreening. Youth are screened upon admission for healthcare concerns which may
require a referral for a further assessment. Five Individual Healthcare Records (IHCRs) were
reviewed, and all five youth records had a valid Facility Entry Physical Health Screening
(FEPHS) form completed on the day of admission. The screenings for all five youth records
reviewed were completed by the nurses. None of the five youth records were applicable for a
change in physical custody for greater that twenty-four hours. An interview was completed with
the nursing staff at the program. The nurses are notified by email and during the morning
meeting about newly admitted youth. Medical is the first stop for all intakes and the medical staff
complete the FEPHS form. If the youth’s FEPHS form is completed by direct care staff, the
nurse will review the form within twenty-four hours.
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4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a written policy and procedures in place for youth orientation to healthcare
services and health education. All youth admitted into the program shall be oriented to the
general process of healthcare delivery services. A review of five youth Individual Healthcare
Records (IHCRs) showed each youth received a general care orientation which 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 case of a sexual assault or attempted sexual assault, the non-disciplinary role of
the healthcare providers, and standard universal precautions. The program has an education
and orientation binder to ensure all required orientation topics are reviewed. Topics included
seatbelt usage, alcohol and drug related problems, sexually transmitted diseases/infections,
tobacco products including smoking cessation, dental hygiene and dental care, basic personal
hygiene, immunizations, infection control, prevention of sexual and other physical violence,
nutrition, physical fitness, self-examinations, parenting skills, and parenting education as
applicable. A review of the program’s contract and indicated the frequency of health education
was monthly.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a written policy and procedures in place for the designated health authority
(DHA)/designee admission notification. Five youth Individual Healthcare Records (IHCRs) were
reviewed and only three youth records were applicable for suspected chronic conditions. A
referral was made to the physician for each youth. None of the reviewed records were
applicable for being in-need of emergency care upon admission. The three youth with
suspected chronic conditions were applicable for notification to the DHA/designee and
notification was documented in each youth’s progress note in the IHCR. The DHA was notified
within twelve hours for the three applicable youth records. One reviewed record showed the
youth was taking psychotropic medication upon admission and the psychiatrist was notified. An
interview with the health services administrator indicated youth admitted with serious or chronic
conditions are processed within the required time frame for notifying the DHA. This notification
to the DHA happens upon admission, in real time. Medical staff is responsible for the
notification, and the notifications to the DHA are documented in the youth’s progress notes.
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 in place for obtaining a Health-Related History
(HRH) form. The HRH form is used on behalf of all youth admitted into physical custody. Five
youth Individual Healthcare Records (IHCRs) were reviewed and all five had the HRH
completed within seven days of admission. All five records showed the HRH form was updated
and completed prior to the Comprehensive Physical Assessment (CPA) and documented a
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review by the physician. The interviewed nursing staff reported the program has a policy in
place for HRH forms. The medical office is the first stop for all intakes at the program. The
medical staff are notified about youth being admitted into the program by email and through
morning management meetings. The medical staff complete the admission screening, including
the HRH, within seven days. If the admission screening is completed by direct care staff, the
nurse will review and document their review on the Facility Entry Physical Health Screening
(FEPHS) form.
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.
A review of five Individual Healthcare Records (IHCRs) indicated each was applicable for a
Comprehensive Physical Assessment (CPA) to be completed within seven days of admission.
All five CPAs were completed by a medical doctor and referenced the Medical Grade for each
youth. None of the records were applicable for a change in the youth’s medical condition or
having a previous CPA reviewed after readmission. Each youth received a new CPA; therefore,
a focused evaluation for a readmission was not applicable. Each reviewed CPA showed all
sections were marked with an “O” or an “X.” Four youth refused part of the exam and the
refusals were clearly documented and matched the date of the exam. The Department’s
Problem List was updated as required for each of the five IHCRs reviewed. Each of the youth
had at least one verified Tuberculosis Skin Test (TST) documented in the IHCR within the last
year. Each youth’s result was documented on their CPA and their Infectious and Communicable
Disease (ICD) form, and the information matched on both forms. An interview with the nursing
staff indicated the designated health authority (DHA) completes a new CPA within seven days
of admission and on a yearly basis thereafter. The time frame for tuberculosis (TB) screenings
to occur is upon admission within seventy-two hours, if needed, or annually.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a written policy and procedures in place for sexually transmitted infections
(STIs) and human immunodeficiency virus (HIV) screenings. All admitted youth are evaluated
and treated for STIs. The program has a policy and procedures in place reflecting HIV test
results are only disclosed to the youth and the youth’s legal authorized representative,
healthcare providers during the course of consultation, diagnosis, or treatment, 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. Five youth Individual Healthcare Records (IHCRs) were reviewed and
only four youth records were applicable for the youth being sexually active and being clinically
screened for STIs. Each record was applicable for further evaluation and each youth was
referred to the medical doctor (MD). Each record contained the referral documented on the STI
screening tool. The four applicable youth records documented testing, screening results, clinical
evaluations, and diagnosis information on the Infectious and Communicable Diseases (ICD)
form. None of the records were applicable for a re-screening to be completed. The four youth
records indicated none of the youth consented to HIV testing. Five interviewed youth reported
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they can request an HIV/AIDS test and make a request to see the MD. The interviewed nurse
reported the program has a policy and procedures in place for STIs and HIV. The youth are
screened upon intake and upon request by the youth. If the screening indicates a need for
further evaluation, the designated health authority (DHA) is notified immediately, and orders are
received. STI screenings, evaluations, referrals, and testing are documented in the ICD section
in each Individual Healthcare Record (IHCR). The HIV testing and results are kept in the
laboratory section, in sealed envelope, which is signed by DHA. The DHA completes HIV pre-
counseling, testing, and post-counseling at the program.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a written policy and procedures in place for the sick call process. Only a
licensed nurse conducts sick call and when there is not a licensed nurse on-site, the program
has procedures whereby the shift supervisor reviews all sick call requests as soon as possible
and within four hours. All youth in the program shall be able to submit sick call requests and
have complaints treated appropriately through the sick call system. Five youth Individual
Healthcare Records (IHCRs) were reviewed and only one youth record was applicable;
therefore, two additional records were requested and reviewed. None of the three youth records
were applicable for presenting with a similar sick call complaint three or more times within a two-
week period. All three youth records contained the Sick Call Request form, and the nurse
completed the Sick Call Request form. All three youth records documented the sick call was
completed by a registered nurse (RN). All three youth records contained progress note
documentation, documentation in the Sick Call Index, and documentation in the program’s Sick
Call Referral Log. The dates for all three youth records corresponded with the Sick Call Index,
which corresponded to the completed Sick Call Request forms. A review of the posted daily
schedule and nursing interview confirmed sick call is conducted daily. Sick calls are conducted
twice daily at 9:30 a.m. and 2:30 p.m. and the hours are posted on the medical office door and
in all living units. Sick Call Request forms are available to the youth and an exam table in the
medical office is used to perform sick call. Five interviewed youth reported they can see a nurse
immediately after making the sick call request, and the other four youth reported they can see a
nurse within one day of making the sick call request. The interviewed nursing staff reported the
program has a process for youth requesting to see a nurse and/or physician for health
complaints. Sick calls are conducted twice a day and within four hours of the request. The
licensed practical nurse (LPN) or RN conducts sick call. If the LPN conducts the sick call the RN
will review the documentation. The designated health authority (DHA) will conduct the sick call if
they are on-site. All sick calls are conducted in the medical office at the program. The program
has a process for referring youth to the medical doctor when they have presented with repeated
similar sick call complaints and the list is provided to the DHA during their on-site site visits. The
DHA approves all treatment protocols. For the youth in restricted housing or confinement, the
nursing or medical staff meet with youth daily or by request, if needed. Program staff ask youth
in confinement if sick call is needed or if they have medical complaints daily. A sick call
observation was completed during the annual compliance review week. The youth was escorted
to the medical clinic by the assistant facility administrator (AFA). The medical provider identified
themselves and stated why the youth was there. The youth was seen in a private area with no
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other youth present to hear or see the examination. The youth was examined by the licensed
medical staff and the medical staff was able to maintain privacy
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a written policy and procedures in place for episodic care and first-aid care.
Five youth Individual Healthcare Records (IHCRs) were reviewed and only one youth record
was applicable; therefore, two additional records were requested. Two youth records were
applicable for on-site care provided by licensed healthcare staff using the problem-oriented
subjective, objective, assessment, and plan (SOAP) format or standard narrative charting. One
youth record was applicable for a non-healthcare staff providing episodic or first-aid care. One
youth record indicated the youth required and received a follow-up evaluation from a licensed
healthcare staff. The program has a total of eight first-aid kits located in master control, one for
each of the program’s two transport vans, one in dietary, one in the Home Builder’s Institute
(HBI) workshop, one in medical, one on the east wing, and one on the west wing. The first-aid
kits for the vans are stored in master control until the vans are used for transport. The program’s
process for ensuring contents are maintained and stored in accordance with guidelines to
prevent expiration or deterioration is to replenish them as needed, and for the medical staff to
complete weekly inventories of contents and expiration dates. The checks are documented, and
contents are replenished as needed. An observation of three first-aid kits revealed each kit was
fully stocked with the designated health authority (DHA) approved contents. At the time of the
annual compliance review the health services administrator (HSA) conducted a self-test of the
program’s two automated external defibrillators (AEDs) and there were no discrepancies. The
expiration dates of the AED batteries were October 31, 2027, for the AED stored in medical and
August 2, 2027, for the AED stored in master control. The two AED batteries were changed last
on April 1, 2024, for the AED located in medical and August 2, 2023, for the AED located in
master control. The expiration date for each of the AED pads was June 27,2025, for the AED in
medical and November 17, 2025, for the AED stored in master control. The AED pads were last
changed on June 30, 2023. A list of emergency numbers was posted and accessible for non-
licensed and licensed staff and these numbers were inaccessible to all youth in the program.
Reviewed documentation indicated the supervisory direct care staff were appropriately trained
in the administration of the epinephrine auto-injector. A review of five staff training records
revealed staff training requirements were met regarding episodic, first-aid, and emergency care.
The program has two operational shifts from 7:00 a.m. to 7:00 p.m., and from 7:00 p.m. to 7:00
a.m. A review of the program’s emergency medical drills reflected a drill was conducted on each
shift monthly from January 9, 2024, through October 14, 2024. Emergency medical drills which
include the demonstration of cardiopulmonary resuscitation (CPR), first-aid, and AED are
conducted at a minimum of quarterly. The emergency medical drills consisted of both
announced and unannounced drills and were conducted at least monthly on each shift. A review
of the program’s logbooks showed direct care staff participated in at least one drill which
included the use of CPR annually. A video observation review of drills confirmed drills simulated
episodic care events which called for immediate first-aid and/or the administration of CPR
techniques and the initiation of the emergency procedures to follow when there was a life-
threatening emergency. An episodic care event observation was not conducted at time of
annual compliance review as one did not occur. The program currently has a policy in place for
the use of NARCAN® and the program’s policy on the use, access, and inventory of
NARCAN®. The instructions for the use of NARCAN® are located on the box. The program
stores the NARCAN® in a locked box behind a locked door. Nursing staff and trained
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supervisors have access to NARCAN®. Each staff with access to NARCAN® has been trained
on when to and how to use NARCAN® by the health services administrator (HSA). The
program’s inventory process of NARCAN® is for weekly counts to be conducted by medical
staff. Five staff were interviewed each stated they are personally allowed to call 9-1-1 if a youth
has a medical emergency. Five youth were interviewed, and each youth stated they can see a
dentist and doctor if needed. In an interview with the HSA, it was confirmed the program has a
total of eight first-aid kits. The HSA indicated on-site episodic care is documented in the
progress notes and on the Episodic Care Log, and if non-healthcare staff provide emergency
care the non-healthcare staff form is reviewed by the nurse.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a written policy and procedures in place for off-site care and referrals. An
interview with the program’s regional nurse indicated only one off-site referral was made during
the annual compliance review period and youth do not require off-site care often. Five youth
records were reviewed, only one youth record was applicable for off-site care in which the
Summary of Off-Site Care Consultation Report form was utilized and filed in the Individual
Healthcare Record (IHCR) and documented in the Episodic First-Aid Emergency Care Log.
Parental/guardian notification was sent out and the discharge paperwork and other applicable
documents were filed in the IHCR. The designated health authority (DHA) reviewed and
signed/initialed all off-site care findings, instructions, and information. The single youth did not
require follow-up testing, referrals, or appointments. The nursing staff interview results indicated
the program has a process for off-site care and referrals. Episodic and off-site care is
documented in the progress note and Episodic Care Log. The youth who are sent for off-site
care are tracked by using a Transport Log and off-site care forms. If non-healthcare staff
provide first-aid/emergency care to youth, a non-healthcare staff form is completed and
reviewed by the nurse.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a written policy and procedures in place for chronic conditions and periodic
evaluations. Five youth Individual Healthcare Records (IHCRs) were reviewed and only three
youth records were applicable for chronic conditions. All three youth records indicated the youth
was identified on the Facility Entry Physical Health Screening (FEPHS) form with a current
chronic condition. The youth were undergoing treatment for a physical health condition, which
included abnormal body mass index (BMI). None of the three youth records were applicable for
a communicable disease or for taking prescribed medication on an ongoing basis. Three youth
records were reviewed, and each had a documented Medical Grade. All three youth were
placed on the chronic illness list. All three-youth received periodic evaluations at least every
ninety-days. None of the three youth records reviewed were applicable for anti-tuberculosis (TB)
medication. None of the three records were applicable for pregnant youth or for periodic
evaluations conducted prior to renewing a prescription medication which expired. All three youth
were updated on the Department’s Problem List. The facility administrator (FA) was interviewed
and reported there are formalized procedures in place with the healthcare staff to review
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important youth medical issues. The FA reported they review youth needs with healthcare staff
during the daily morning management meeting and weekly for designated health authority
(DHA) updates.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a written policy and procedures in place for medication management. Five
youth Individual Healthcare Records (IHCRs) were reviewed and only one youth was applicable
for taking medication at the time of admission. Only one youth record was applicable for the
Facility Entry Physical Health Screening (FEPHS) form and progress notes showing the youth
was admitted with medication. The medication was verified prior to the youth being admitted into
the program and the prescription verification was included in the progress note. The designated
health authority (DHA)/designee and the psychiatrist were contacted to obtain the order to
resume the specified medications prescribed prior to admission, all medications hade a current
or valid order, and were administered pursuant to a current prescription. Five youth records
were reviewed and none of the five youth records were applicable before being in restricted
housing. Five youth records were reviewed for over-the-counter (OTC) medications not listed on
the Authority for Evaluation and Treatment (AET) and three youth records were applicable. The
four applicable youth records were reviewed for the standard Department Medication
Administration Record (MAR) to document all medication and treatment. Each MAR clearly
indicated medication start and stop dates for the four youth records reviewed. None of the five
youth records reviewed were applicable for trained non-healthcare staff assistance in the
delivery of medications when licensed staff were not on-site. Each of the four youth applicable
for medication initialed each administered medication entry. None of the four youth records
reviewed had lapses or errors in medication administration. None of the four records were
applicable for the refusal of medication. Five youth records were reviewed in reference to the
MAR and all five youth records contained a MAR which documented youth’s name, Department
identification number (DJJID), date of birth, youth allergies, precautions, Medical Grade, medical
alerts, and a current picture of the youth. There was one youth who entered the program with
psychotropic medication and the DHA and psychiatrist were notified on behalf of this youth. The
youth received an Initial Diagnostic Psychiatric Interview within fourteen days of admission and
medication monitoring/reviews every thirty days. Standing orders for psychotropic medications,
emergency treatment orders for psychotropic medications, and pro re nata (PRN) orders for
psychotropic medications are not allowed, and none were observed during the annual
compliance review week. An observation of a medication administration was conducted. The
youth was escorted by the assistant facility administrator (AFA). The youth approached the
nurse administering the medication individually and the medical provider identified themselves.
The nurse verified the youth’s allergy and alert status. The staff and the youth initialed the MAR
and medication delivery was the sole responsibility of the nurse. The nurse observed the youth
to make sure medication was swallowed and the OTC administrations were documented. The
Six Rights of Medication Delivery/Administration were verified. The nursing staff at the program
conduct medication management. The nursing interview results were reviewed and indicated
the program has a process for the nursing staff to verify a youth's medication regimen when a
youth is admitted with medications and for non-healthcare staff to verify medication upon
admission. This information is documented on the Prescription Verification form and the
pharmacist, prescribing doctor, and nursing staff review medication upon admission into the
program. The health service administrator (HSA) trains non-healthcare staff annually on
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medication administration. The list of non-healthcare staff trained annually is in the medical
office. The program’s medications and prescriptions are procured through a local pharmacy.
The program’s process for disposal of medication is to maintain a Destruction Log and Return
Log for medications sent back to pharmacy for credit, and controlled medication is destroyed
with a pharmacy consultant and witnessed by nursing staff.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a written policy and procedures ensuring medical equipment classified as
medications/sharps are secured and inventoried by using a routine perpetual inventory. The
medical equipment classified as sharps include syringe needles, scissors, and suture removal
kits, and each was secured and inventoried utilizing a routine perpetual inventory descending
count as each sharp was being utilized and disposed. All medications were identified and
secured in the locked area designated for storage of medications and different medications such
as injectable, topicals, drops, and liquids were separated. 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. All medications
were stored in a separate, secured/locked area, inaccessible to youth. Narcotics and other
controlled medications were stored behind two locks. Medications which required 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 consists of
controlled substances being given to the pharmacy consultant for disposal, and discontinued
medications are given to the pharmacy consultant for credit. Destruction Logs and Return Logs
are kept updated for medications being destroyed and returned to the pharmacy. Perpetual and
weekly inventories of all sharps and stock over-the-counter (OTC) medications were completed
as required. There was a shift-to-shift inventory count of all controlled substances documented
on the youth’s Individualized Controlled Medication Inventory Record. Supervisory-level, non-
healthcare staff were trained in the delivery and oversight of medication self-administration for
which the training was delivered by a registered nurse (RN) or higher. During the annual
compliance review week an observation of the nurse completing a count for three controlled
medications, three OTC medications, and three sharps showed the actual counts were listed on
each log as well as the final count and shift to shift count after each administration of
medication. There were no discrepancies during these observations. All counts matched the
ending inventory numbers. The program’s reporting criteria and procedures regarding inventory
discrepancies starts with the nursing staff reviewing all inventory logs ensuring it matches the
actual counts. An interview with the health service administrator (HSA) indicated the process for
disposal of medication consists of a destruction log and a return log for medications sent back to
the pharmacy for credit. Controlled medications are destroyed with the pharmacy consultant
which is witnessed by nursing staff. The practice in securing controlled substances such as
narcotics consists of them being stored in double locked in the medication cart. An interview
with the HSA indicated the program has a current agreement with a consultant pharmacist who
comes on-site monthly to review medication, Medication Administration Records (MARs), and
for the destruction of medication. The program maintains a copy of a pharmacy consultant
license on-site.
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4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a written policy and procedures ensuring there is an approved plan for
exposure control and infection control so staff, youth, volunteers, and visitors are not exposed to
infectious and communicable diseases. The infection control procedures in place included
prevention, containment, treatment, and reporting requirements related to infectious diseases,
according to Occupational Safety and Health Administration (OSHA) federal regulations and the
Centers for Disease Control and Prevention (CDC). The designated health authority (DHA) and
the facility administrator (FA) signed the program’s Infection and Exposure Control Plans on
January 11, 2024 and nursing staff reviewed and signed the Infection Control and Exposure
Control Plans on February 14, 2024. The infection control procedures included common
infectious diseases of childhood, self-limiting, episodic contagious illnesses, viral or bacterial
infectious diseases, Tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus (HIV),
infectious diseases caused by bloodborne 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, foodborne illnesses, bio-
terrorist agents, and chemical exposures. The program maintains procedures for staff to adhere
to universal precautions and the program provides staff with the opportunity for Hepatitis B
immunizations and access to protective equipment. There weren’t any instances in which the
local county health department, CDC, and/or the Department’s Central Communications Center
(CCC) should have been notified of an infectious disease. The program director established a
binder containing all documents for youth and staff who have experienced a facility/occupational
exposure. The Exposure Control Plan was written in accordance with OSHA standards and is
available to all staff. The plan was reviewed and signed annually by the administration of the
program on February 14, 2024. The program’s process for needle stick post-exposure
evaluation consists of counseling, evaluation of reported illness, and providing the follow-up
information to the individual who was exposed. The FA was interviewed and stated the
Exposure Control Plan is in medical and master control and it is reviewed annually with staff. An
interview with the health services administrator (HSA) indicated the nursing staff conduct
infection control training for staff upon hire.
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-ten 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 classroom activities, line movement, school breaks, youth head counts, mental health
groups, vocational activities, youth searches, and outdoor/indoor recreation activities. In
addition, youth were observed working in the kitchen and using tools while participating in Home
Builder’s Institute (HBI) projects. The observations ensured staff-to-youth ratios were
maintained, as required. A tour of the program verified the program and living units were clean,
well maintained, and graffiti free. A perimeter check was conducted, and fencing appeared to be
in good repair. Staff and youth were appropriately attired. During outdoor activities and/or
movement, observations verified staff were strategically positioned to ensure proper supervision
of youth and to ensure there were no physical obstructions in their view of the youth.
Observations of interactions between program staff and youth reflected the interactions were
positive and consistent with the program’s BMS. Three informally interviewed staff knew how
many youth they were supervising. The program’s policy states active supervision ensures
appropriate supervision of the youth is maintained at all times. Staff are to provide effective
positioning for optimal sight and sound supervision of youth. Staff shall communicate with youth
and co-workers effectively to ensure expectations are clearly defined. Video observations of
youth were conducted during sleep hours. The observations verified the youth to staff ratio was
in compliance and staff were awake and alert.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program 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
last annual compliance review. The program utilizes the iChoose BMS, which is a coordinated
system of promoting, monitoring, recognizing, and rewarding a youth’s progress. It is a program
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of incentives and consequences which promotes individualized skill building, appropriate
behavior, and accountability. Staff use point cards to monitor how well the youth are progressing
in the program. Youth earn points daily for complying with the program rules. At the end of the
week, the points are totaled, and the youth can obtain rewards based on the number of points
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 beginner,
intermediate, veteran, and expert 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. In addition, the
parent/guardian handbook includes a description of the BMS. A review of five staff training
records indicated staff were trained on the BMS by the staff development coordinator. A review
of five position descriptions confirmed the job functions included implementation of the BMS. A
review of five 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 verified staff were adhering to the BMS by utilizing a ratio of four-to-one
positive rewards to negative consequences when redirecting the youth as indicated in the
program’s policy. The incentives for youth include using points to purchase items from canteen,
participating in Mega Monday and Phat Friday activities, playing board games, and receiving
extra snacks. Five staff were interviewed, and each reported the BMS consists of a point system
and consists of incentives and consequences. Each of the interviewed staff verified youth
receive incentives which include the purchase of canteen items, receiving extra snacks, earning
extra phone calls, and youth can participate in Mega Mondays and Phat Fridays. Five
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 Behavior Reports (BRs). Five youth were interviewed,
and each stated the consequences for negative behaviors included not earning daily points,
level freezes up to twenty-one days, and early bedtime. Each youth stated they receive
incentives such as special meals, snacks, and participate in Mega Mondays and Phat Friday.
Five interviewed youth stated staff use rewards the same for all youth. All five youth were able
to explain the difference between each level and how they move from level to level. All five
youth verified youth are never allowed to punish other youth. An interview with the facility
administrator (FA) confirmed the program utilizes the iChoose BMS. The BMS is responsive to
the unique characteristics of the program’s population. The system is designed to maintain
order and security fostering compliance with the program rules teaching youth alternative pro-
social methods of dealing with problems using both rewards and a system of progressive
discipline. The BMS promotes safety, respect, fairness and protection of rights within the
community, provides for constructive discipline and a system of positive and negative logical
consequences to encourage youth in meeting expectations for behavior, provides for positive
reinforcement and recognition for accomplishments and positive behaviors at a minimum ratio of
four-to-one positive to negative consequences, promotes socially acceptable means for youth to
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meet their needs, and includes processes which address the needs of and cognitive capacity of
youth. The BMS promotes dialogue and peaceful conflict resolution, minimizes the separation of
youth from the general population, and assures consistent implementation and equitable
treatment through oversight and training. The FA stated rewards include incentive calendars,
nightly incentive, Phat Friday, Mega Monday, random reinforcers to include additional telephone
calls, food incentives, music, and free time. The program ensures consistency by reviewing the
BMS during behavior review team meetings, annual performance evaluations, all-staff training,
and monthly coaching.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
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 113 video cameras capable of recording thirty-days of video footage.
During the annual compliance review week, the program reported two cameras were not
operational; however, a call was made to the Department’s Central Communications Center
(CCC) on October 29, 2024, stating there were several inoperable cameras which were not
reported. Prior to conducting checks, staff are situated where they are able to see any
movement within the living unit. Staff are required to conduct room checks every ten-minutes
and document the time of the check on the Ten-Minute Check Log when youth are sleeping.
The informally interviewed facility administrator (FA) stated there were two shifts from 7:00 a.m.
to 7:00 p.m., and 7:00 p.m. to 7:00 a.m. during the annual compliance review period. A video
review of three ten-minute checks from the overnight shift and from the program’s one living
unit, verified staff were conducting checks every ten-minutes and documented the times
accurately on the ten-minute check logbook with an exception on October 23, 2024 at 12:45
p.m. During the annual compliance review week, a documented check which did not occur was
discovered. Program staff documented a check which did not occur on a ten-minute check
sheet on September 16, 2024 at 12:42 a.m. and this was reported to the CCC. Video footage
showed the staff did not conduct the 12:42 a.m., ten-minute check; however, documented the
check was completed in the logbook. In addition, the Ten-Minute Check Logs since the last
annual review were reviewed. A sample of various days, times, and shifts indicated the ten-
minute checks were completed within the required frequencies. Five interviewed staff verified
room checks were conducted every nine-minutes when a youth is placed in their room for
sleeping or non-punishment reasons. In a formal interview, the FA stated the program has 113
cameras with two cameras out of service and the program has video recording capabilities for
thirty-days.
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5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program maintains a written policy and procedures to ensure youth are always accounted
for through a system of physically counting youth at various times throughout each day. The
program’s policy 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 in the care and custody of the program. This includes the need for continual head counts
to be conducted minimally at the beginning of each shift, during any emergency situation, and at
regular intervals. Eleven randomly selected dates and times in the program’s logbook were
reviewed for census counts during the annual compliance review period. Documentation
validated head counts and movements were conducted at the beginning of each shift, after
outdoor activities, during emergency situations such as program disturbances, and during actual
and/or simulated drills. 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 youth counts. Five interviewed staff
verified formal counts are conducted every hour. Each staff stated if a count cannot be
reconciled, the program is locked down, all movement is stopped, and an emergency count is
conducted until the count is reconciled. Each staff stated emergency counts are conducted
anytime a code is called, during power outages, if there is a discrepancy in the count, if a youth
is missing, and during drills.
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. The program
maintains a bound logbook with numbered pages for each month. Observations and a review of
logbooks since the last annual compliance review 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 randomly
selected days 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, and the name and signature of the
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staff making the entry. A review of logbook entries indicated recreation was conducted as
scheduled. The program ensures direct care staff, including each supervisor, are briefed when
coming on duty. Each staff signs the shift briefing sign-in sheet to acknowledge receiving the
information. A review of shift reports since the last annual compliance review verified each
report was completed on a daily basis. Staff have access to the shift report for at least forty-
eight hours after the briefing. 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 CCC.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a written policy and procedures for assignment, inventory, tracking, 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. Active keys are assigned to direct care staff while restricted keys are
designated for medical staff, kitchen staff, 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 on a board in master control.
Medical staff, kitchen staff, 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 a program key initial the key log before and again at the end of
the shift when the keys are returned. A review of the key logs and logbooks since the last
annual compliance review verified this practice. In addition, the program has a list of staff who
are assigned permanent keys. Permanent keys are issued, and staff sign an acknowledgment
form indicating a key identification number and the number of keys issued. A review of the
signed acknowledgment forms indicated each staff signed for the use of permanent keys. A
random check of three staff verified the number of keys on the key ring matched inventory and
each staff knew their function. A review of the Department’s Central Communications Center
(CCC) reports since the last annual compliance review indicated there were no incidents related
to key control. Five staff were interviewed and were able to explain the program’s key control
process.
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5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program 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 are oriented to the program rules including the list of items considered to be contraband.
The program’s policy and youth handbook included all items considered contraband as outlined
in Florida Administrative Code. The list of contraband items include sharps, escape
paraphernalia, tobacco products, lighters or matches, electronic or vaporless cigarettes,
unauthorized food or clothing, any intoxicating beverages, any controlled substance, any
prescription or non-prescription drug, any firearm or weapon, any explosive substance, non-
program issued keys, unauthorized currency, non-program issued cellular telephones and/or
equipment or electronic devices capable of taking pictures or video recordings, 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 specifies the
manner in which any unauthorized or contraband item is to be disposed of, to include return to
the sender, mailed to the youth’s home, returned to the youth upon release, or, in the case of
illegal contraband, turned over to law enforcement. Unannounced room searches are conducted
at least weekly at irregular and unpredictable times and common area searches are conducted
daily. During the program tour, several randomly selected rooms were checked, and no
contraband was observed. A review of shift reports, the master control logbook, visitation forms,
and common area search forms validated the program’s practice of monitoring areas of the
program, grounds, and youth rooms for contraband. The program’s policy requires case
managers to inspect all outgoing and incoming correspondence in the presence of the youth for
unauthorized items, contraband, or information which may breach the security of the program.
The program’s policy and procedures, with orientation training provided to all new staff, stipulate
staff, including supervisors and administrators, found in possession of contraband will be
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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. The program documents the confiscation and disposal of
contraband. All instances involving confiscation of illegal contraband require the program to turn
the item over to local law enforcement authorities and file a criminal report. A review of the
Department’s Central Communications Center (CCC) reports since the last annual compliance
review indicated there were no instances of contraband found at the program applicable to be
turned over to law enforcement. The interviewed facility administrator (FA) reported the program
adheres to the Florida Statute which addresses contraband in residential programs. Search
practices are initiated according to the Department’s Right Interactions (RI) training curriculum
to assist in prevention, detection, and removal of all items considered contraband or
unauthorized within the program. Program staff, including school staff, subcontracted staff,
visitors, and volunteers are prohibited from introducing any item into the secure area without
authorization from the FA or designee. Any item or situation which may compromise safety or
security is to be reported immediately to the on-duty supervisor. The introduction, removal, or
possession of certain unlawful articles and the associated penalties are outlined in Florida
Statutes. Five staff were interviewed, and each stated room checks are conducted daily during
youth shower time, and twice a week by the assistant facility administrator (AFA) and the shift
supervisor.
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 way of the parent/guardian intake letter, which is mailed at the time of each youth’s
admission. Youth are searched before entering and prior to leaving the classroom, after outdoor
recreation activities, after work detail, and upon all movement. Youth who are a new admission,
re-admission, returning from visitation, returning from off-campus activities and/or appointments,
suspected of contraband, or are a security risk are full body searched. Observations made
throughout the annual compliance review week validated youth are provided instructions
regarding the search, youth searches were conducted by staff of the same gender as the youth,
were conducted in a manner so as not to degrade the youth, and were based on the Right
Interactions (RI) training manuals. Searches observed during the annual compliance review
week verified youth were searched after every movement and after using tools while
participating in Home Builder’s Institute (HBI) 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 for those activities could not be
observed. In-person observations and a video footage review of five staff indicated searches
were conducted as required. Five staff were interviewed, and each stated youth are searched
after every movement. Five youth were interviewed, and all indicated searches occur after
outdoor activities, when items are missing, and after visitation. Four youth stated they are
searched when returning from off campus, and after work detail.
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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.
Two are used to transport youth and one is for program use. Each vehicle used to transport
youth had an annual safety inspection conducted by a certified automobile mechanic.
Observations of the two program vehicles verified each was locked when not in use. One
vehicle used to transport youth was being serviced at a mechanic shop and could not be
observed. An observation of one vehicle used to transport youth found it had the appropriate
number of seatbelts, a seatbelt cutter, a window punch, an up-to-date fire extinguisher, and a
first-aid kit with items approved by the designated health authority (DHA). Documentation
indicated weekly visual vehicle inspection checks are conducted on all vehicles as required and
documented on the preventative maintenance check sheets. The one observed vehicle used to
transport youth had passenger doors which could not be opened from the inside and had a
safety screen separating the front seat from the rear passenger’s compartment. A random
check of five staff personal vehicles and one program vehicle 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. The program
provides transportation for secure maximum-risk youth determined to be at greater risk. 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. Five staff were interviewed, and each stated prior to conducting
a transport the youth and vehicles are searched for contraband and youth are secured in the
vehicle with hand and leg cuffs, and by wearing the seatbelt. All five interviewed staff stated
they use the program’s cellular telephone or their approved personal telephone during
transports. 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 five staff confirmed they are not
allowed to use personal vehicles to transport youth. All five interviewed staff stated the safety
equipment in the transport vehicles included a first-aid kit, suicide kit, seatbelt cutter, and fire
extinguisher. All five interviewed staff stated the transport vehicles are searched for contraband
prior to and after each use. All five interviewed staff stated they would call 9-1-1 and/or contact
the program if an emergency arises during vehicle transport. Each interviewed staff knew the
staff to youth ratio during transport. Each staff verified there are safety screens in the vehicles
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used to transport youth. Five interviewed youth stated they never witnessed anyone placing
contraband in a transport vehicle. Five youth were interviewed, and each stated they were not
secured to any part of the vehicle during transportation. An interview with the facility
administrator (FA) verified all vehicles transporting youth have a safety screen.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program 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 facility administrator (FA) 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.
In addition, deficiencies are discussed during the morning management meeting. A review of
the safety and security inspection forms since the last annual compliance review indicated
inspections were completed as required. Supervisors conduct perimeter checks on each shift
and checks are documented in the program’s logbook. A review of the program’s logbooks
verified this practice. A review of deficiencies entered in the Department’s Juvenile Justice
Information System (JJIS) verified there were no deficiencies assigned in regard to safety and
security audits during the annual compliance review period. An interview with the FA indicated
Weekly Safety and Security Audit forms are submitted to the Department each week and they
identify any security issues or deficiencies.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program 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, inventoried prior to, and following work activities. All sharp
edged and pointed tools are inventoried daily when in use. The maintenance staff are
responsible for conducting the inventories and securely maintaining all Class A tools and
equipment. The maintenance staff completes a tool inventory list which documents each tool in
inventory. All maintenance tools were inaccessible to youth and were observed to be secured in
the maintenance building. Observations of the tool storage area found it was organized and
secure. Class B tools including mops, brooms, and buckets are maintained in a locked closet in
the hallway between the east and west wings which are inaccessible to the youth. The items are
used by staff and youth when performing daily cleanup activities. Staff are required to complete
a sign-out and sign-in log when items are taken and are returned to the designated storage
room. Kitchen staff are responsible for securing, maintaining an inventory log and sign-out/sign-
in log for kitchen utensils and sharps. A random review of ten unique kitchen utensils and
sharps and unique tools in the maintenance building verified the tool inventory and the logs
were accurate. Reviewed documentation and the Department’s Central Communications Center
(CCC) reports verified there were no instances of missing or lost tools since the last annual
compliance review. If a tool is broken or inoperable, the physical plant manager is responsible
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for replacing the broken tool. If a tool is missing staff will notify administration, fill out an incident
report, document the incident in the logbook, call the CCC, and the program will be searched
until the tool is found. The program has a vocational woodshop program on-site which is
operated by the Home Builder’s Institute (HBI) in which Class A tools are utilized by the youth.
Observations of tools in the vocational building indicated tools are maintained under lock and
key with access only to HBI staff.
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, established ratios which include one staff to five
youth during work detail or vocational training. A review of the program’s procedures verified
staff are required to complete a sign-out and sign-in log when Class B tools are taken and are
returned to the designated storage room. A Youth Risk Assessment is completed by the case
manager for youth to use Class A and Class B tools. In addition, the Home Builder’s Institute
(HBI) program completes a risk assessment prior to youth participating in the program. Five
youth case management records were reviewed, and each youth had a Youth Risk Assessment
completed by the case manager prior to youth using tools. Five youth case management
records included documentation each youth was trained on the intended and safe use of Class
B tools. An observation of two youth working kitchen detail and two youth mopping the living unit
was conducted. In addition, youth were observed using Class A tools while participating in the
HBI program. The youth were properly supervised and followed safety protocols. Five youth
were interviewed, and each stated they use mops, brooms, saws, and scrub brushes. In
addition, five youth participating in the HBI program stated they use saws, hammers, and
screwdrivers. Five staff were interviewed, and each indicated youth are allowed to use mops
and brooms. In addition, five staff reported youth can use tools when enrolled in the HBI
program with a risk assessment conducted prior to the use of tools.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a written policy and procedures establishing guidelines for outside contractors
who come on-site to complete repairs. When a contractor or vendor enters the program, they
sign the Outside Contractor On-Site Work Project Log which lists unauthorized items. The
program’s policy states personal cellular telephones 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 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
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reviewed, all tools are verified, then the form is signed. Any tools required to be used within the
program are inventoried and recorded on the contractor’s agreement form before and after the
repair is completed. Reviewed documentation for three project invoices showed the vendors
signed contractor agreements. Documentation for the Outside Contractor forms verified the
forms were completed and all requirements were met. A review of the work project logs since
the last annual compliance review verified the contractors signed the log confirming notification
of what items are considered unauthorized. If any unauthorized items are needed by the
contractor while in the program, approval is obtained by the facility administrator (FA) or
designee.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program’s Continuity of Operations Plan (COOP) addresses fire, safety, and evacuation
emergency processes and the frequency of conducting drills at random times, and under varied
conditions. Reviewed documentation validated fire and COOP drills were conducted for all shifts
each month, as required. COOP drills included fire, riot, severe weather, flooding, hostage
situation, chemical spills, medical situations, and bomb threats, which were covered on a
rotating basis. Drill documentation included the type of drill, date and time, participants, a brief
scenario description, deficiencies identified during the drill, and applicable corrective actions.
Documentation verified COOP drills were held during the all-staff meetings one time each
month. Observations and an informal interview with the facility administrator (FA) verified there
were twenty-six annually inspected fire extinguishers and egress plans were posted throughout
the program. Five interviewed staff all reported they had participated in COOP drills, suicide,
and medical drills. Five youth were interviewed, and each indicated drills are conducted at least
monthly and they have been instructed on what to do in the case of an emergency. An interview
with the FA indicated the program facilitates emergency/COOP, medical, mental health, fire,
and Right Interactions (RI) drills. Drills are conducted according to the program’s drill calendar.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program maintains a Department-approved Continuity of Operations Plan (COOP) available
for all staff to review. The COOP was reviewed and submitted to the Department on April 11,
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. The COOP addresses
phases of a disaster plan as well as emergency management including preparedness,
response, and recovery. The COOP addresses emergencies including fire prevention, severe
weather, riots, bomb threats, hostage situations, chemical spills, flooding, and terrorist threats.
In addition, the COOP includes staff roles and responsibilities, equipment and supplies needed,
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youth information, provisions for continuity of care and custody of youth, and provisions for
public protection. The COOP is readily available to all staff and is located in the administration
conference room, the facility administrator’s (FA’s) office, and in the assistant facility
administrator’s (AFA’s) office. A review of the plan indicated alternative housing has been
identified should the program require evacuation due to an emergency or disaster. The program
has provisions of equipment and supplies maintained in the kitchen and master control to
ensure a continuous operation of services during emergency or disaster situations. In addition,
the program has a generator to provide continuous power. The program maintains identifying
information on each youth in the program in the event the program has to evacuate, and the
youth record accompanies the youth to the temporary location. A review of five youth case
management records indicated each had the youth’s name, Department identification number,
admission date, gender, race, contact information, emergency contact, assigned juvenile
probation officer (JPO), committing judge, victim information, physical description, health status,
and a photograph. The interviewed FA reported staff have full access to the COOP.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a written policy and procedures for the storage and inventory of flammable,
poisonous and toxic materials. Toxic items are stored outside the program in locked cabinets
within a locked chain link fence. A list of staff which includes the facility administrator (FA),
assistant facility administrators (AFAs), unit managers, medical staff, shift supervisors, and food
service staff confirmed they are authorized to use chemicals maintained in the storage cabinet.
All caustic materials are stored according to type and use. A Safety Data Sheet (SDS) binder is
located inside the storage area with a picture of each material and a number corresponding to
the SDS for each chemical. A perpetual chemical inventory list is maintained, and the chemicals
are checked daily. A review of the inventory list verified this practice. The program has a
Chemical Daily Usage Log used to track all toxic items when in use by authorized staff.
Observations of the storage area indicated it is clearly marked for hazardous chemicals and
securely locked. Items were stored on metal shelving and numbered according to the SDS.
Flammable items are stored in a metal cabinet clearly marked as flammable items. Chemicals
used to clean the program are stored in locked closets located in the main hallway of the
program and in a secured closet in the kitchen. An inventory sheet is maintained and
documents daily use. A review of the storage closet verified the number and type of chemicals
were maintained on the inventory list. A random sample of ten chemicals verified the actual
count matched the inventory logs, the chemicals were secured, and the SDSs were present for
the items reviewed. In addition, the program maintains a written policy and procedures to
ensure all flammable, toxic, caustic, and poisonous items are disposed appropriately. The FA or
designee and maintenance staff are responsible for the control and accountability of all caustic,
toxic, poisonous, flammable, hazardous fluids, substances, or chemicals used in the program.
All unused hazardous materials are kept in the secured storage area located outside the
program and are disposed of according to the SDS. In an informal interview, the physical plant
manager stated the program makes every effort to use up all chemicals. Any unused chemicals
are taken to the local waste facility. The physical plant manager stated there were no chemicals
disposed of during the annual compliance review period. Used kitchen grease and waste is
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stored in a large container outside the kitchen area and is disposed of by a local vendor. All
liquid waste from work details is disposed of down plumbing drains. The program’s policy states
all chemical spills are reported to master control and the shift supervisor immediately. An
evacuation of the affected area is conducted and a determination by the FA is made as to
whether to contact outside assistance to contain the spill. Staff and youth are not allowed to
return to the affected area until it has been deemed safe by a qualified professional. The
interviewed FA stated disposal of hazardous items and toxic substances, or chemicals are
disposed of in accordance with Occupational Safety and Health Administration standards.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program 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 materials, bodily fluids, or human waste. Youth are strictly
prohibited from the maintenance area where toxic items and chemicals are stored. An
observation of two youth working kitchen detail, and two youth mopping the living unit was
conducted. None of the observed youth were handling chemicals or cleaning products.
Observations of completed projects at the Home Builder’s Institute (HBI) verified youth used
paint after receiving a risk assessment. Five youth were interviewed, and each youth stated they
have used paint, three stated they used floor wax, two stated they have used cleaning
chemicals, and one stated they used gas, bug spray, and bleach. Youth stated when using
cleaning chemicals, staff spray the cleaner and are supervised by staff. Youth participating in
HBI have an assessment completed prior to handling chemicals.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
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• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
This program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a written policy and procedures to allow youth to have visitation and
communication with family members while in the program. The program assists youth and
families in maintaining connections in a visitation environment which provides monitoring,
control of movement, and security practices to ensure visitor, youth, staff, and program safety.
The program’s policy provides each youth opportunities to promote communication and
engagement which fosters family reunification and community connections. The program
maintains a list of approved visitors; however, attorneys, representatives of the court, juvenile
probation officers (JPO), other agency representatives, and clergy are authorized to visit at any
time. Searches of visitors will be conducted upon entry and all youth are to be searched
following visitation sessions. The program’s visitation policy indicated consideration 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, parent/guardian
handbook, and addressed on the orientation checklist. Visitation is held two days a week on
Saturdays and Sundays from 9:00 a.m. to 11:30 a.m. Youth are given opportunities to
communicate with their family in person, by telephone, and by mail. Each youth is provided an
opportunity to correspond on a regular basis with identified individuals specified on their
Approved Correspondence List and legal representatives. Youth are permitted weekly
telephone calls. The youth’s use of telephone calls is documented in each youth’s case
management chronological documentation. A review of the telephone chronological notes
verified youth have consistent telephone communication with family members. Youth can write
to their parents/guardians at least once each week and are encouraged to correspond with their
JPO and committing judge. All outgoing and incoming mail is searched by the case manager. A
review of the logbooks, visitation sign-in logs, and outgoing and incoming mail logs verified the
program allows visitation and mail only for approved immediate family members to include
parents/guardians, stepparents, siblings, grandparents, and spouses. The JPO must approve
the immediate family members. It is the program’s practice for the assigned case manager to
follow-up with the JPO regarding human trafficking victims to determine whether the
parent/guardian should be permitted to communicate with the youth; however, there were no
youth applicable for a history of human trafficking during the annual compliance review period.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 71 (Revised September 2022)
Five youth were interviewed, and each confirmed they can call and/or send letters to their
parent(s)/guardian(s). The interviewed facility administrator (FA) stated for youth whom English
is not their primary language the program uses interpreter services and a language assistance
program.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a written policy and procedures to ensure each youth has a variety of
recreation and leisure activities. A review of the 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 five youth records verified recreational
therapy is part of each youth’s individual performance plan. 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. Five staff were interviewed regarding the type of recreation activities the program
provided and how long the activities lasted. Staff indicated the program provides youth with at
least one hour each day. Each staff indicated the outdoor activities consist of basketball, and
football. The indoor activities consist of board games, card games, watching television, playing
video games, and using the weight room. Five youth were interviewed, and each youth stated
they are provided at least one hour of physical activity which includes playing basketball,
soccer, football, dodge ball, and access to the gym.
5.23 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program maintains a written policy and procedures to ensure staff searched and inspected
controlled observation rooms prior to placing a youth in controlled observation. The program has
a designated area to house youth who have been placed on controlled observation.
Observations of the rooms indicated the program met the measurements and construction
required by Florida Administrative Code. The Controlled Observation Report was reviewed, and
the program only had one controlled observation placement since the last annual compliance
review. The one reviewed Controlled Observation Report indicated a same gender staff
searched the youth and staff inspected the room before the youth was placed in controlled
observation.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 71 (Revised September 2022)
5.24 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program maintains a written policy and procedures regarding controlled observation.
Program staff are authorized to temporarily place a youth in a controlled observation room if
there is an imminent risk to the youth harming themselves or others, or if the youth is causing
major damage to the program which may cause a security risk. If a youth is placed in controlled
observation for any of these reasons, a Controlled Observation Report is to be completed upon
the youth’s placement. The program had one controlled observation placement since the last
annual compliance review. A review of one Controlled Observation Report verified supervisors
or administration authorized the placement of youth in controlled observation. None of the
reviewed Controlled Observation Reports indicated the youth exhibited behaviors indicative of a
mental health crisis or had suicide ideation. Documentation indicated the youth placed in
controlled observation was identified as aggressive towards others and less restrictive methods
were ineffective, and staff needed to quickly gain control for program safety. The one Controlled
Observation Report indicated staff advised the youth for the reason for controlled observation
and the expected behavior to be released. The Controlled Observation Report indicated medical
staff completed a Health Status Checklist for the youth in controlled observation and there were
no complaints of injury. The one Controlled Observation Report indicated the youth did not
require approval for continued placement in controlled observation.
5.25 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program maintains a written policy and procedures to ensure safety checks for youth on
controlled observation are conducted. A safety check is to be conducted every fifteen minutes to
ensure the youth is safe and observe the youth’s behavior. Once the youth is determined to be
appropriate for release from controlled observation, the facility administrator (FA) or designated
supervisor gives approval for the youth’s release. The release is documented on the Controlled
Observation Report. The program had one controlled observation placement since the last
annual compliance review. The one Controlled Observation Report was reviewed, which
indicated staff completed the first page of the report and the report was submitted to a
supervisor. Staff conducted safety checks at least every fifteen minutes and documented the
Controlled Observation Safety Check form. The one Controlled Observation Safety Check form
indicated the FA or designee approved the release of the youth from controlled observation
based on the youth’s behavior and no longer being a threat to self and others. A review of the
one Controlled Observation Report verified the FA or designee approved the report within
fourteen days of the youth’s release from controlled observation. Documentation verified staff
made a determination if an alert was warranted after the youth was released from controlled
observation. Documentation showed the Controlled Observation Report, Health Status
Checklist, and Controlled Observation Safety Check forms were maintained in an administrative
record and in the youth’s individual case management record. Reviewed documentation verified
staff designations for controlled observations were included in the program’s operating
procedures.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 71 (Revised September 2022)
Standard 6: Career and Technical Education (CTE), and Education
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 (CTE) services being provided as contracted include Florida
Ready to Work Soft Skills, Occupational Safety and Health Administration-10 (OSHA-10),
industry certifications, and automated external defibrillator (AED). Qualified instructors provide
all CTE services. Florida Ready to Work certifications include Soft Skills, Digital Skills, and
academic employability skills. Youth can receive certifications in OSHA-10, culinary, and
construction. In addition, youth can participate in Home Builder’s Institute (HBI) and learn Pre-
Apprenticeship Certificate Training (PACT) and carpentry skills. All youth in the program are
enrolled in coursework towards earning industry certifications during school hours from 8:00
a.m. to 3:00 p.m. Monday through Friday. Five youth records were reviewed, and each youth
had completed OSHA-10, first-aid/CPR, and Florida Ready to Work Soft Skills within the
contracted time frame. Five interviewed youth stated there are no interruptions during the school
day. Five youth were interviewed and one youth responded the program is preparing them well
for their high school equivalency diploma, high school, vocational school, employment, and/or
college, and four youth responded not well. The interviewed facility administrator (FA) stated
contract specific vocational services include Florida Ready to Work, HBI, food handler
certification, and other CTE certifications.
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 to provide for educational access. The
program integrates education into the daily schedule. A sample of three videos and three
logbook reviews showed youth were going to and returning from class on time. In addition,
randomly selected logbook entries over the past year were reviewed and youth were moved
accordingly. Five interviewed youth stated there are no interruptions during the school day.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 71 (Revised September 2022)
6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Education services are provided through a contract with Florida Virtual School (FLVS) which
ensures the integrity of the required minimum instruction time distributed over a twelve-month
period. This indicator was reviewed; however, will not be rated until the 25/26 review cycle. The
district approved calendar and daily school schedule were reviewed, which incorporated the
required 250 days of instruction, with twenty days used for teacher planning, and a minimum of
twenty-five hours of instruction weekly. The daily school schedule was approved by the school
board on April 29, 2024. Youth are enrolled in academic courses through Florida Scholars
Academy and receive credit, as appropriate, when courses are completed. A sample of three
videos and three logbook reviews showed youth classes were facilitated appropriately; however,
it was noted in one video sample the teacher arrived in the classroom late, as the teacher
rotates between two classrooms. An informal interview with the instructional leader reported the
educational schedule is adhered to.
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. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle. The education
contract provider is responsible for developing a career education program appropriate for the
educational abilities and goals of youth in the program and appropriate for the length of stay and
classification of youth in the program. The career education program does include Type 1
programming through Life Management Skills, Personal Finance, and Money Management
courses. The career education program does include Type 3 programming through course
offerings, to include Digital Information Technology and Life Management, which provide
content and competencies for specific careers. Each course offered by the education provider
includes soft skills for specific careers. The education contracted provider is responsible for
providing Career and Professional Education (CAPE) courses leading to pre-apprentice
certifications and industry certifications. The interviewed instructional leader stated youth
complete a career strengths and interest questionnaire upon entry and are placed into Digital
Information Technology and Life Management courses. Progress reports are sent to case
management by email within twenty-four hours of treatment team meetings. Teachers add
behavior notes to the academic progress reports.
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. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle. The contracted
education provider maintains a policy and procedures requiring an Education Transition Plan to
be developed upon each youth’s admission. Three closed case management records were
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 71 (Revised September 2022)
reviewed, and none contained an Education Transition Plan. Many youth entered the program
before July 1, 2024, when the new education provider began their contract, so they would not
have had an Education Transition Plan developed by the provider. Any youth who was admitted
between July 10, 2024, and December 1, 2024, may have had a paper Education Transition
Plan filled out; however, it was from an old form. Starting December 2, 2024, all
paraprofessionals were trained how to complete the new Education Transition Plan and those
will be uploaded into the Department’s Juvenile Justice Information System, (JJIS) by the school
counselors/transition specialists.
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. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle. The contracted
education provider has procedures in place to provide for qualified instructional personnel. A
review of seven instructional personnel and four flex instructional personnel found each had a
valid Florida educator’s certificate. All eleven teachers’ credentials were active on the
Department of Education (DOE) website. Seven instructional personnel taught out-of-field
courses at the program, however, none obtained approval by the school board for teaching out-
of-field. Each instructor taught one to seven out-of-field courses at the program. A review of the
three youth’s school schedules confirmed all teachers were accurately listed. A review of three
youth records for out-of-field parent/guardian notification letters showed no notifications were
sent out prior to October 7, 2024, and none of the letters accurately reflected the classes or
teaching assignments outside of their field of expertise.
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. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle. The education
contracted provider is responsible for referring all youth who receive their high school diploma or
equivalent to Florida Youth College (FYC). A review of three closed youth records found two
were applicable for a referral to FYC. There were no additional youth applicable for a referral
during the annual compliance review period. Documentation supported both youth were referred
to FYC and had received certifications from Tallahassee State College.
6.08 Florida Youth College (Post-Secondary Contract Provider) Failed Compliance
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 Registered Pre-apprenticeship/
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 71 (Revised September 2022)
Registered Apprenticeship programming that leads to a Registered Pre-apprenticeship
Certificate of Completion from FLDOE. For youth transitioning from the Department, follow-up
shall be completed in thirty, sixty, ninety, and 180 days after their release.
Each referral received by Florida Youth College (FYC) from the education contracted provider is
assigned a career navigator. The career navigator then connects with youth through the
residential contracted 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
contracted provider. A review of three youth closed records found two youth met the eligibility
criteria for a referral to FYC. A review of two applicable youth records found there was no
documentation a FYC career navigator was assigned for either youth. There was no
documentation a thirty-day follow up was conducted after the youths’ release from the program.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 71 of 71 (Revised September 2022)

source: DJJ

program_name_raw: Everglades Youth Academy - SOP

rule: Indicator 3.08