state: FL

facility_name: DOVE Academy

summary: QI Residential - FY25-26 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
DOVE Academy
Twin Oaks Juvenile Development, Inc.
(Contract Provider)
5270 Ezell Road
Graceville, Florida 32440
Review Date(s): October 21-24, 2025
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Patrick McKinstry, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Patrick Brock, Office of Education, Education Coordinator (Education Standard 1 and
Residential Standard 2)
Lea Herring, Office of Accountability and Program Support, Operations Coordinator (Standard
2)
Dehryl McCall, Office of Education, Education Coordinator (Education Standard 1 and
Residential Standard 2)
Kayshala Patterson, Office of Accountability and Program Support, Regional Monitor (Standard
5)
Ken Phillips, Office of Accountability and Program Support, Regional Monitor (Interviews)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: DOVE Academy MQI Program Code: 1102
Provider Name: Twin Oaks Juvenile Development, Inc. Contract Number: 10774
Location: Jackson County / Circuit 14 Number of Beds: 40
Review Date(s): October 21-24, 2025 Lead Reviewer Code: 144
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
5.04 Ten Minute Checks *
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 64 (Revised August 2025)
Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 64 (Revised August 2025)
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t a n d M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 3
In c id e n t R e p o rtin g (C C C ) * 1 .0 4
R ig h t In te ra c tio n s (R I) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 5
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 6
In -S e rv ic e T ra in in g 1 .0 7
G rie v a n c e P ro c e s s 1 .0 8
D e lin q u e n c y In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .0 9
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 0
R e s to ra tiv e J u s tic e A w a re n e s s fo r Y o u th 1 .1 1
In te rn a l A le rts S y s te m a n d A le rts (J J IS ) * 1 .1 2
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 3
A d v is o ry B o a rd 1 .1 4
S ta ff P e rfo rm a n c e 1 .1 5
S p e c ia l C o n tra c t C o n d itio n s 1 .1 6
D a ta T re n d A n a ly s is 1 .1 7
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 64 (Revised August 2025)
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n 2 .0 1
Y o u th O rie n ta tio n 2 .0 2
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r 2 .0 3
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s 2 .0 4
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t 2 .0 5
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s 2 .0 6
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y ) A s s e s s m e n ts a n d R e a s s e s s m e n ts 2 .0 7
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S ) 2 .0 8
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls , a n d T ra n s m itta l * 2 .0 9
P e rfo rm a n c e P la n R e v is io n s a n d In c o rp o ra tio n o f O th e r P la n s 2 .1 0
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls 2 .1 1
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s 2 .1 2
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s ) 2 .1 3
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T ) 2 .1 4
E x it P o rtfo lio 2 .1 5
E x it C o n fe re n c e 2 .1 6
Y o u th In p u t 2 .1 7
E d u c a tio n A c c e s s (R e s id e n tia l P ro v id e r) * 2 .1 8
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s (R e s id e n tia l C o n tra c t P ro v id e 2 .1 9
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Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 64 (Revised August 2025)
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity o r C lin ic a l C o o rd in a to r 3 .0 1
L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff * 3 .0 2
N o n -L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff 3 .0 3
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A d m is s io n S c re e n in g 3 .0 4
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A s s e s s m e n t/E v a lu a tio n 3 .0 5
M e n ta l H e a lth a n d S u b s ta n c e A b u s e T re a tm e n t * 3 .0 6
T re a tm e n t a n d D is c h a rg e P la n n in g * 3 .0 7
S p e c ia liz e d T re a tm e n t S e rv ic e s * 3 .0 8
S u ic id e P re v e n tio n P la n * 3 .0 9
S u ic id e P re v e n tio n S e rv ic e s * 3 .1 0
S e c u re O b s e rv a tio n * 3 .1 1
S u ic id e P re c a u tio n O b s e rv a tio n L o g s * 3 .1 2
S u ic id e P re v e n tio n T ra in in g * 3 .1 3
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s * 3 .1 4
C ris is A s s e s s m e n ts * 3 .1 5
E m e rg e n c y M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e rv ic e s * 3 .1 6
B a k e r a n d M a rc h m a n A c ts * 3 .1 7
S a fe ty P la n n in g P ro c e s s fo r Y o u th 3 .1 8
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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 Psychiatric Services * Satisfactory
4.18 Medication/Sharps Inventory and Storage Process Satisfactory
4.19 Infection Control/Exposure Control Satisfactory
4.20 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 64 (Revised August 2025)
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 * Limited
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control * Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 64 (Revised August 2025)
Program Overview
The DOVE Academy is a forty bed program, for fourteen to eighteen year old females, which is
located in Graceville, Florida. The program is operated by Twin Oaks Juvenile Development,
Incorporated, through a contract with the Department. The program provides the following
services: thirty-two beds with Substance Abuse Treatment Overlay Services (SAOS) or Mental
Health Overlay Services (MHOS), and eight Intensive Mental Health services (IMH) type beds.
The program includes innovation in delinquency programming and treatment services by
providing Moral Reconation Therapy (MRT), Dialectical Behavior Therapy (DBT), Seven
Challenges, and Impact of Crime (IOC). The program treatment services may include family,
group, individual, and/or recreational therapy as prescribed by the youth’s treatment team.
Program administration is comprised of a program director, an operations specialist, one
maintenance staff, and human resource staff. Case management services are provided by three
case managers, one transitional specialist, and one recreational therapist. Medical services are
comprised of one contracted designated health authority, one health services administrator, one
registered nurse, and one licensed practical nurse. Mental health services are comprised of a
contracted psychiatric nurse, a designated mental health clinician authority, and four clinical
counselors. Operations and shift coverage is maintained with two day shift supervisors, two
night shift supervisors, one Department of Transportation crew leader, one food service
manager, two dietary workers, and twenty-seven direct care staff. Educational services are
provided by Florida Scholars Academy and Florida Youth College. The program has one
administration building which houses administration and the dining hall. There are five other
buildings on-site; three are utilized for youth housing, one for education, and one for staff
training. The program has sixty-two security cameras providing coverage. At the time of the
annual compliance review, the program had no vacant staff positions.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 64 (Revised August 2025)
Standard 1: Management Accountability
Satisfactory
1.01 Initial Background Screening (Critical)
Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures which addresses volunteers, mentors, and interns
who work with youth less than ten hours a month requiring sight and sound supervision. The
program has an annual affidavit of compliance with level 2 screening completed on January 17,
2025. The program had a total of ten new staff who were reviewed for completion of a
background screening since the last annual compliance review. The reviewed staff had a
background screening completed prior to contact with youth and confidential records. The
program conducts a review of each staff’s criminal history report as part of the hiring process.
None of the staff required any exemption prior to working with youth. There was no indication of
staff having a break in service as indicated within the staff verification system. A pre-
employment assessment tool was administered to all direct care staff, with no issues observed.
Each staff had a passing score documented in the applicant’s file. The program added each of
the reviewed staff to their Clearinghouse employee roster. All ten staff had a signed contraband
attestation form filed in their employee record.
Satisfactory
1.02 Five-Year Rescreening
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.)
Three staff required a five-year background rescreening since the last annual compliance
review. Each staff had a rescreening completed every five years. The rescreening was
submitted to the Department’s Background Screening Unit at least ten business prior to the
staff’s five-year anniversary date.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 64 (Revised August 2025)
Satisfactory
1.03 Provision of an Abuse-Free Environment (Critical)
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.
There were only two incidents since the last annual compliance review which were related to
physical, psychological, or emotional abuse. There was no indication of any potential human
trafficking victim, child sexual exploitation, or labor trafficking having been reported. A review of
seven staff records indicated each reviewed and signed a code of conduct. While conducting a
tour, the Florida Abuse Hotline and the Department’s Central Communications Center (CCC)
numbers were observed posted throughout the program. The program had a written policy and
procedures on how to report abuse if necessary. The program completed a Trauma Responsive
and Caring Environment Self-assessment on April 8, 2025. There were no substantiated
incidents related physical, psychological, or emotional abuse since the last annual compliance
review. Only two incidents related to an abuse-free environment during the annual compliance
review period were reviewed and there was evidence management took immediate action to
address allegations of any type of physical, psychological, or emotional abuse. Both incidents
were found to be unsubstantiated.
The program director was interviewed and confirmed the program provides an environment in
which the youth, staff, and others feel safe, secure, and never threatened by any form of abuse
or harassment. All allegations of child abuse or suspected child abuse shall be immediately
reported first to the Florida Abuse Hotline and then second to the CCC. The program shall be
cognizant of youth and staff needs and provide directions to each on how to access the Florida
Abuse Hotline. Management will take immediate action to address incidents of physical,
psychological, and emotional abuse. All youth and staff at the program must believe the
community is free of physical, psychological, and emotional abuse. The program recognizes
and addresses the following key areas in youth programming: Trauma-informed practices,
forming strong and meaningful relationships, creating a physical environment which is
conducive to developing a youth into a strong and independent woman, empowering youth by
allowing them to have a voice in programmatic decisions and drive the development of
treatment and transition goals, and hiring and training staff who are committed to working with
youth. The abuse reporting phone numbers are posted throughout the facility. Staff are required
to make a report to the Florida Abuse Hotline if they know or have reasonable cause to suspect
a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other
person responsible for the child’s welfare, or a child is in need of supervision and care and has
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 64 (Revised August 2025)
no parent, legal custodian, or responsible adult relative immediately known and available to
provide supervision and care.
Satisfactory
1.04 Incident Reporting (CCC) (Critical)
Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program had a total of thirty-seven incidents reported since the last annual compliance
review. A review of five incidents were reviewed to ensure the program notified 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. All five
incidents reviewed had no issues with being reported timely once notified of the incident. Each
incident was documented accordingly in the program’s logbook. There were no documented
internal incidents or grievances which should have been reported to the CCC. The program has
experienced an increase by one of reportable incidents since the last annual compliance review;
however, there was not an increase of five or more sense the last annual compliance review.
Satisfactory
1.05 Right Interactions (RI) and Physical Intervention Rate
Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
There was a total of fifty-six Right Interaction (RI) interventions completed during the annual
compliance review period. Monthly summaries were maintained by the program of all right
interaction incidents submitted to the Department’s regional office by the fifteenth of each
month, during the annual compliance review period. The program’s RI plan was updated and
approved by the Department on January 17, 2025. The program’s Protective Action Response
(PAR) rate during the annual compliance review period was 3.28 for Substance Abuse
Treatment Overlay Services (SAOS) or Mental Health Overlay Services (MHOS) side and 9.72
for Intensive Mental Health services side, which is above the statewide Residential PAR rate of
2.57. Seven staff were interviewed and were able to articulate the process for use of RI if
necessary. The program director was interviewed and explained and RI report shall be reviewed
within seventy-two hours by the assistant director or designee and determine if the restraint
followed the policy. The report must also be reviewed by a RI instructor or certified supervisory
staff. The report shall then be submitted to the assistant director. A sample size of five RI
reports was reviewed. One of the five reports indicated the administrator, or designee did not
review the right interaction report within seventy-two hours of the incident being completed. The
remaining four reports were reviewed timely. In each report reviewed, all other report elements
were completed as required with no exceptions.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 64 (Revised August 2025)
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
A total of seven staff were reviewed for pre-service training for staff who have completed their
required training within 180 days of hire. Each staff completed all pre-service requirement
trainings within 180-days of hire. A total of three staff were reviewed for pre-service training who
were still within their 180-days of hire. Each of the staff have completed all training required
prior to being in the presence of any youth. An informal interview with the assist program
director provided, only specific designated staff will supervise youth. All instructors at the
program are qualified to deliver training. The program submitted a pre-service training plan prior
to implementation. The pre-service training calendar is approved by all parties as needed.
1.07 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
A total of seven staff were reviewed for in-service training. Each of the staff completed at a
minimum twenty-four hours of training annually. Two of the seven staff were found missing eight
hours of Right Interaction (RI) update training. One of the two staff was out on extended medical
leave during the update period; upon return to work, the staff completed the update in the
current calendar year. The remaining one staff had been certified in RI in December 2023 and
did not receive the update until January 2025. The seven reviewed staff completed all
mandatory training as required. A total of three supervisory staff were reviewed for completion
of eight hours of supervisory training in either coaching, leadership, and or personal
accountability, which were all completed as required. All instructors are qualified to deliver
training. The program has an annual in-service training calendar which is updated as changes
occur. The program submitted an in-service training plan prior to implementation. The in-service
training calendar is approved by all parties as needed.
1.08 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a written policy and procedures pertaining to grievances, which included
training requirements of the grievance process. The program’s grievance process also included
an informal, formal, and appeal phase. The program had a total of thirty grievances documented
since the last annual compliance review. A sample of five grievances were reviewed and affirm
the program’s practice correlates with their process. The program maintains copies of
grievances for the past twelve months. Seven youth were interviewed. Youth were able to
identify the process for submitting a grievance if needed. In addition, youth may ask for
assistance when completing a grievance form. Seven staff were interviewed. Staff were able to
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explain the programs grievance process for youth. The program director (PD) was interviewed
and confirmed the grievance procedures allow the youth to grieve, in writing, the actions of
program staff or the youth’s peers or conditions or circumstances of care and treatment which
are a violation of their rights. The grievance includes the following elements: informal phase,
which permits the youth to attempt to resolve the complaint or condition with the staff involved
on duty at the time. The youth may go to phase two (formal phase) if the issue is unresolved. In
the formal phase, the youth submit a written grievance requiring a written response from a
supervisory staff. If, in the informal phase, the grievance is not resolved, the grievance will be
submitted to the shift leader by the end of the shift in which the incident occurred. The shift
leader will investigate the facts of the grievance and submit a decision within seventy-two hours
of receiving the grievance. The shift leader can and should consult other members of the team.
The youth shall check the appropriate box on the grievance form. Both the youth and shift
leader will sign and date the form. The shift leader will return the grievance to the youth, and the
youth will place the grievance in the grievance box located in the cafeteria. During the appeal
phase, if the youth does not agree with the solution offered by the shift leader, the grievance
officer shall review the grievance with the staff and youth separately and issue a decision within
seventy-two hours. All grievances must be signed by staff and youth. The PD or designee will
review and sign all grievances with the grievance officer.
1.9 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 does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.10 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has policy and procedures addressing life and social skill services for youth. The
program’s only life skill groups are conducted through clinical primary services. The program
provides life skill intervention services which address educational, inter-personal,
health/hygiene, and financial, through off-site functions like financial literacy, religious
engagement, senior citizen luncheon, food drives, and incentive trips. Seven youth were
interviewed and were able to describe what life skills groups and/or activities they have
participated in.
The program director was interviewed and explained all youth at the program will participate in a
delinquency intervention model or strategy which is an evidence-based practice, promising
practice, or practice with demonstrated effectiveness for each youth. Moral Reconation Therapy
(MRT), which is the chosen evidence-based curriculum and is currently being used to address
behaviors associated with anti-social/conduct disorder in addressing criminal patterns of
behavior. MRT is a systematic, cognitive behavioral, step-by-step treatment strategy designed
to enhance self-image, promote the growth of a positive, productive identity, and facilitate the
development of higher stages of moral reasoning. The Seven Challenges and/or Seeking Safety
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are evidence-based treatment substance abuse curriculums designed to treat adolescents with
drug and other behavioral problems. Rather than using pre-structured sessions, counselors and
clients identify the most important issues at the moment and discuss these issues while the
counselor seamlessly integrates a set of concepts called the Seven Challenges into the
conversation through the journaling process. These concepts are woven into the counseling
session to help the youth make decisions and follow through. Skills training, problem-solving,
and sometimes family participation is integrated into sessions which address drug problems, co-
occurring problems, and life skills deficits. Impact of crime (IOC) addresses the harm to victims
and the community. The IOC curriculum will be provided by staff trained in the model, and
technical assistance will be requested to ensure fidelity and effective implementation. Individual
youth progression will be discussed during treatment team meetings. The designated mental
health clinician authority was interviewed and stated, upon intake, each youth undergoes a
comprehensive assessment to identify needs which are then addressed on the youth’s
treatment plan. These goals are addressed in both individual, group, and family therapy.
1.11 Restorative Justice Awareness for Youth Non-Applicable
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at DOVE Academy program. For details related specific to IOC service delivery,
please refer to the annual SPEP report.”
1.12 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures which address identifying, documenting, updating,
and how alerts are communicated to staff. The policy goes on to address those risk factors or
special needs identified during or after the classification process, the program will immediately
enter the information into the Department’s Juvenile Justice Information System (JJIS) and the
program’s internal alert system, which was confirmed by a review of each process system. A
review process at the beginning of each shift will review the posted alerts. Seven sampled youth
revealed ten total alerts to be reviewed. Two of the ten alerts were found to have been entered
into JJIS late; one was ten days late and the other was thirteen days late. The remaining eight
alerts were entered timely into JJIS.
The program director was interviewed and described the process as it relates to internal alerts.
Any direct care, supervisory, or clinical staff may place a youth on an alert status if criteria are
met. A suicide risk alert will be entered by a licensed mental health professional or mental
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health clinical staff if a youth is identified during the screening or evaluation process as a
potential suicide risk or other mental health alert. A mental health alert will be entered if a youth
is identified as having a mental disorder or is in acute mental distress which may cause a
security or safety risk. Medical alerts are entered by nursing staff. At the beginning of each shift,
all on-coming staff shall review the posted internal alerts located on clipboards in the resource
office. Once staff review each internal alert, the staff sign the internal alert acknowledgement
form located in shift leader’s office. In addition, all oncoming staff shall review and sign the shift
report for the previous shift. Shift reports shall capture recent alert activity which includes youth
who have been added to the alerts. Program staff can review the alert system located on the
public drive of each computer. The following available means are utilized to ensure all staff are
fully informed of the program’s alert process: public drive on all network computers, hard copy
on clipboards located in the resource office, daily printout for all staff who sign in and out keys,
and immediate access to e-mail for any changes in alert status. The shift reports are reviewed
and signed by incoming shifts. The program’s internal alert system warranting a youth to be
placed on the program’s medical alert system includes the following categories: gang affiliation,
assaultive or violent behavior risk, escape risks, mental health risk, youth who might have
serious traumatic experiences, sexual predator, and any youth with Medical Grades two through
five. The following medical conditions and issues warrant placement on the medical alert:
allergies, anaphylaxis, medication interactions, head trauma/injury, pregnancy, chronic
conditions, hearing, speech, visual or physical impairment, developmental disability or mental
retardation, and any medication side effects. Downgrading and discontinuance from the internal
alert system can only be done by a licensed mental health professional, or mental health clinical
staff for suicide risks and or mental health alerts. Food allergies alert sheet will be maintained in
the food service and shall be updated as needed by the medical department. The nursing staff
were interviewed, and medical alerts are entered by the nursing staff. Seven staff were
interviewed and articulated the practices for being informed of youth alerts including mental
health, medical, and security.
1.13 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program separates the youth records into two separate files: an individual healthcare record
and an individual management record. Each record contained all required identification and
sections. All youth records were found labeled “confidential”. The youth records were observed
secured in either a locked cabinet and or locked room, which was inaccessible to youth. Filing
cabinets utilized to store youth records were marked as “confidential”.
1.14 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program conducted a community advisory board on three separate occasions since the last
annual compliance review. The community advisory board meetings were conducted at least
every ninety to 120 days. Documents reviewed support the program is actively engaged with
and soliciting necessary community partners for community advisory meetings. An informal
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interview was held with one of the program’s community advisory board members. The board
member was able to articulate participation with the program and added their excitement with
being able to foster a positive relationship with the program. A review of ancillary meeting notes
and agendas supports the program on-going efforts in conducting community advisory board
meetings. The program director (PD) was interviewed and indicated the advisory board shall
consist of citizens of the local community who are interested inactively supporting the growth of
the program, including representatives from law enforcement, the judiciary community, business
community, faith community, local school district, and, if possible, the LGBTQI community. In
addition, at least one member of the board will be a victim, a victim advocate, or another
representative of the victim services community, and a parent/guardian whose child was
previously involved in the juvenile justice system. The PD or designee shall ensure the
involvement with a community advisory board and meetings will be held at least every ninety to
120 days. The PD will send out invites to each board member, notifying them of the upcoming
meeting. The PD or designee shall ensure proper documentation of each advisory board
meeting is maintained, which includes agendas and minutes. The PD or designee shall actively
participate in local juvenile justice meetings and will be involved with local community civic
organizations. The PD shall review the progress of the program, goals, objectives, and quality
improvement initiatives with the advisory board and shall actively attempt to recruit volunteers
from local businesses, civic organizations, and churches to donate their time and effort toward
enhancing program activities. The PD shall document all efforts made to include flyers,
newsletters, or other promotional means and, shall schedule activities which would facilitate
volunteer participation in the enhancement of program activities and shall actively work with the
community advisory board to ensure the availability of community work projects and
involvement in community activities.
1.15 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures which addresses a system for evaluating staff,
performance standards, and frequency of evaluations. A total of three job position descriptions
were reviewed. Each staff’s performance standards were clearly identified. A total of seven
performance evaluations were reviewed to ensure evaluations were completed as outlined in
policy at least annually. Each of the performance standards matched staff job descriptions. In
addition, applicable position descriptions revealed staff whose job functions include
implementation of the program’s behavior management system matched. The program had no
vacancies, therefore meeting all contractual required positions. The program has a recreational
therapist, who was employed during the last annual compliance review. The program director
was interviewed and reported there have been no problems. The program uses “Trendstat” to
track trends as related to turnover. Staff retention planning includes monthly celebrations for
staff of the month and quarter with monetary gifts. The program also has shift parties for each
shift and celebratory parties for major holidays and family days. All employees will receive
annual evaluations which will be conducted by their immediate supervisor. Seven staff were
interviewed. Two of seven staff replied they had never received a formal evaluation; these two
staff have not been at the program for a year. Two staff replied they get a formal evaluation
every six months. Two staff replied they received a formal evaluation yearly. One staff had been
with the program for three months and just received an evaluation a couple days ago.
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1.16 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program has implemented those items or services which were negotiated and or outlined in
contract and are either considered special contract conditions, listed within scope of services,
and or referenced in the memorandum of negotiation. Specific services include the opportunity
for youth to participate in Alcoholic Anonymous, no co-mingling of youth from Department of
Children and Families contract, recreational therapist, medical and or mental health staff
competency-based test, Boys and Girls Club, and thirty-day supply of non-perishable food items
kept available. A review of these negotiated areas and documentation revealed the program is
completed each as required.
1.17 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program utilizes “Trendstat” to track data on a monthly basis. The “Trendstat” is discussed
in the weekly management meetings, all staff meetings, and is posted within the administrative
building on the “Trendstat” bulletin board for staff to view. The data is used to inform decision
making for youth, staff, and the program in general. Data is shared in-house with corporate staff
and stakeholders at a minimum quarterly. The program is able to capture and continually
measure trends of bed utilization, physical interventions, youth behavior, abuse, central
communication center contact, baker acts, injuries, Commission on Accreditation of
Rehabilitation Facilities (CARF), incentive trips, Department of Transportation usage, training,
evidence-based system entries, and case management. A continuum of monitoring data allows
the program to make adjustments as needed.
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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.
Seven reviewed case management records had documentation verifying each youth’s
parent/guardian was called within twenty-four hours of the youth’s admission. Six youth records
documented in the chronological notes the contact with the parent was made with one record
documented the attempt to contact the youth’s father on the date of admission but spoke with
him on the telephone six days later. All seven reviewed case management records included
written notification of each youth’s parent/guardian within forty-eight hours of admission. All
seven reviewed case management records reflected program staff notified the committing court
and assigned juvenile probation officer of each youth’s arrival on the day of admission in writing.
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 policy and procedures to address the youth orientation process. A program
orientation was conducted for all seven reviewed youth within twenty-four hours of admission.
Orientation included expectations and responsibilities of each youth, written behavioral
management system, access to medical and mental health and substance abuse services,
access to the Department’s Central Communications Center and Florida Abuse Hotline, zero
tolerance regarding sexual misconduct, what is considered contraband and illegal items and
consequences for having these items, performance plan process, hygiene and dress code,
procedures for visitation, mail, and telephone usage, each youth’s anticipated length of stay,
goal completion, expectations for release, access to community, grievance process, fire drills
and emergency procedures, facility tour, health education topics, services available, daily
schedule, living unit, and treatment team assignment. Seven interviewed youth each indicated
the orientation process with program rules, procedures, schedule, and more were reviewed by
the case manager when they arrived at the program. All seven-youth reported they received
orientation within twenty-four hours of arriving at the program. One youth was admitted to the
program during the annual compliance review week and orientation was observed. The case
manager reviewed all the items on the orientation checklist in detail on the day of the youth’s
admission.
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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.
Three of the seven reviewed records were applicable for written consent of youth eighteen
years of age or older. Two of the three youth records reviewed did include a written consent
form signed by the youth to consent to provide physical and mental health information to their
parents/guardians. One youth record did not contain the written consent of youth eighteen years
or older to release information to the parents. Review of the youth record showed the youth’s
parent involvement in case management services. A consent form was requested, and the
program provided an eighteen and older Authority for Evaluation and Treatment form by the
youth.
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 policy and procedures outlining the classification process for youth upon
admission to the program which promotes safety and security, effective delivery of treatment
services based on individual needs and risk factors, and completion of reassessments every
thirty days or as necessary. A review of seven records found documentation in all records
addressing each youth’s gender, height, weight, physical stature, age and maturity level, special
needs, history of violence, gang status, criminal behavior, sexual aggression or vulnerability to
victimization, perception of vulnerability, potential or verified human trafficking history, and risk
factors for medical, suicide, escape, and security. All seven records demonstrated each youth
was assigned to a living unit and room based on the program’s classification system. Seven
reviewed records each included the Vulnerability to Victimization and Sexually Aggressive
Behavior (VSAB) documents. The program utilizes an alert system which staff have access to
and provides updated information on each youth, including medical, mental health, suicide,
sexual predator, aggression, and escape or security risks. Review of the Department’s Juvenile
Justice Information System (JJIS) alert list did not contain any information for issues affecting
classification. All seven reviewed records included reclassification forms and documented
reclassification prior to the addition of privileges including an increase in freedom of movement,
participation in work projects or other activities, and participation in off-campus activities.
The program director (PD) interview indicated a pre-admission staffing will be held by members
of the treatment team for each youth prior to their admission to the program. The pre-staff
guides the review of the youth’s case management records to determine tentative assignments
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to dorm, case manager, and therapist. During the pre-admission of a youth, the case manager
reviews the youth’s record, intake packet, history, collateral contacts, and initial interactions
during orientation. The case manager will make the final dorm assignment based on the
recommendation of the treatment team during the pre-admission staffing and their interaction
with the youth upon admission. All newly admitted youth shall be screened using the VSAB prior
to room assignments. The PD also reported the VSAB screening tool will be utilized to
determine the youth’s potential risks, which will be entered into JJIS. Other documentation to
the VSAB are considered in the classification process of the youth are criminal behavior, history
of violence, medical or mental health issues, co-offenders present at program or other girls from
immediate area in which the new girl is coming from, history of suicidal ideations and suicide
risk, history of offenses, separation of younger girls from older girls from non-aggressive girls,
background including level of aggression and ability to act responsibly, past involvement in
assaults or aggressive behaviors or demonstration of emotional disturbance, and risk of escape
or to the public. The classification process will also provide documentation if the girl needs
deoxyribonucleic acid testing and a youth’s history of potential or verified human trafficking.
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 policy and procedures outlining the gang identification and notification of law
enforcement. None of the seven reviewed case management records were applicable for gang
identification and notification. During the annual compliance review period, there were no youth
applicable for gang identification.
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 policy and procedures to address a youth’s participation in gang prevention
and intervention activities. During this annual compliance review period, there were no youth
applicable for gang identification prevention and intervention. Any youth identified to be a gang
member, have gang affiliations, or are at a high risk of gang involvement will participate in
Impact of Crime group weekly. In addition, a goal shall be included on their individual
performance plan pertaining to gang membership and/or affiliation. The program’s policy and
procedures address providing youth an opportunity, if they desire, to develop a plan to
disaffiliate with a criminal street gang. The program’s gang prevention and awareness include
training and observation regarding wearing and displaying colors, gang insignias, tattoos,
graffiti, hand signs, street slang, area codes, and other gang related manner.
The program director (PD) interview reports all staff will be trained during pre-service training.
All new youth intakes will be interviewed for any gang affiliation during the admissions and
orientation process, and this information will be passed on to the leadership team and
documented on the youth’s classification form. If the youth is found to have a gang affiliation
throughout their stay, the classification form will be revised. If a youth has been identified as a
gang member or suspected of criminal gang activity, the proper notifications must be made to
the youth’s home county by the program unless the notification has been made before
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placement in the program. Current gang information shall be disseminated to staff as it is
obtained and there will be zero tolerance for gang-related behavior. The PD or designee shall
attend gang-related training sessions or seminars when available and maintain documentation
of gang-related training in the program. The two gang prevention specialist enhance the
implementation and development of the program’s overall gang prevention strategy and are
trained to ensure the program always has a gang prevention specialist available.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
A review of seven youth case management records found documentation in all records verifying
the Residential Assessment for Youth (RAY) was completed within thirty days of admission. All
initial assessments were maintained in the Department’s Juvenile Justice Information System.
All seven reviewed records were applicable for the ninety-day RAY reassessment. All seven
records had reassessments completed every ninety days as required and were applicable for
additional reassessments deemed necessary by the intervention and treatment team. Each
record maintained all reassessment documentation as required.
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.
A review of seven youth case management records verified each record included a Youth
Needs Assessment Summary (YNAS) completed in the Department’s Juvenile Justice
Information System. Six of the seven case management records documented the YNAS was
completed within thirty days of each youth’s admission. One record reviewed was completed
one day late. Each record documented the youth’s top three criminogenic needs.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. 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.
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Each of the seven reviewed youth case management records included completion of an
Individual Performance Plan (IPP). Six of the seven case management records documented the
IPP was completed within thirty days of admission in the Department’s Juvenile Justice
Information System. One record reviewed showed the plan was one day late. All seven records
reviewed documented the performance plan was completed after completion of the Youth
Needs Assessment Summary (YNAS). Documentation in each of the seven youth case
management records indicated team members were present to provide input to the IPP. Each of
the seven youth interviews reflected each youth participated in the development of their plan. All
IPP goals were measurable and included target completion dates and were based upon the
prioritized needs reflecting the risk and protective factors identified during the initial assessment,
which included the top three criminogenic needs. Performance plan goals identified
responsibilities of staff and youth and included delinquency interventions, transition goals, and
targeted court-ordered sanctions which could be reasonably initiated or completed while at the
program. All seven case management records included IPP transmittal letters which were sent
out to the committing court, juvenile probation office, and parent/guardian within the required
time frame. Performance plans were signed by the treatment team leader, youth, and other
parties who are responsible for goal completion. Seven interviewed youth reported they
participated in the development of their IPP.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
All seven reviewed case management records were applicable for Individual Performance Plan
(IPP) revisions. Each youth’s treatment team was involved in determining the need for IPP
revisions. Revisions were made based on goal progress, new information revealed, and
Residential Assessment for Youth (RAY) Reassessment results. All seven youth records had
additional plans, including academic or treatment plans, incorporated into the IPP. One youth
case management record reviewed did not incorporate the RAY reassessment results in the
revised performance plan until it was pointed out to the program approximately two weeks later.
No youth were applicable to receive services with the Department of Children and Families
(DCF)or 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.
All seven reviewed case management records were applicable for Performance Summaries and
transmittals every ninety-days. Each Performance Summary included the youth’s status on each
performance plan goal, overall treatment progress, behavior adjustments and progress,
academic status including grades, credits earned in the program including performance and
behavior in school, significant events, interactions with peers and staff, and level of motivation
or readiness to change. All seven Performance Summaries were done within ninety days of the
Individual Performance Plan signatures and every ninety-days thereafter. Reviewed
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documentation in each record indicated the youth were allowed to read and add comments prior
to signing the summary, the youth 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 all required parties and sent within ten business days to the committing court, juvenile
probation officer, and parent/guardian. A review of three closed case management records
verified each release summary included the justification for release, discharge, or transfer and
was attached with the Pre-Release Notification (PRN). The release summary and PRN were
sent at least forty-five days prior to the youth’s expected release. A signed copy was maintained
in each youth’s record. One of the youth records including the court objecting to PRN’s first
request for release and was resubmitted to meet the court’s expectation. Once approved, the
program provided written notification to each youth’s parent/guardian. Each closed case
management record contained an Exit Residential Assessment for Youth (RAY). None of the
youth were applicable for the Sexually Violent Predator Program and none required victim
notification to be sent. Original Performance Summaries and copies of release summaries were
in each youth case management record.
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.
Seven reviewed case management records included documentation confirming program staff
involved attempted to involve parent/guardian in the assessment process, performance plan
development, progress review, and transition planning, when applicable. Parents/guardians
were provided with advanced notification of meetings and provided opportunities to attend or
participate in these events. If unable to attend, the parent/guardian is provided the opportunity to
participate by telephone or video conferencing, or to provide verbal or written input prior to the
meeting. A treatment team meeting could not be observed as there was no treatment team
meeting conducted during the annual compliance review week. The program director (PD)
interview indicated program staff encourage and facilitate involvement of the youth’s
parent/guardian in the case management process, including assessments, performance plan
development, progress reviews, treatment team meetings and transition planning. Parents are
notified of all treatment team meetings and can participate by phone or video conference, if
unable to attend in person. Seven youth were interviewed, and six youth reported their parent is
called during treatment team meetings and three indicated the program contacts their parent
regularly. One youth is twenty years of age and has no guardian but stays in contact with foster
mother.
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.
Seven youth case management records were reviewed for formal and informal treatment team
reviews. In each record, the case manager and therapist were identified as treatment team
leaders. The treatment team for each youth included the youth, administration representative,
case manager, living unit representative, education, clinical staff, medical staff, juvenile
probation officer (JPO), and parent/guardian. Participants were present and provided written
input. The youth’s JPO and parent/guardian participated by telephone. Each reviewed case
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management record included mostly formal treatment team reviews meetings completed bi-
weekly. There were sixty-nine treatment team meetings reviewed with sixty formal meetings,
nine informal meeting, and one formal meeting form blank. All treatment team meetings
included all required elements which were youth name, review date, attendees, input from team
members, how youth are progressing, youth behavior, any physical interventions, and
Residential Assessment for Youth (RAY) Reassessment results. All treatment team
documentation was maintained in each youth’s record. The youth’s treatment team members,
JPO, and parent/guardian were invited and encouraged to participate in youth formal treatment
team reviews. A treatment team meeting could not be observed as there was no treatment team
meeting conducted during the week of the annual compliance review. Each of the seven
interviewed youth reported they have an opportunity to demonstrate learned skills and youth
progress is discussed during formal treatment team meetings. Each youth stated staff talk about
performance to include progress on performance plan goals, positive and negative behavior,
and treatment progress. Six youth stated they are given a self-report to show the skills they
have learned in the program. One youth state they can speak out, but usually does not because
can make things worse.
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.
Three closed case management records were reviewed for transition planning and the
Community Re-Entry Team (CRT) meeting. Transition Conferences were conducted at least
sixty days prior to each youth’s scheduled release date. The youth, treatment team leader,
program director or designee, juvenile probation officer (JPO), parent/guardian, medical, and
education staff were invited and participated in each youth’s Transition Conference. During the
Transition Conference the team conducted a review of the transition activities on each youth’s
Individual Performance Plan (IPP), revised the IPP as necessary, identified additional transition
activities as needed, identified target completion dates, and identified persons responsible for
completion. A copy of each plan was sent to each applicable party not in attendance at the
Transition Conference with a request for return with a signature. The treatment team leader
obtained participant signatures or electronic acknowledgement of responsibilities. All three
closed case management records included supporting documentation indicating the program
and youth participated in the CRT meeting prior to release and an invitation sent through email
was maintained within the youth records.
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2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three closed case management records were reviewed for Exit Portfolios. Documentation
indicated the Exit Portfolio was discussed and initiated for the youth during the Transition
Conference for all three youth. The three closed case management records included all required
documents including a state-issued identification card, Social Security card, and birth certificate,
community appointment calendar, education and vocation certifications, and sample
employment applications. The Exit Portfolio was provided to each youth and juvenile probation
officer. The youth were not applicable for requirements specific to youth in a secure maximum
risk program. The program did not have any additional requirements related to the Exit Portfolio
included in the contract. Each Exit Portfolio was verified during the Exit Conference.
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.
Three closed case management records were reviewed for Exit Conference requirements. Exit
Conferences were conducted for each youth after notification to the juvenile probation officer
(JPO) and at least fourteen days prior to the anticipated release date. Each reviewed record
confirmed the JPO, parent/guardian, education representative, intervention and treatment team
leader, and other pertinent parties participated in each youth’s Exit Conference. All three Exit
Conferences were documented in each youth’s case management record and held separately
from the Transition Conference and Community Re-Entry Team meetings. Review of the three
youth’s dates of admission and termination documented in the case management record did
correlate within the Department’s Juvenile Justice Information System. The Exit Conference
documents included a review of Transition Conference goals, a summary of pending transition
goals, provisions for continuation of education and/or employment, evidence the youth’s case
manager and parent/guardian are aware of the plan, documents, and post-release discharge
plans, and signatures for all required parties. The youth’s JPO and parent/guardian participated
by telephone.
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 to promote formal constructive input by youth. A
review of the program’s youth advisory council documents reflected youth can provide input and
feedback concerning services, community, improvements, and staff and youth quality of life.
Documentation supported these meetings were held quarterly as the program’s policy dictates.
The program also conducts monthly community/dorm meetings for all youth to participate and
provide feedback. The program has youth complete a youth survey before they are released
from the program to obtain feedback from youth input. All seven interviewed youth indicated
input can be provided through request to speak forms and community meetings. The
interviewed program director (PD) stated the program provides the youth opportunities to
develop self-advocacy, leadership, teamwork, and empowerment skills. Youth will be provided
the opportunity to provide feedback regarding the services they receive, daily programming, as
well as any treatment relative to their stay at the program. Youth will participate in the
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development of the behavior modification system (BMS)/handbook and take responsibility for
their community. Youth are chosen by the youth advisory council in conjunction with the PD.
Meetings are held quarterly or as needed with the PD and/or designee. Youth advisory
representatives will serve for the duration of their stay or until they become ineligible.
2.18 Educational Access (Residential Contract Provide) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide educational access. A review of the
activity schedule, which reflects the education schedule, found, Florida Scholars Academy
provided education services which coincides with the 250-day calendar, distributed over twelve
months, including twenty days used for teacher training and planning. A review of seven random
dates in the logbook, one per month, showed the daily class schedule was being followed.
Further review of logbook entries and video footage for three random days verified the youth
were attending school as scheduled. All seven interviewed youth stated educational services
are being provided with no interruptions.
2.19 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
Documentation review confirmed the program is delivering and documenting the contract
mandated foundational credentials of Occupational Safety and Health Administration (OSHA)
10, Florida Ready to Work (Soft Skills Credential), and cardiopulmonary resuscitation
(CPR)/First Aid. Records for these completions were verified in record for each of the three
youth reviewed. While the program offers Career and Technical Education (CTE) instruction in
culinary arts and preparing students to take the ServSafe “Food Handler” certificate, a further
expansion of this program could include preparing students to earn a “Certified Food Protection
Manager (ServSafe)”, which is currently on the Master Credentials List. The program previously
had a successful welding program; however, due to an instructor vacancy the program is
working with the Florida Trade Academy to establish a manufacturing/soldering course. Seven
interviewed youth stated they are being provided CTE courses in OSHA, welding, Soft Skills,
ServeSafe, culinary, and well as preparing for Scholastic Aptitude Test (SAT) and researching
colleges. The interviewed program director verified the probation is providing all contracted
vocational and career educational services as required,
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program has a designated mental health clinician authority (DMHCA) who is a licensed
mental health counselor and holds a valid and active license in the State of Florida. The
DMHCA’s license expires on March 31, 2027. The DMHCA is on-site weekly to ensure
appropriate coordination and implementation of mental health and substance abuse services
are taking place as required. The DMCHA’s position description was reviewed and included all
required information. The program delivers specialized treatment services, with the DMHCA
serving as the sole licensed health professional responsible for overseeing the coordination and
implementation of mental health and substance abuse services. These services include
Intensive Mental Health Treatment (IMH), Substance Abuse Treatment Overlay Services
(SAOS), and Mental Health Overlay Services (MHOS). The program has a designated back-up
DMHCA who holds an active and valid license which expires March 31, 2027. An interview with
the DMHCA confirmed full-time employment status and on-site presence Monday through
Friday for a total of forty hours a week. The DMHCA also verified the credentials of the back-up
DMHCA and affirmed the specialized treatment services provided the program.
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 designated mental health clinician authority (DMHCA) serves as the clinical supervisor in
the program. The program does not have any additional licensed mental health and substance
abuse clinical staff outside of the DMHCA. A review of the staff roster confirmed clinical staffing
is in accordance with the program’s contract. The program employs a licensed psychologist who
is on-site one to two hours a week, or as needed. The psychologist holds a current Florida
license valid through May 31, 2026. Additionally, the program retains a psychiatric nurse
practitioner who provides on-site services weekly and maintains an active Florida license valid
through April 30, 2027.
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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 designated mental health clinician authority (DMHCA) serves as the clinical supervisor in
the program. The DMHCA ensures all non-licensed staff are performing services they are
qualified to provide based upon education, training, and experience. The DMHCA provided the
weekly supervision records for review. All non-licensed therapists received one hour a week of
face-to-face direct supervision as evidenced by a review of the supervision logs. All direct
supervision was recorded on a form developed by the program and included all required
elements form the Department’s Licensed Mental Health Professionals and Licensed/Certified
Substance Abuse Professional Direct Supervision Log form. The program maintains a valid
Chapter 397 license, which is displayed in the administration building’s front lobby and expires
on July 6, 2026. The program’s contract authorizes four non-licensed clinical positions. A review
of the staff roster confirmed four clinical staff were employed during the annual compliance
review period. One vacancy occurred during this period but was promptly filled, and the program
currently operates at full clinical staffing. Of the four clinical staff, three hold a master’s degree
from an accredited university in counseling, social work, psychology, or a related human
services field. The remaining staff holds a bachelor’s degree in a related field, is currently
enrolled in a master’s degree program, and has a minimum of two years of clinical experience in
assessing, counseling, and treating youth with serious emotional disturbances or substance use
issues. The program’s staff operate under the direct supervision of a qualified professional in
accordance with Chapter 397 requirements. The DMCHA provided training documentation for
Assessments of Suicide Risk (ASR). All non-licensed staff received twenty hours of training for
conducting ASR and were supervised in assessing suicide risk, mental health crisis intervention,
and emergency mental health services.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Seven youth mental health and substance abuse records were reviewed for the mental health
and substance abuse admission screening. All seven youth were given a Massachusetts Youth
Screening Instrument (MAYSI-2). All seven records included documentation the screener
reviewed available information to include the commitment packet and existing reports for
documentation of mental health and/or substance abuse problems. Four different staff
conducted the MAYSI-2 screenings, and all were formally trained as evidenced by a review of
the Department’s Learning Management System (SkillPro). All seven screenings were
completed in the Department’s Juvenile Justice Information System (JJIS) on the day of
admission. All seven assessments were completed in full, and all required further assessment.
Referrals were made to the designated mental health clinician authority (DMHCA) due to the
assessments indicating a need for further assessments as evidenced by a review of the youth
records. The program director (PD) ensured an Assessments of Suicide Risk (ASR) was
completed within twenty-four hours for all seven youth. None of the youth were placed on
Precautionary Observation as a result of the ASR upon admission to the program. All seven
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youth records included a MAYSI-2 assessment referral form which indicated the youth were
referred for an ASR and comprehensive evaluation along with the reason for each referral. The
PD developed a policy and procedures for the implementation of standardized admission/intake
mental health and substance abuse screening process. The policy included a comprehensive
screening protocol which involves reviewing commitment packet information, reports, and
records; administering the MAYSI-2 through the Department’s Juvenile Justice Information
System (JJIS) or conducting a Clinical Mental Health Screening by a licensed mental health
professional and a Clinical Substance Abuse Screening by a qualified professional; and
ensuring appropriate referral of juveniles identified as needing further evaluation or immediate
attention. Additionally, the policy must outline staff training requirements on mental health and
substance abuse issues, including proper administration of the MAYSI-2, and define a
standardized referral process for youth requiring further evaluation or immediate intervention,
ensuring timely referral to appropriate service providers, professionals, hospitals, or Baker Act
or Marchman Act receiving facilities as necessary. An interview with the PD revealed the
program employs a comprehensive and standardized process to identify youth at risk for mental
health, substance abuse, and suicide concerns. Upon admission, every youth is confidentially
screened by the clinical coordinator using the MAYSI-2 or a Clinical Mental Health/Substance
Abuse Screening, with suicide risk assessed through the MAYSI-2 in JJIS or manually if the
system is unavailable. Only trained staff may administer the MAYSI-2, and all screenings are
reviewed and signed by a licensed or qualified mental health professional. The process includes
reviewing psychological, psychiatric, and pre-dispositional reports, with re-screenings conducted
when youth return from outside placements. If a screening indicates a need for further
evaluation, a referral is made within twenty-four hours, and precautionary measures are
implemented if suicide risk is identified. Nursing staff observe for physical indicators of self-
harm, and all staff are trained to recognize and respond to signs of depression or suicidal
ideation, ensuring immediate intervention and documentation in the youth’s record.
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.
Seven youth mental health and substance abuse records were reviewed for the mental health
and substance abuse assessment and evaluation. All seven records included documentation
the program completed a new and combined mental health and substance abuse evaluation for
the youth upon admission. All seven evaluations were completed within thirty calendar days of
admission. All seven records included signed consents for substance abuse services. While
non-licensed staff conducted the assessments, each evaluation was reviewed and signed by
the designated mental health clinician authority (DMHCA) within ten calendar days of
completion. All reviewed evaluations included identifying information of the youth, reason for the
evaluation, relevant background, behavioral observation, mental status examinations, interview
documentation, findings, diagnostic impression which included the Diagnostic and Statistical
Manual of Mental Disorders-Fifth Edition (DSM-V), patterns and impacts of substance abuse,
associated risk factors, and recommendations. An interview with the DMHCA outlined the
process for obtaining a comprehensive mental health and/or substance abuse assessment
following the initial screening. Each youth is admitted with a Department comprehensive
evaluation, and within thirty days of admission the program completes its own comprehensive
mental health and substance abuse assessment. Based on the assessment findings and
observed behaviors, youth are referred to appropriate evidence-based therapeutic interventions,
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which may include Moral Reconation Therapy, Seven Challenges, Seeking Safety, Dialectical
Behavior Therapy, or Coping with Anger.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
Seven youth mental health and substance abuse records were reviewed for mental health and
substance abuse treatment. All seven reviewed initial treatment plans were developed on the
day of admission. All initial treatment plans included all required elements from the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Five of the seven
youth entered the program on psychotropic medications, and all five initial treatment plans
included psychiatric services. All reviewed initial treatment plans were signed by the mental
health clinical staff completing the form. All seven initial treatment plans were completed by non-
licensed clinical staff, and all were reviewed and signed by the clinical supervisor within ten days
of completion. The initial treatment plans reviewed were signed by the youth, treatment team
leader, and program management. Five of the seven treatment plans included psychiatric
services due to the five youth entered the program on psychotropic medications. The remaining
two youth did not enter the program on medications, but the reviewed individualized treatment
plans included psychiatric services if needed during the youth’s stay at the program. Seven
individualized treatment plan reviews included all elements from the Department’s Individualized
Mental Health/Substance Abuse Treatment Plan Review form. All seven records included
documentation treatment plan reviews were completed every thirty days as required. All
reviewed treatment plans were signed by the mental health clinical staff completing the form. All
seven treatment plans were completed by non-licensed clinical staff, and all were reviewed and
signed by the clinical supervisor within ten days of completion. All reviewed treatment plans and
reviews included signatures from the youth, treatment team leader, program management, living
unit representative, education, and medical staff. Four of the seven included the parent/guardian
by phone. The remaining three were documented as attempts to speak to parent/guardian by
phone. The treatment plan reviews did not include signatures for the juvenile probation officers
(JPO); however, a review of the treatment team documentation showed the JPOs were present
by telephone during the treatment plan reviews and this was indicated on the treatment team
signature pages. All individualized treatment plans included prescribed services, goals, and
objectives which were individualized for each youth. All mental health services are primary
services, and documentation is reviewed by the technical assistance specialist. A review of
three groups on video was observed and revealed all required groups were being held on the
scheduled days at the scheduled times for the correct length of time.
An interview with the designated mental health clinician authority (DMHCA) detailed the
program’s process for obtaining and managing comprehensive mental health and substance
abuse assessments and services. Each youth enters the program with a Department
comprehensive evaluation, and within thirty days of admission the program completes its own
comprehensive mental health and substance abuse assessment. This process includes
reviewing the Department evaluation, interviewing the youth and their parent/guardian,
examining psychiatric history, reviewing MAYSI results and the Department’s Juvenile Justice
Information System (JJIS) alerts, and consulting with program staff. To ensure services are
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appropriately provided, the clinical director assigns youth to therapeutic groups during pre-
admission staffing and periodically observes group sessions. Clinical coordinators complete
daily progress notes, which are reviewed by the clinical director, and participate in weekly
supervision sessions where clinical documentation and youth progress are discussed. Mental
health and substance abuse services are reviewed during formal treatment team meetings, and
treatment plans are evaluated bi-monthly and updated as needed to ensure ongoing relevance
and effectiveness.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
Seven youth mental health and substance abuse records were reviewed for treatment and
discharge planning. All seven records included documentation the youth was assigned a
treatment team upon arrival to the program. Documentation revealed the treatment teams were
comprised of the youth, program administration, residential living unit representative, education,
medical staff, mental health staff, and parents/guardians. All seven youth reviewed records
indicated the youth were in need of substance abuse treatment services and received
substance abuse treatment in the program. All seven youth had a properly executed Authority of
Evaluation and Treatment (AET). Three of the seven youth were eighteen years of age or older
but had a properly executed AET in the record. All seven youth receiving substance abuse
treatment services had a signed Department Youth Consent for Substance Abuse Treatment. All
reviewed mental health treatment notes included all elements of the Department’s
Counseling/Therapy Progress Notes form. All seven youth were receiving individual
psychotherapy and/or counseling and psychosocial skills training. A review of the progress
notes revealed all seven youth were receiving services as stipulated in the individualized
treatment plans.
Three closed youth mental health and substance abuse records were reviewed for discharge
planning. Each included a completed discharge plan documented on the Department’s Mental
Health and Substance Abuse Treatment Discharge Summary form. None of the youth were
released while on suicide alert or precautions; therefore, notification to parents/guardians and
juvenile probation officers (JPOs) was not required. All three discharge summaries documented
future service needs; however, two of the three summaries lacked documentation indicating the
discharge plan was discussed with, and copies were provided to, the parent/guardian and JPO
during the exit conference. The remaining discharge summary included appropriate
documentation confirming the discussion and distribution of copies to both the parent/guardian
and JPO. An interview with the designated mental health clinician authority (DMHCA) revealed
the process used for individualized mental health and treatment planning is weekly and each
youth participates in a pre-planning meeting to identify specific needs; parent/guardians also
provide feedback and identify areas the youth may need to address in treatment.
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3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
Comprehensive mental health and substance abuse services are provided to all the youth who
meet eligibility criteria for Mental Health Overlay Services (MHOS), Substance Abuse Overlay
Services (SAOS), and Intensive Mental Health (IMH) services. The program is licensed to
provide thirty-two of forty beds designated with MHOS and/or SAOS and an additional eight
beds designated for Specialized Treatment Services, which include IMH programming. The
designated mental health clinician authority (DMHCA) is on-site for forty-hours a week, and
licensed mental health staff are present at least five days a week. Both the DMHCA and the
program director (PD) are on-site on some weekends to ensure continuity of care. A licensed
psychologist is also on-site at least once a week to provide clinical services to youth and
consultation to staff, as needed. No youth missed clinical groups or services due to medical
quarantine during the review period. Counselor caseloads for MHOS youth do not exceed
eleven youth per counselor. Of the four non-licensed clinical staff, three hold master’s degrees,
as verified by documentation on file, and the remaining staff member is currently enrolled in a
master’s degree program. The program provides individual therapy at least biweekly, with
increased frequency as clinically indicated. Family therapy is conducted at least monthly, or
more often when needed. The psychiatrist provides on-site services at least every two weeks.
Primary clinical group therapy sessions are held a minimum of four days a week, with
supplemental clinical services provided as needed. Clinical staff serving SAOS youth maintain
caseloads of no more than eleven youth, and these youth participate in four substance abuse
group sessions a week. Clinical staff serving IMH youth maintain caseloads of no more than
eight youth, and these youth participate in five mental health and substance abuse groups each
week. Required clinical groups include Dialectical Behavior Therapy (DBT) and Moral
Reconation Therapy (MRT). Interviews with seven youth revealed six were currently
participating in individual and/or family counseling. One youth stated they were scheduled to
begin therapy soon. Three youth reported receiving individual therapy once a week; one
reported family therapy every other week; one stated they were waiting to begin therapy; and
one noted a lapse in therapy services due to a recent change in therapist. Interviews with seven
staff members confirmed direct care staff do not facilitate mental health or substance abuse
groups. An interview with the DMHCA indicated each youth participates in a pre-planning
meeting to identify specific treatment needs, with parent/guardians providing input regarding
areas of concern to address in treatment. The interviewed PD confirmed the program delivers
specialized treatment services in compliance with Florida Statutes, Administrative Rules, and
the program contract.
3.09 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program maintains a policy and procedures for a suicide prevention plan and includes
suicide prevention procedures. The plan included protocols for identification and assessment of
youth at risk of suicide, staff training, suicide precautions, levels of supervision, referrals,
communication, notifications, and documentation standards. The review determined the plan
was missing a section addressing immediate staff response to a suicide attempt or incident.
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The plan also incorporates all required elements of the review process for suicide attempts and
mortality reviews. The Suicide Prevention Plan was reviewed and signed by both the program
director and the designated mental health clinician authority (DMHCA) on August 15, 2025.
3.10 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
Seven youth mental health and substance abuse records were reviewed for suicide prevention
services. Of the seven records, five were applicable for review. Four youth were identified as
being at risk for suicide through staff observation, while the remaining youth was identified
through a journal entry. All five youth received an Assessment of Suicide Risk (ASR), which was
documented on the Department’s form. Each ASR included the precautionary observation
placement start date, referral date, and level of observation. Two youth were placed on constant
supervision, two youth were placed on close supervision, and one youth was Baker Acted.
Three of the five youth required notifications to parent/guardians and juvenile probation officers
(JPOs). Documentation confirmed all three parent/guardians were notified of the youth’s
potential suicide risk as indicated by the ASR; however, only one of the three assigned JPOs
was notified of the youth’s risk status as required. Mental health staff provided supportive
services to all five youth. Four of the ASRs were completed by non-licensed mental health staff
working under the supervision of a licensed mental health professional. The remaining ASR was
completed by the designated mental health clinician authority (DMHCA). The results of the
ASRs indicated two youth continued on constant supervision, two youth continued on close
supervision, and one youth was Baker Acted. Four of the five ASRs were completed within
twenty-four hours of the observed behavior or screening, while the remaining ASR was
completed three days late. Prior to any change in supervision level, the non-licensed staff
consulted with the DMHCA and the program director. A follow-up ASR was completed for each
youth prior to removal from precautionary observation and transition to close supervision. All
follow-up ASRs were documented on the Department’s form. Each youth remained on the
assigned level of supervision until the follow-up ASR indicated the level could be safely
discontinued and stepped down to close supervision. Close supervision was maintained for all
five youth until it was determined to be no longer necessary by the DMHCA following a
conference with the program director. A review of documentation indicated the program is
following its written suicide prevention plan. Review of the Department’s Juvenile Justice
Information System (JJIS) showed three of the five youth were applicable for an alert to be
initiated. Only two of the three alerts were initiated for the youth placed on suicide precautions.
The two alerts were initiated were accurately closed in accordance with the recommendations of
the ASR or follow-up ASR. Evidence in the program’s logbooks confirmed each youth placed on
precautionary observation was documented along with specific instructions related to ASR
findings and supervision decisions. All five youth were permitted to participate in designated
activities while on precautionary observation, as documented in the safe housing section of
each ASR and follow-up ASR. A video review of three different days was conducted to confirm
youth on suicide risk status were being properly observed. No issues were noted regarding
observation practices.
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3.11 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated “Non-
Applicable.”
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Seven youth mental health and substance abuse records were reviewed for suicide precaution
observation (PO) logs. Of the seven records, five were applicable for review. All five contained
documentation confirming Department PO logs were maintained throughout the duration each
youth was placed on suicide precaution. A review of the PO logs revealed supervision and
observations were documented in real time and not exceeding thirty-minute intervals. One of
five youth had documented warning signs on the PO logs and notification of the program
director and mental health clinical staff was documented on the Suicide Precaution Observation
Log. All PO logs were reviewed and signed by each shift supervisor and mental health clinical
staff as evidenced by signatures and dates on each PO log. Additionally, each log documented
safe housing requirements.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains three suicide response kits, which include the knife-for-life, wire cutters,
and needle nose pliers. The kits are located in each laundry room of the dorms. All suicide kits
are co-located with first-aid kits. Staff training includes quarterly mock suicide drills conducted
on each shift. These drills involve all personnel who may have contact with youth, including
kitchen and maintenance staff. A video review could not be completed, as no mock drill had
been conducted within the past thirty days; therefore, verification of simulated drills involving
suicide attempts or incidents of serious self-injury could not be confirmed. According to the
assistant program director (PD), youth are not utilized in drill simulations. A review of
documentation of drills confirmed the program provided semi-annual training on emergency
response procedures, which included mock suicide response components. The assistant PD
reported staff who are unable to attend a quarterly drill are required to review the drill scenario
and procedures to ensure understanding of appropriate responses to suicide attempts or
serious self-inflicted injuries. Staff members document their review by signing the form. A review
of drill records confirmed mock suicide response drills are completed quarterly on each shift. Of
the fifteen drills conducted during the annual compliance review period, all included life-saving
measures, and six incorporated cardiopulmonary resuscitation (CPR) procedures. Interviews
were conducted with seven staff. Six of the seven reported medical emergency and suicide drills
are conducted on their shift once a month. The remaining staff member reported not having
participated in any drills to date. An interview with the PD revealed all staff working with youth
are required to complete a minimum of six hours of annual training in recognizing suicide risk,
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suicide prevention, and implementing suicide precautions. Training includes quarterly “mock”
suicide drills for each shift, which are simulated and do not involve program youth. Drills
address responses to suicide attempts or serious self-inflicted injury, and staff who miss a drill
must review the scenario and procedures to ensure competency. While not all drills require
CPR, all direct-care staff must participate in at least one CPR drill annually.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a combined mental health crisis intervention and emergency mental health
and substance abuse services plan, which was provided for review. The plan includes the
required components, such as notification and alert systems, referral procedures,
communication, documentation, and review procedures; however, the plan did not include
provisions for youth self-referral or detailed descriptions of supervision levels, specifically
outlining one-to-one, close, and standard supervision requirements.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program maintains a policy and procedures for Crisis Assessments. Crisis Assessments
consist of a detailed evaluation of a youth demonstrating acute psychological distress and are
conducted by a licensed mental health professional (LMHP) or by a non-licensed mental health
clinical staff member under the direct supervision of an LMHP. The assessment process is
designed to determine the severity of the youth’s symptoms and assess any risk to self or
others. There were no youth who met the criteria for a Crisis Assessment during the annual
compliance review period.
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3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a combined emergency mental health and substance abuse plan and crisis
intervention plan, which was provided for review. The plan included immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health or substance abuse services, transport for emergency Mental Health Evaluation and/or
Substance Abuse Treatment under Chapter 397, documentation, training, and review.
3.17 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.
Seven youth mental health and substance abuse records were reviewed for Baker and/or
Marchman Act documentation. Of the seven records, two were applicable for review, with one
additional Baker Act documented in one of the two records. In one case, the youth made a
suicidal statement, and in the other two cases, the youth attempted suicide. These incidents
resulted in the determination the youth required emergency mental health care. Each youth was
immediately placed on Precautionary Observation (PO), and notifications were made to the
designated mental health clinician authority (DMHCA). In all three cases, the youth were
removed from the program and transported by local law enforcement in accordance with
program protocol. Upon their return, documentation indicated two of the three youth were
placed on Precautionary Observation and received mental status examinations. Assessments of
Suicide Risk (ASRs) were completed by the DMHCA for both cases, and supervision levels
were maintained until the assessments were finalized. For the remaining case, documentation
of PO logs and the ASR could not be located in the youth’s record. Therefore, verification could
not be made regarding whether the youth was placed on constant supervision upon return, who
completed the ASR, or whether the youth’s supervision level was maintained until an
appropriate assessment was conducted.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Seven youth mental health and substance abuse records were provided for review of safety
plan documentation. All seven youth records included documentation a safety plan was
completed within fourteen days of admission. Each plan reflected joint development by the
youth, parent/guardian, and clinical staff, and incorporated recommendations from current
clinical assessments and screenings. Five of the seven youth had safety plans updated every
thirty days as required. Two youth records were missing one monthly safety plan update;
however; all other safety plan reviews were complete as required. Safety plans were reviewed
and revised as necessary following any significant behavioral or mental health event, as
documented by the youth’s intervention and treatment team. All reviewed safety plans included
essential components such as warning signs, baseline behaviors, crisis recognition, coping
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strategies, preferred intervention methods identified by the youth, and a debriefing process.
Safety plans are reviewed by all staff who have contact with the youth and are maintained both
in the youth’s record and in a binder located in supervisor’s office. Seven youth were
interviewed and all reported participating in the development of their safety plans. An interview
with the program director (PD) revealed the program maintains an ongoing safety planning
process for each youth. The safety plan is designed to identify stimuli which have both positive
and negative effects on the youth. According to the PD, each completed safety plan is reviewed
at least every thirty days by clinical staff who have direct contact with the youth and may be
updated at any time as needed. The safety plan binder is maintained in the supervisor’s office to
ensure staff accessibility.
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 board certified autonomous advanced registered practice registered nurse
(APRN) who holds an unrestricted license and meets all requirements for independent an
unsupervised practice in Florida who serves as the designated health authority (DHA). The
DHA’s license is clear and active with an expiration date of April 30, 2027, and contains no
disciplinary action. The program did not utilize a physician assistant. Review of sign-in and out
logs confirmed the DHA was on site at least once a week. The program does have a back-up
DHA who holds a clear and active license with an expiration date of January 31, 2027. The
back-up DHA was not utilized during the scope of the annual compliance review. The program
does not utilize telehealth services. The DHA was interviewed and reported responsibilities as
overseeing and providing comprehensive healthcare services to the youth within the program.
Responsibilities include conducting Comprehensive Physical Assessments (CPAs), managing
sick call visits, performing periodic and follow-up evaluations, and addressing both acute and
chronic medical needs. Providing direct patient care while ensuring compliance with Department
healthcare standards and clinical protocols as well as supervise and support nursing staff and
collaborate with mental health and administrative teams to promote continuity of care and
overall wellness for all residents. The DHA further confirmed reviewing, signing, and dating all
documents.
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 utilizes registered nurses (RNs) as well as license practical nurses (LPNs) to
provide daily clinical care. LPNs were provided direction by the designated health authority
(DHA). Licensure credentials for all nurses were reviewed and each maintains a clear and
active license according to Florida Department of Health (DOH) website. All nursing staff
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Office of Accountability and Program Support Page 38 of 64 (Revised August 2025)
maintain current cardiopulmonary resuscitation (CPR) certifications as required. According to
the program’s contract, the required on-site hours for the nursing staff is eighty hours per week.
Documentation review confirmed scheduling meets contractual requirements.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The designated health authority (DHA) and program director (PD) signed and dated all
respective treatment facility operating procedures (FOPs). The DHA signed on August 12, 2025
and the (PD) signed October 15, 2025. Nursing staff reviewed, signed, and dated the cover
page on which all FOPs, healthcare protocols, and other procedures were listed, as required.
New policies or changes in policies made during the year were reviewed, signed, and dated by
each nurse on the individual policy changes which occurred between annual compliance
reviews or as signature pages added with the specific policy listed, date of revision, and
signatures, as required. The annual review of medical FOPs and protocols was conducted and
signed on August 12, 2025. All newly employed healthcare personnel receive a comprehensive
clinical orientation to the Department’s healthcare policies and procedures, given by a
registered nurse or designated, licensed health care professional, as required. 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.
Seven youth individual healthcare records (IHCRs) were reviewed for authorization for
evaluation and treatment (AET) documentation. Documentation review confirmed each youth
IHCR contained an original or legible filed copy of the AET which was signed and dated by a
parent/guardian and Department representative. Each AET was valid. Three of seven youth
were eighteen years of age and each IHCR contained documentation of release of information.
None of the youth were under the care of the Department of Children and Families (DCF). The
nurse was interviewed and reported at the time of, or prior to admission, the AET will be
reviewed by nursing staff to ensure parent/guardian's signature is present dated and witnessed
by a Department representative. In the event the parent/guardian refuses to sign the AET or if
the assigned guardian is not the parent/guardian nor cannot be located after all reasonable
attempts, a court order should be obtained/identified as a basis for the provision of care and
filed in the IHRC. Youth who are eighteen years of age may provide their own consent once
treatments are selected and explained and they authorize the release of healthcare information
records. Each youth is responsible for accepting and providing consent for care.
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.
Seven youth individual healthcare records (IHCRs) were reviewed for parental
notification/consent. Five of seven youth were receiving over-the-counter (OTC) medications.
Each IHCRs contained documentation of parental consent for OTC medications beyond those
covered by the Authorization for Evaluation and Treatment (AET). Each of the seven IHCRs
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contained documentation of attempted contact to parent/guardian as new medications were
ordered and each notification was documented on the appropriate Department parental
notification form. Five of seven youth were taking psychotropic medications at the time of
admission, and one was prescribed psychotropic medications after admission. Each IHCR of
youth prescribed psychotropic medications contained documentation to confirm written parental
notification. All telephone call attempts were witnessed by staff for each of the six youth. None
of the youth were under the care of the Department of Children and Families (DCF).
Vaccinations were verified within thirty days of the youth’s admission in all seven IHCRs
reviewed. None of the youth were applicable for administration of vaccinations. None of the
youth were applicable for religious exemption from immunizations. The program utilizes the
Department of Health (DOH) website to determine the youth’s immunization status at the time of
admission, but no longer than seven days. The nurse was interviewed and reported
parents/guardians shall be informed of any significant changes in youth's condition and consent
obtained prior to initiation of new medications or treatments are prescribed. Youth records shall
be checked upon admission for a current AET, if an updated form is not in the medical record,
the nurse shall obtain consent immediately by parent/guardian or court order. The
parent/guardian will be notified prior to transport when at all possible. Verbal consent will be
obtained by phone with a second witness present then documented in chronological section of
the youth's IHCR. Written notification shall be sent by regular mail to parent/guardian. Antibiotics
will not be delayed in the event parent's consent cannot be obtained. No psychotropic
medication will be administered without prior parental consent. Vaccinations are provided on-
site. Immunization records are obtained from the DOH. Records are reviewed at time of
admission leaving no longer than seven days to pass. In the event of immunization exemption,
parent/guardian shall compete the Religious Exemption from Immunizations form provided by
the DOH.
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.
Seven youth individual healthcare records (IHCRs) were reviewed for Facility Entry Physical
Health Screening (FEPHS) form. Each IHCR contained a FEPHS completed on the date of
youth admission. Six of seven FEPHS were completed by a registered nurse (RN), and the
remaining screening was completed by a licensed practice nurse (LPN) and each screening
was reviewed by a licensed staff within twenty-four hours. Two of the seven youth had a change
in physical custody greater than twenty-four hours, thus requiring a new FEPHS re-screening.
Documentation review confirmed each applicable IHCRs contained a new FEPHS re-screening.
The nurse was interviewed and reported newly admitted youth are seen on admission or within
seven days upon admission. Notification of new admissions are obtained prior to arrival to
program. Admission screenings are completed by the LPN or direct care staff and is witnessed
by the RN. The designated health authority (DHA) will review all information obtained. When
completed by direct care staff, information is recorded in chronological notes of the IHCR.
Additional screenings are completed for each youth if physical custody has changed.
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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.
Seven youth individual healthcare records (IHCRs) were reviewed for youth orientation to
healthcare services/health education. Documentation review confirmed each IHCR contained
evidence of general care admission orientation. Each health education record included required
topics such as access to medical care, sick call access, what constitutes an emergency and
when to notify staff, medication process to include side effects monitoring, the right to refuse
care and how it is documented, what to do in case of a sexual assault or attempted assault, the
non-disciplinary role of the healthcare provider, and standard universal precautions. Health
Education is conducted monthly as contractually required. Health education includes topics
such as seatbelt usage, alcohol and drug related problems, sexually transmitted
diseases/infections, tobacco products and smoking cessation, dental hygiene and dental care,
immunizations, infection control, prevention of sexual and other physical violence, nutrition,
physical fitness, breast self-examinations, parenting skills, prenatal, postpartum, and parenting
education, as applicable, and chronic conditions/medications, as applicable.
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.
Seven youth individual healthcare records (IHCRs) were reviewed for designated health
authority (DHA)/designee admission notification for youth admitted requiring emergency or
routine notification. Three of the seven youth were applicable for having a chronic condition.
None of the applicable youth were identified as in-need of emergency care upon admission.
Each applicable IHCR contained documentation of a referral being sent to the DHA within
twelve hours of the youth’s admission. Two of three youth applicable for chronic conditions were
taking psychotropic medication upon admission and the psychiatrist was notified on each. The
nurse was interviewed and was able to articulate the process for youth admitted to the program
with chronic conditions.
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.
Seven youth individual healthcare records (IHCRs) were reviewed for a completed Health
Related History (HRH) form. Each IHRC contained an HRH form which was completed within
seven days of admission and each HRH was completed prior to completion of the
Comprehensive Physical Assessment (CPA) as evidenced by date and signature. Each HRH
was reviewed by the physician as evidenced by the checked box on the CPA. The nurse was
interviewed and reported the HRH is completed by the designated health authority (DHA) within
seven days of admission to program and within seventy-two hours if purified protein test (PPD)
test is out of date.
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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.
Seven youth individual healthcare records (IHCRs) were reviewed for a completed
Comprehensive Physical Assessment (CPA) and Tuberculosis Screening (TB). Each youth CPA
was completed on the appropriate Department form. Each IHCR contained a current CPA on file
at the time of admission. The program’s practice is to complete a new CPA on all newly
admitted youth, and each had a new CPA completed. Four of the seven CPAs were completed
by the designated health authority (DHA), and the remaining CPAs were completed by the
advanced practice registered nurse (APRN). Each CPA contained the youth’s Medical Grade
and there was no missing or incomplete information in either. All sections of each CPA were
marked with an X or O as applicable. Each youth refused gynecological examinations, and each
was documented as not clinically indicated as well. The clinician documented refusal in each
record, and each youth signed the CPA as well as a refusal form which reflected the refused
portion of the exam and dates matched. Each IHCR contained an updated Department Problem
List form. Each IHCR contained documentation of a completed TB skin test completed within
the last year. Six of seven IHCRs contained TB test results documented on the CPA which
matched the Communicable Disease form. The remaining youth’s TB test results did not match
the date of the CPA. The nurse was interviewed and reported CPAs are completed upon
admission if a youth presents without a current CPA which must be completed within seven
days. A CPA is good for one year. The nurse further reported the process and timeframe for TB
screenings as after the initial screening, and a TB test shall be completed within seven days of
admission if there is no documentation of a current TB test on file. Gynecological exams are not
routinely completed for youth.
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.
Seven youth individual healthcare records (IHCRs) were reviewed for sexually transmitted
infection (STI) screening and human immunodeficiency virus (HIV) screening requirements. Six
of seven youth met requirements for being sexually active and were screened and evaluated for
STI. The remaining youth reported not being sexually active. None of the youth required further
evaluation as documented on the Department Sexually Transmitted Infection Screening form.
None of the youth were out of the custody of the Department or had symptoms present which
would require rescreening. Each youth refused human immunodeficiency virus (HIV) testing.
The program maintains a policy and procedures which addresses HIV testing results disclosure
which is limited to the youth and legally authorized representatives, health care providers during
the course of consultation, diagnosis, or treatment of the individual, the Department of Health
(DOH) for purposes of reporting and controlling the spread of disease, health facility staff
committees conducting program monitoring, evaluation, service reviews, medical personnel who
have been subject to a significant exposure, and health care facility personnel or agents for the
healthcare provider who have a need to know in the course of patient care activities or
administrative operations. Seven youth were interviewed, and each stated they can ask for a
HIV test. The nurse was interviewed and was able to articulate the process for STI
documentation, screening, evaluation, referrals, and testing.
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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.
Seven youth individual healthcare records (IHCRs) were reviewed for sick call process. Each of
the seven youth were applicable for the sick call process. None of the youth presented with
similar sick call complaints three or more times within a two-week period. Each youth completed
a Sick Call Request form. Documentation review confirmed the appropriate section of the Sick
Call Request form was completed by nursing. Four of seven youth had a sick call conducted by
a licensed practice nurse (LPN), which was reviewed with the appropriate licensed professional
as documented on the form. Each IHCR contained a Sick Call Request form which was filed in
reverse chronological order. No youth was in restricted housing of any kind. All Sick Call
Request forms and progress notes were documented in accordance with the Health Services
Rule. Each sick call was documented on the Sick Call Index and on the program’s Sick Call
Referral Log. The dates listed on the Sick Call Index correspond to the completed Sick Call
forms located in the IHCR. Sick call is conducted Monday through Friday from 11:00 a.m. to
12:15 p.m. Sick call hours are posted in the dining hall, the medical building, and in each
dormitory. Sick call is only conducted by licensed nurses. The program has a policy wherein
supervisors can review all sick call requests as soon as possible and within four hours after the
request is made when there is not a licensed nurse on-site. Sick Call Request forms are in each
dormitory, the dining hall, and the medical building. An exam table and equipment are used to
perform sick calls. An observation of sick call was conducted during the annual compliance
review. Prior to observation, youth consent was provided. The youth was escorted to sick by
direct care staff. Prior to initiation of sick call, the medical provider self-identified and stated the
reason the youth was there. The youth was seen in a private area with no other youth present to
see or hear the examination. The sick call was conducted by a licensed staff. The direct care
staff escorting the youth was positioned just outside in another area of the medical office. Seven
youth were interviewed. Six of seven youth reported they are seen within one day of making a
sick call request. The remaining youth reported they are seen within three days of making a
request. The nurse was interviewed and was able to articulate the program’s sick call process.
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.
Seven youth individual healthcare records (IHCRs) were reviewed for episodic first-aid and
emergency care. Four of seven youth were applicable for completion of episodic, first-aid, and
or emergency care. The healthcare staff documented each case in subjective, objective,
assessment, and plan (SOAP) format. Two of the four applicable youth had additional episodic
or first-aid care events in which they received care from a non-healthcare staff. Each of the two-
youth received Tylenol and both received follow-up evaluations from a licensed healthcare staff
the next time staff was on-site. The program’s episodic and emergency care procedures were
reviewed with no issues. The program has a total of sixteen first-aid kits. First-aid kits are in the
medical building, each of three case manager’s office, each dormitory, administration, staff
break room, culinary, education, each of three supervisor’s office, kitchen, and laundry room.
Two of the first-aid kits are used for transportation vehicles. The program’s process for ensuring
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content is maintained and stored in accordance with guidelines to prevent expiration or
deterioration and replenishment consists of nursing staff conducting monthly monitoring of first-
aid kits. Each kit is documented on an inventory log which nursing signs off on as checked, and
items needing replacing due to expiration or items needing to be replenished is conducted at
time of monitoring. Visual inspection of a sample of three first-aid kits was conducted to ensure
the kits were fully stocked with approved contents. Each sampled first-aid kit contained
designated health authority (DHA) approved content. Documentation review confirmed first-aid
kits were monitored as required. The program has one automated external defibrillator (AED)
which is in the supervisor’s office in the main lobby. The AED procedures are located with the
AED. On-site nursing staff conducts checks to ensure AED batteries and pads are operable,
which was confirmed by inventory check sheets. A self-test of the AED was conducted by
nursing staff with no issues observed. The battery indicator light during self-test was observed
to be green The AED batteries have an expiration date of January 20, 2027. The batteries were
last changed on April 28, 2015. The AED pads were last changed on April 28, 2025, and has an
expiration date of August 4, 2027. A list of emergency numbers, which included the number to
Poison Information Center, was posted and accessible to licensed and unlicensed staff. The
numbers were not accessible to any youth. All authorized direct care staff were appropriately
trained by a registered nurse (RN) on the administration of an epinephrin auto-injector. Seven
staff training records were reviewed which showed training requirements were met regarding
episodic care, first-aid, and emergency care.
Documentation review of emergency and medical drills was conducted for a period of twelve
months and the review confirmed staff participated in at least one drill which included
cardiopulmonary resuscitation (CPR) annually. Video review confirmed the drills were simulated
and drills included an episodic care event which calls for immediate first-aid and/or
administration of CPR techniques and the initiation of the emergency procedures to follow when
a life-threatening emergency does occur. An episodic care event was unable to be observed
during the annual compliance review as none occurred. The program’s policy on the use,
access, and inventory of Narcan dictates nursing staff inventories Narcan on a weekly perpetual
basis. Narcan is stored in the supervisors’ office, in a locked medical cabinet in the medical
building, and in the medial cart. Medical staff, supervisors, team leads, and administrators have
access to Narcan. Each staff member with access to Narcan has received training as required.
Seven youth were interviewed, and each reported they can see a doctor if needed. Seven staff
were interviewed, and six of seven staff reported they are allowed to call 9-1-1. The remaining
staff reported they would notify the nurse. The nurse was interviewed and reported the program
has a total of sixteen first-aid kits in various locations throughout the program. The nurse further
described the program’s process for documenting on-site episodic care as information will be
documented in chronological progress notes. The information will be documented in SOAP
format. The information is documented in the episodic index binder and the appropriate
Department form. The nurse was able to further articulate the program’s process for tracking
and monitoring AED and emergency drill procedure.
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.
Seven youth individual healthcare records (IHCRs) were reviewed for off-site care referral
requirement. Three of seven youth met requirements and had indications for off-site referral
requirements. Documentation review confirmed the Summary of Off-Site Care Consultation form
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was utilized and filed in each youth IHCR. One of three IHCRs contained documentation on the
Episodic) first aid or emergency) Care Log and parental notification efforts were documented.
The remaining two were not documented as they were non-emergent and were for the purpose
of laboratory work. The one applicable youth’s IHCR contained documentation to confirm the
designated health authority (DHA) reviewed and signed all off-site care findings, instruction, and
information. None of the youth required follow-up testing, referrals or appointments. The nurse
was interviewed and reported off-site emergency care is tracked using the Summary of Off-Site
Care form All follow-up testing, referrals, and appointments require documentation indicating
youth received appropriate and timely follow-up care, as needed, with the DHA will document
and review all off-site care findings.
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.
Seven youth individual healthcare records (IHCRs) were reviewed for chronic condition and
periodic evaluation requirement. Five of seven youth were applicable. Each of the applicable
youth were identified on the Facility Entry Physical Health Screening (FEPHS) form as having a
chronic condition. None of the youth were identified as having a communicable disease. Each of
the applicable youth was taking medication on an ongoing basis for some reason. Two of five
applicable youth were undergoing treatment for a physical health condition. All applicable youth
were classified with a Medical Grade two through five. Three of the five youth Medical Grades
were increased as they were prescribed psychotropic medications as well. None of the youth
were identified as pregnant or were taking anti tuberculosis medications (TB). All five youth
were placed on the chronic illness list and received periodic evaluations at least every ninety-
days. None of the youth required off-site evaluations. There were no indications of lapses in
care or missed periodic evaluations for all applicable youth. The Department’s Problem List was
updated in accordance with the Health Services Rule for all five applicable youth, as required.
The program director (PD) was interviewed and reported a flow sheet is prepared by the nurse
with the name of the youth, date of admission (DOA), and a date to be seen and placed behind
the monthly tab of when follow-up is needed. It is placed in the chronic condition binder. At the
beginning of each month, all flow sheets are taken out of binder in each IHCR to be provided to
the designated health authority (DHA). The youth is placed on the DHA’s monthly schedule. The
flow sheet is completed by the DHA once youth are evaluated. The PD meets with the director
of nursing weekly. The DHA was interviewed and reported responsibilities as overseeing and
providing comprehensive healthcare services to the youth within the facility, conducting
Comprehensive Physical Assessments (CPAs), managing sick call visits, performing periodic
and follow-up evaluations, and addressing both acute and chronic medical needs, as well as
providing direct patient care while ensuring compliance with Department healthcare standards
and clinical protocols, and to supervise and support nursing staff and collaborate with mental
health and administrative teams to promote continuity of care and overall wellness. The DHA
further confirmed reviewing, signing, and dating all documents. The nurse was interviewed and
reported periodic evaluations conducted by the DHA is the program’s process for monitoring
youth with chronic conditions.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
Seven youth individual healthcare records (IHCRs) were reviewed for medication management.
Five of seven youth were taking medications at the time of admission to the program.
Medication verification for each youth was verified prior to being admitted to the program as
evidenced by documentation in each youth’s IHCR. Documentation further confirmed the
designated health authority (DHA) and psychiatrist, as applicable, was notified to obtain orders
to resume medications prior to admission. Medication for each youth had a current valid order
and medications were administered pursuant to the current prescription. All medications
prescribed had a practitioner order form completed by the DHA. None of the youth were in
restricted housing. Each of seven youth was applicable for being prescribed over-the-counter
(OTC) medication not listed on the Authority for Evaluation and Treatment (AET) form and each
was administered according to approved protocols or the Practitioner’s Order unless the
parent/guardian prohibited the administration of OTC medications. The standard Department
Medication Administration Record (MAR) was used to document all medication and treatment
and the MAR clearly indicated medication start and stop dates for all seven youth. Two of seven
youth received medication administration services from trained non-healthcare staff only when
licensed healthcare staff were not present. In each record documentation review confirmed staff
initialed each medication entry. There were no undocumented explanations for lapses or errors
in medication administration in any of the IHCRs. The nursing staff documented weekly side-
effect monitoring on the MAR in each of seven IHCRs. Two of seven youth were applicable for
medication refusal and each youth IHCR contained a signed Refusal of Treatment form.
Medication refusals were clearly documented on the MAR. Each of the seven MARs contained
all the required elements such as youth’s name, Department of Juvenile Justice identification
number (DJJID), date of birth, youth allergies, precautions, Medical Grade, medical alerts, and
current picture of youth. The two youth who received medication administration services from
non-healthcare staff initialed each MAR entry. No youth required parental medications.
Documentation review confirmed there were no standing orders for psychotropic medications,
emergency treatment orders for psychotropic medication, or any orders pro re nata (PRN)
psychotropic medications.
During the annual compliance review an observation of medication administration was
conducted. Youth consent was acquired prior to the observation. The youth was escorted to the
medical station by direct staff. The youth individually approached the licensed medical staff
administering the medication. The licensed medical staff identified themselves and informed the
youth why they were there. The same licensed medical staff preparing the medication also
administered the medication. The youth’s allergy status was verified. Medications were
administered by licensed healthcare staff. Prescription medications were not pre-poured from
original packaging. Nursing staff observed youth to make sure medications was swallowed and
further confirmed by completing a mouth sweep with a swab. After administering medications,
nursing staff initialed the MAR. Seven youth were interviewed. Five of seven youth were able to
articulate the medication administration process and each reported nurses provide medications.
The remaining two youth reported not taking medications. The nurse was interviewed and
reported the medical staff will ensure medications are received, stored, inventoried, and
provided in a safe and effective manner and the MAR is used. Non-healthcare staff do provide
medications. Medication pass is conducted from 6:00 a.m. to 7:00 a.m.,12:00 p.m. to 1:00 p.m.,
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6:00 p.m. to 7:00 p.m., and 9:00 p.m. The program does not have a modified Class II pharmacy
permit. Medications and prescriptions are procured through a provider.
4.17 Psychiatric Services Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program maintains a policy and procedures addressing psychiatric services which includes
psychiatric evaluation, consultation, medication management, and medical supportive
counseling to youth with a diagnosed mental disorder. Psychiatric services are provided by a
psychiatric advanced practice registered nurse (APRN) who has a clear and active license with
an expiration date of April 30, 2027, meeting requirements in Florida Administrative Code. The
psychiatrist is available for emergency consultation twenty-four hours a day, seven days a
week. The psychiatric APRN providing psychiatric services briefs a representative of the
treatment team regarding the psychiatric status of each youth receiving psychiatric services who
is scheduled for treatment team review. The psychiatrist or psychiatric APRN’s evaluation and
recommendations for the youth are incorporated into the mental health clinical staff’s
evaluations of the youth and the youth’s individualized mental health or substance abuse
treatment plan. The psychiatric APRN position is utilized for clinical responsibilities only. The
psychiatric APRN’s education, experience, and certification/licensure is in psychiatry/mental
health, as stated on the Department of Health website. The psychiatric APRN possesses a
license to practice autonomously which does not require a collaborative practice protocol. A
review of sign-in logs confirmed the APRN visits were conducted as contractually required. The
psychiatric APRN actively participates in, manages, and supervise psychotropic medication
services in the program. The program did not utilize a back-up psychiatrist and does not utilize
tele-psychiatry. Seven youth mental health and substance abuse records were reviewed for
psychiatric services. Five of seven youth were applicable for entering the program on psychiatric
medications. The program’s practice is to refer all youth for a psychiatric interview. Each of the
five-youth admitted to the program on medications received an initial diagnostic interview within
fourteen days of admission which included all required elements and documented on the
Department’s Clinical Psychotropic Progress Note (CPPN) form. No additional youth was placed
on psychotropic medications as a result of the interview. One youth was placed on psychiatric
medication after a second additional evaluation after the initial evaluation which included all
required evaluation elements. Each CPPN was clearly identified as an Initial Diagnostic
Psychiatric Interview with page three completed as required. Each of the six applicable youth
received a medication review every thirty days. When an evaluation resulted in the prescription
of psychiatric medication or changed, page three of the CPPN was completed with the required
elements of identifying data, diagnosis, target symptoms, side effects, adherence to regime,
physical characteristics as needed, parental telephone contact, Tardive Dyskinesia, and name,
dosage, and quantity of medication. Each CPPN was singed by the Psychiatric APRN. The
designated mental health clinician authority (DMHCA) was interviewed and reported meeting
with the psychiatric provider weekly. Psychiatric provider interview results were not provided at
time of reporting.
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4.18 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program maintains a policy and procedures addressing medication/sharps inventory and
storage. Visual observation confirmed medical equipment classified as sharps were secured
and inventoried utilizing routine perpetual inventory with descending counts as each sharp was
utilized and disposed. All medications were identified and secured in the appropriately
designated storage area. The medication cart was clean and organized with stock items
separate from youth specific medications. Visual observation confirmed all controlled
substances were perpetually inventoried and stored separately from other medications. All
medications were stored in a separate secured area which was inaccessible to youth. Narcotics
and other controlled medications were stored behind two locks. Medications which required
refrigeration were stored in a secured refrigerator which was only used for medications. The
program’s process for the destruction and disposal or return of expired or discontinued
medications entails inventorying medication and all medication which are expired or needing to
be returned are given to the pharmacist during monthly visits. Medications are destroyed off-site
by the pharmacist. Visual observation confirmed inventory of all sharps and stock over-the-
counter (OTC) medications was conducted perpetually and weekly. Pursuant to Board of
Pharmacy regulatory requirements, a shift-to-shift inventory count of all controlled substances
was conducted and documented on the youth’s individualized Controlled Medication Inventory
Record. Documentation review confirmed non-healthcare staff were trained in the delivery and
oversight of medication self-administration when non-licensed medical staff are not on-site.
Non-healthcare staff training was conducted by registered nurse. A sample of three controlled
medications were reviewed and counts of the items matched the ending inventory numbers. A
sample of three OTC medications were reviewed and counts of the items matched the ending
inventory numbers. A sample of three sharps were reviewed and counts of the items matched
the ending inventory numbers. The reporting criteria and procedures regarding inventory
discrepancies dictates any medication inventory discrepancy shall require an attempt to rectify
discrepancy, notification to the program director (PD), as well as the Department’s Central
Communications Center (CCC). The nurse was interviewed and was able to describe the
process for medication disposal, and the process for securing controlled substances. Nursing
staff was interviewed and reported any discontinued and or controlled medications shall be
counted until disposed of and inventoried by the pharmacist. All controlled substances shall
have a perpetual inventory and will be inventoried weekly and stored separately from other daily
medications.
4.19 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program maintains a policy and procedures addressing Infection Control
procedures/exposure which includes prevention, containment, treatment, and reporting
requirements related to infectious diseases, as according to Occupational Safety and Health
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Administration (OSHA) federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines which were signed by the program’s designated health authority (DHA) and
program director (PD) on October 22, 2025, and October 23, 2025, respectively. The infection
control procedures include all the required elements. Hepatitis B immunizations are available for
all staff and staff have access to protective equipment. There were no instances in which the
local county health department, CDC, and/or Department’s Central Communication Center
(CCC) should have been notified of an infectious disease. The PD has established a separate
file used for 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 and/or designees and was signed October 23, 2025. The
program’s process for needle stick post-exposure requires immediate notification to the medical
department, arrangements for a confidential medical evaluation, follow-up post-exposure
analysis, and counseling as required by the OSHA Standards. The PD has an established
separate file maintained for any youth or staff who may have experienced a facility and or
occupational exposure. There were not three or more cases of any reportable infectious
diseases which needed to be reported to the local county health department and/or CDC during
the review period. The PD was interviewed and reported the Exposure Control and Infection
Control Plan is kept in the medical department and is reviewed monthly. The plan will be
updated annually or more often to address risks and compliance of procedures which are
potentially hazardous to employees or the youth health/safety.
4.20 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
The program maintains a policy and procedures addressing the access to prenatal care for all
pregnant youth. During the scope of the annual compliance review period, the program had no
pregnant youth. If a youth is identified as pregnant, the youth will be provided with healthcare
education training to include topics such as contraception, prenatal care, the birthing process,
postpartum care, basic bay care, child/infant development, parenting skills, effects of alcohol
and, drugs, smoking, sexually transmitted infections, nutritional needs, abuse, milestones,
hygiene, testing, Shaken Baby Syndrome, and adoption. Non-healthcare staff receive annual in-
service training from a licensed healthcare staff on health-related topics of providing supervision
to pregnant youth. The nurse was interviewed and reported pregnant youth are provided health
education, training, and observation of emergency needs. Youth will have a special treatment
team, and the program will develop a care plan specific to youth needs.
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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 policy and procedures addressing youth supervision. The program
has a one staff to eight youth ratio during daytime activities and a one staff to ten youth ratio
during nighttime. For the intensive mental health component, the program has a one staff to six
youth ratio during daytime activities and a one staff to eight youth ratio during nighttime. The
program’s policy and procedures consider active supervision as the need for a nurturing
environment where staff in direct supervision consistently interacts with youth in a positive
caring manner, consistently monitoring the youth's self-management and any behavioral
changes. Staff are to vigilantly supervise youth, maintain control of youth, and provide for the
safety of youth. Staff to youth ratios were observed during the annual compliance review. Ratios
were observed during movements to and from school, mealtimes, and bathroom breaks, which
the program was in compliance with their ratio at all times. An informal interview was conducted
with three random staff. Each staff was able to accurately provide the number of youths being
supervised. The program’s daily activity schedule is posted on each living unit. Visual
observation confirmed youth were engaged in a full schedule of activities. Observation of youth
rooms confirmed there were no obstructions of staffs’ line of sight. Staff observed youth during
sleeping hours as documented on ten-minute check logs.
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 policy and procedures addressing the implementation of the behavior
management system (BMS). Documentation review confirmed appropriate parties were involved
in the development, implementation, and on-going maintenance of the BMS. There are
protocols in the program’s BMS where staff are provided feedback regarding the implementation
of the BMS. There is an agreement between the program and the school related to the BMS.
The assistant program director is responsible for providing joint training with education staff.
Seven reviewed youth case management records included evidence each youth received BMS
training as part of their orientation to the program. The youth handbook is provided for each
newly admitted youth. The handbook outlines the BMS in detail and discusses the program’s
level system, rewards, and consequences. A total of fourteen position descriptions were
reviewed to confirm staff job functions included implementation of the program’s BMS. A total of
seven training records were reviewed to confirm staff training on the program’s BMS. Each
record contained documentation of completed BMS training. The program’s BMS is posted in
each living unit and is accessible to youth. The program has had no changes or updates to its
BMS during the annual compliance review period. Documentation review confirmed the
program’s BMS contains required elements such as promoting safety, respect, and fairness,
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promoting and protecting youth rights, positive and negative consequences, constructive
disciplinary actions/non-punitive, and opportunity for positive reinforcement. The BMS further
incorporates recognition of accomplishments and behaviors at a four to one ratio, promotes
socially acceptable means for youth to meet their needs, a process for explaining to youth the
reasons for any sanctions imposed, youth having the opportunity to explain their behaviors,
opportunities for staff and youth to discuss the impact of behaviors on others, reasonable
reparations for harm caused to others, discussions of alternate behaviors, and promoting
positive dialogue and peaceful conflict resolution. Documentation review of the program’s BMS
confirmed practices such as increased length of stay, denial of a youth’s basic rights or
services, promotion of group discipline, punishment of youth by other youth, or disciplinary
confinement were not included. Visual observation confirmed staff and youth interactions were
in adherence to practices. The program’s BMS includes a process wherein staff explain to youth
the reason for sanctions imposed prior to the end of staff’s workday and the youth is given an
opportunity to explain behaviors exhibited and staff and youth discuss the impact behaviors may
have on others, reasonable reparation for harm caused, and alternate acceptable behaviors.
Incentives provided by the program include incentive trips, canteen/point store items, telephone
calls, and special activities.
Seven staff were interviewed, and each was able to explain the program's BMS. Additionally,
each staff was able to describe the types of rewards/incentives the program provides as part of
the BMS. Examples included incentive trips/outing, point store, movie night, special
food/snacks, and items such as lip gloss, socks, and mascara. Also, each staff explained the
basic rights of the youth’s and how these rights cannot be taken away from the youth as a
consequence. Further, each staff was able to articulate how youth are informed of the
consequences and are able to explain their behaviors. Seven youth were interviewed. All seven
youth were able to identify consequences for bad behaviors. Examples included a major,
special treatment team and incentives taken away. Additionally, all youth were able to identify
the kind of rewards they can earn at the program. Examples included outings, point store items,
incentive trips, and reduction in length of stay. Also, each youth reported staff are consistent
with rewards and consequences they give because of behaviors. Further, each youth was able
to explain the differences between each level and how they move from level to level. Each youth
also reported they are not allowed to punish other youth. The program director was interviewed
and was able to explain the policy and procedures on the BMS system, how rewards are
monitored, how the program ensures rewards outnumber consequences at a minimum of four to
one, how consequences are monitored, and how the program monitors staff implementation of
the BMS to ensure consistency.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Limited 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 policy and procedures to conduct and document ten-minute checks
during sleep hours or at other times. The program has a total of sixty-two cameras and all of
them were operational during the annual compliance review week. Video recordings are stored
for up to thirty days. The above was also confirmed in an interview with the program director.
Video observations of nine thirty-minute period increments were conducted during the annual
compliance review week and revealed eight of the ten-minute checks were conducted in the
required frequency, in real time, and the checks were met with fidelity. The remaining thirty-
minute period increment indicated one ten-minute check was not conducted in the required
frequency. Specifically, the ten-minute check was missed. A review of the security tape
indicates the staff was sitting in the day room. Corresponding documentation for this incident
indicated the staff documented the check was done in less than ten-minute increments, thus
resulting in falsification of documentation. Contact with the Department’s Central
Communications Center was made to report the incident. A sample of logs for seven months,
was reviewed to verify ten-minute checks and revealed each of the thirty-minute increments
from each shift from each month were initialed and conducted as required. Seven staff were
interviewed. Five staff stated room checks are conducted in ten-minute intervals when youth are
placed in their room for sleeping. The remaining two staff stated room checks are conducted
every five to six minutes when youth are placed in their room for sleeping.
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 policy and procedures addressing census, counting, and tracking of
youth. The program’s policy and procedures indicate youth are always accounted for through a
system of physically counting youth at various times throughout the day. The program will
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. An observation of a head count was conducted during the annual compliance
review. The master control operator called for a headcount. All movement of youth stopped and
a headcount for each area containing youth was conducted. The headcount was tallied and an
all clear was given. A logbook review was conducted for one day each month of the annual
compliance review period and found no exceptions. Reviewed documentation confirmed counts
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are conducted at the beginning of each shift, after each outdoor activity, and during emergency
situations. Each logbook entry contained documentation of total daily census, head counts,
youth movements, transfers, and youth temporarily away from the program. Seven staff were
interviewed and reported counts are conducted every hour. Additionally, each staff was able to
articulate the procedures when a youth count cannot be reconciled. Also, each staff was able to
explain when emergency counts are conducted. Examples included fire drill, escape, unable to
locate a youth, and serious disruption.
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 policy and procedures addressing logbook entries and shift reports. A
review of one full day each month during the annual compliance review period revealed master
control logbooks were bound with pages numbered. All entries were made in ink with no
erasures of white-out areas. There was no indication of logbook entries being destroyed or
removed. There were no errors which required being stricken through. All entries included dates
and times of events, staff and youth names involved, and brief description of events. All
applicable entries requiring notification to the Florida Abuse Hotline or the Department’s Central
Communication Center were documented. According to the program director, the program does
not maintain living unit logbooks. A review of shift reports maintained during the annual
compliance review period indicated each contained a summary of events, incidents, and
activities documented in the program’s central logbook. In each of the shift reports incoming
staff signed and dated the shift reports for the previous shift. A review of documentation
confirmed entries were entered for emergency situations, special instructions, population
counts, perimeter and security checks, transports, and admission and releases, as required.
There were no reviewed entries related to incidents including the use of mechanical restraints,
requests by law enforcement to access any youth, removal of youth from the mainstream
population, or information relating to escapes or attempted escape incidents. A copy of the shift
report was maintained in living units for at least forty-eight hours.
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 maintains a policy and procedures which address key assignment and restrictions
on program key usage, inventory and tracking of program keys, secure storage of keys, and
procedures for missing or damaged keys. Visitor keys were observed being collected and
exchanged for a numbered chit during the annual compliance review week. Visitor keys were
stored securely in the lock box located in the master control station at the front of the
administration building. All program keys which are distributed to staff are maintained in this
secured key box. The key box was observed to be secured when not being accessed.
According to the program’s policy, all keys which are permanently issued must be signed for by
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the staff receiving the keys and the key control officer issuing the keys. Upon return of the keys,
the staff and the key control officer must initial indicating they were returned. The program’s
safety and security officer shall document the contents of each ring of keys issued to each staff
member. Direct care staff turn in their personal keys which are exchanged for their program
assigned keys for the shift they are working. This exchange and issuance are documented on
the Daily Key Tracking Log. These tracking logs were observed, which confirmed the program’s
practice. According to program administration, damaged keys are reported to the safety and
security specialist and maintenance staff who are responsible for replacing the keys. The
program reported having had no incidents of damaged or lost keys for the annual compliance
review period. According to the assistant program director, permanent issued keys are restricted
keys. These include keys for medical, administration, maintenance, and education staff. Direct
care staff do not have access to these keys. A sampling of five sets of keys in the key storage
box were reviewed and found each set was noted on the key inventory log and included the
correct number of keys on each ring. In addition, three staff were randomly selected and asked
to present their assigned staff keys. All staff keys matched the keys assigned and signed out for
on the Daily Key Tracking Log for the shift. All keys had the correct number of keys as indicated
on the key log. Each staff stated they were aware of the function of each key. Each of the seven
interviewed staff were able to summarize the program’s key control process.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a policy and procedures addressing the introduction of contraband into
the program. The program’s policy and procedures define items/material which are considered
contraband. The program provides a list of items considered contraband to each youth. Youth
are given this information in their handbook upon admission. The program policy and
procedures also outline searches of the physical plant, facility grounds, searches of youth, staff
and visitors, and incoming and outgoing mail. The program’s visitation log contains a
contraband attestation statement. The program hired a total of ten new staff since their last
annual compliance review. All ten new employees’ records contained a signed contraband
attestation form. The program’s policy and procedures address any staff who is found in
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possession of contraband in the program will be subject to disciplinary action up to and
including dismissal as outlined in Florida Administrative Code. Law enforcement is contacted in
the event any item found which would be considered illegal as defined in Florida Statutes. The
program’s policy and procedures clearly delineate items which are considered contraband. The
program documents the confiscation of contraband and maintains the documentation on search
forms and within the youth case management records in the event contraband is found.
Random searches are completed twice daily, which covers both day and night shifts, and are
documented on Search Report forms. Searches for contraband were also documented within
logbooks and shift reports, indicating program area and perimeter searches were completed. A
review of the Department’s Central Communications Center (CCC) since the last annual
compliance review confirmed the program did not have any reported incidents of illegal
contraband being discovered; however, the policy indicates it would be disposed of through the
program director (PD). A review of the program’s facility logbooks and search reports confirmed
the frequency, quality, and results of searches. The PD was interviewed and was able to
articulate the program’s policy and procedures regarding contraband and illegal contraband,
reporting contraband incidents to the CCC, and contacting law enforcement if applicable. Seven
staff were interviewed, and each staff was able to articulate the process for youth room
searches. Staff indicated rooms are searched at least every shift, randomly, every day, and
whenever youth are returning from school.
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 policy and procedures addressing searches ensuring no contraband is
being introduced into the facility. During the annual compliance review week, observations of
youth being searched prior to exiting the lunchroom, prior to being transported off-site, upon
return from an off-campus activity involving the Department of Transportation work crew, and
during admission. Youth were treated with dignity and respect to minimize the youth’s stress
and embarrassment. Searches were conducted by the appropriate number of staff and gender.
Observations revealed searches were thoroughly completed, provided clear instructions, and
were conducted as required by the Right Interactions training manual. Searches before and
after visitation were unable to be observed during the annual compliance review week. Video
observation of staff and visitors was unable to be observed as the program does not have
surveillance equipment located in the visitor/staff entry area where searches are conducted;
however, during the annual compliance review week, the search process on the team upon
entering the program was observed. Program staff were observed using electronic equipment to
search staff/visitors. The procedure included frisk search, shoe removal, emptying of pockets,
and visual inspection of all bags prior to entering the program. Each of the seven interviewed
staff confirmed searches are conducted before and after every movement. Each of the seven
interviewed youth was able to explain when searches occur. Examples included when entering
and exiting the building, every movement, and daily.
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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 policy and procedures addressing proper maintenance and
documentation of vehicles used to transport youth. The program has four vehicles which are
used to transport youth. A total of five staff vehicles and the four program vehicles were
checked to ensure they were properly secured when not in use. Each vehicle was properly
secured and locked when not in use. There was documented evidence which confirmed an
annual safety inspection and maintenance records of each vehicle and identified and corrected
deficiencies if applicable. Visual observation confirmed each vehicle contained an annually
inspected fire extinguisher, approved first aid kit, seatbelt cutter, window punch, and appropriate
number of seatbelts. Youth passenger areas for each of the four transport vehicles were unable
to be opened from the inside. None of the program transport vehicles required a safety screen.
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 policy and procedures addressing transportation of youth ensuring
minimum staff-to-youth ratio is maintained while youth are transported off facility grounds to
ensure the safety and security of youth, staff, and the public. Based on interview and
observations, the program provides a cellular telephone to staff when transporting youth. The
one-to-five staff-to-youth ratio is used during all transports. An observation of a transport was
conducted during the annual compliance review week. It was determined the staff-to-youth ratio
was within the requirement and there was a staff of the same gender of the youth being
transported. There were two staff, and four youth observed for the transport. Staff and youth
were all the same gender. Both staff and youth were observed properly secured with seatbelts.
To ensure staff operating a vehicle have a current and valid driver’s license, the human
resources manager compiles a list of each employee once a year. From the compiled list, the
human resources manager takes note of each employee’s license expiration date. The program
is automatically notified by the Florida Department of Highway Safety and Motor Vehicles when
an employee becomes disqualified. According to the program’s policy, youth are not permitted
to operate program or staff vehicles.
Seven staff were interviewed and five staff reported youth are secured with a seatbelt. The
remaining two staff reported they have never participated in a transport. Additionally, each staff
reported a cell phone is provided to transport staff and six of the seven staff were able to
articulate safety equipment in a transport vehicle. Staff provided examples such as fire
extinguisher, seatbelt cutter, first-aid kit, and window punch. The remaining staff was unable to
provide examples and reported they had never participated in a transport. Each staff reported
staff are not allowed to use personal vehicles to transport youth, transport vehicles are searched
for contraband prior to after each use, and were able to explain the emergency response
process during vehicle transport and articulate the staff to youth ratios during transport. Seven
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youth were interviewed. Six of the seven youth reported never being handcuffed to any part of
the vehicles. The remaining youth reported they have never been on a transport. All youth
reported never having seen anyone place contraband in a transport vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a policy and procedures addressing weekly safety and security audits to
ensure a safe and secure physical plant, grounds, and perimeter. The program’s policy and
procedures indicate who is responsible for conducting weekly security audits and safety
inspections. These duties are assigned to the assistant program director. The program’s policy
and procedures include the development and implementation of corrective actions warranted
because of safety and security deficiencies identified during inspection, and an internal system
which verifies deficiencies are corrected and existing systems are improved, or new systems put
in place as need to maintain compliance. Documentation review for the annual compliance
review period was conducted and confirmed weekly safety and security audits were conducted
as required, and preventive maintenance schedules and repairs were conducted as outlined in
Florida Administrative Code and documented on the Preventive Maintenance Checklist.
Confirmation was also provided by the residential safety and security specialist. The program
director (PD) was interviewed and reported the safety and security officer will conduct a weekly
audit which is documented on the facility security audit and safety inspection form. Any
deficiencies found during the audit or safety inspection will be documented in the section
provided, and an anticipated date of correction documented. The information is also logged on
the facility maintenance action plan which is reviewed by the PD or assistant program director
APD) weekly and then monthly during the monthly facility call with the Department. A
maintenance request will be submitted if applicable to the maintenance supervisor and noted on
the audit form for tracking purposes. Additionally, it is the role of the APD or safety and security
officer to ensure safety and security deficiencies are identified and resolved in a timely manner,
failure to do so may result in a written reprimand at the PDs discretion.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures addressing tool inventory, issuance, control,
and management to ensure youth do not use tools or equipment as weapons or security
breaches. All tools are inventoried prior to and following work activities, and all tools which are
pointed or contain sharp edges are inventoried daily. Documentation indicated there is a
monthly inventory of tools which do not have sharp edges or points. Machetes, bowie knives, or
other long bladed knives are prohibited. The program’s policy indicates in the event a tool is
missing, the tool control manager will be immediately notified. In addition, a tool report will be
written and submitted to the tool control manager by the supervising staff. Youth who had
access to the tool will be held at the work site location until a thorough search has been made of
the work area and all youth are frisk searched and electronically searched. Youth who are
searched will be separated from youth who have not been searched. If needed, additional staff
should be called to assist in the search process. If it is determined the missing tool is linked to
another reportable incident, the Department’s Central Communications Center will be notified
within the required time frame. In the event a tool becomes dysfunctional or otherwise broken, a
tool report must be submitted to the tool control manager by the end of the workday. The
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dysfunctional tool will be immediately removed and turned into the tool control manager along
with the tool report. If the tool is repairable, the tool control manager will submit a maintenance
request or repair the tool. If the broken tool is not repairable, the tool control manager shall
submit a purchase request to the site administrator. Tools identified as being dysfunctional or
unsafe must be disposed away from the program. Tool disposals are only completed by the tool
control manager. The tool control manager will maintain a tool disposal log which will document
each time a tool is removed. Class B tools such as mops and brooms were observed for each of
the six living units. Each included the number of items matching the inventory. Each unit had
two brooms, one dustpan, one mop, and one mop bucket. The inventory was observed to have
been maintained daily by direct care staff. Inventory forms were completed as required with no
discrepancies for each of the six living units. Additionally, six tools from the kitchen were
reviewed and compared with the inventory form. Four kitchen knives, one pizza cutter, and a
pair of sheers are maintained in a locked cabinet in the kitchen using a shadow board system.
The kitchen tools were inventoried daily by dietary staff. The six tools were reviewed and
compared with the inventory form. All tools were accounted for and included an engraved
marking for easy identification.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures ensuring youth use tools safely and are
supervised appropriately to prevent injuries. The program’s policy and procedures contain all
required elements including supervision requirements, tool issuance to youth and staff, including
an assessment of youth’s risk, established ratios, tool distribution and collection, and search
criteria during work projects. The program has a one staff to five youth ratio during activities
requiring tool usage, including vocational training. The program does not participate in
completing disciplinary work projects. During the annual compliance review, an observation of
distribution and tool usage was unable to be observed; however, youth were observed upon
returning from the Department of Transportation work crew. Youth were observed being
searched after completing the service. The youth were observed being supervised at a ratio of
one to five as required. A total of seven youth records were reviewed for youth who have been
approved to use tools. All seven youth records had a completed risk assessment prior to the
use of tools. Seven staff were interviewed and reported youth are allowed to use mops and
brooms. Additionally, one of the seven staff reported youth are also allowed to use a scrub
brush. Seven youth were interviewed and reported they are allowed to use mops and brooms.
Additionally, one of the seven youth reported they are allowed to use a scrub brush.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a policy and procedures addressing requirements for outside
contractors. The program’s policy and procedures state all outside contractors will be required
to read the program's tool control policy and sign an agreement letter to become a vendor. The
business card of the vendor shall be attached to the signed agreement. Vendors should
maintain a personal inventory of all tools before working. The contractor should always keep
their tools with them or in clear view and should not allow youth to handle any tools. Before
leaving, the vendor will complete a tool verification form indicating all tools are secured and
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accounted for. A sample of three sign-in sheets for outside contractors was reviewed. Each
sign-in sheet included the vendor’s name and company represented. Each sign-in sheet also
contained the number and type of tool being utilized on the job. Each sign-in sheet contained
the signature of the vendor upon departure and the ending tool inventory count. The program’s
guidelines for outside contractors include tools checked upon arrival and departure, tool
restrictions while in the facility, youth restriction from work area, and missing tool follow-up. A
sample of three project invoices submitted to the program by the vendor were reviewed. Each
invoice included the date the project was worked on and matched the outside contractor sign-in
sheets. Tools are checked in and out and signed off by the program’s maintenance staff person.
Personal cell phones/electronic devices with picture, audio, and video functions are prohibited.
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 maintains a policy and procedures addressing fire, safety, and evacuation drills.
Documentation review confirmed the program conducts Continuity of Operation Plan drills once
a month on each shift. A review of drill documentation confirmed the type of drill, date and time,
participants, brief scenario, and findings and recommendations. Fire evacuation routes and
egress plans were posted throughout the facility. The program has a total of twenty-four fire
extinguishers. Documentation review and visual observation confirmed the fire extinguishers
were inspected annually. Seven staff were interviewed. Five of seven staff reported having
participated in drills. Types of drills included fire, tornado, choking hazard, escape, and mental
health/suicide. The remaining two staff reported not having participated in an emergency drill.
Seven youth were interviewed. All seven youth reported they have been instructed on what to
do in case of a fire. In addition, five of the seven youth reported drills are conducted every
month. One youth reported drills are conducted every two weeks. The remaining youth was
unable to articulate how often drills are conducted but stated they have participated in drills at
the program. The program director was interviewed and reported fire, safety, and evacuation
drills are conducted to ensure youth and staff are prepared for immediate implementation or
mobilization in the event of an emergency or a disaster. Drills are conducted monthly to include
“mock” mental health drills, which are done quarterly. The program conducts a wide variety of
emergency drills at various times and on each shift.
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 Disaster and Continuity of Operations Plan (COOP). The program’s
COOP plan is readily available to staff, and a copy is in the program director’s (PDs) office, the
staff training area, medical, supervisors’ office, clinical director’s office, and human resources
office. The program’s COOP was reviewed and updated on March 11, 2025. The COOP plan
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addresses alternate relocation sites approved by the Department. The program’s emergency
disaster preparedness plan and COOP are combined into one plan. The plan was submitted
and approved by the Department’s regional director on March 13, 2025. Equipment and
supplies required for continuous operation and services during emergency or disaster situations
were identified in the kitchen and facility storage areas of the program and include items such
as dry goods, toiletries, electronic communication devices, water, and clothing. In addition, the
program reports the provider maintains a trailer at a separate location which contains various
emergency supplies. In the event of an evacuation, the trailer is used in the relocation and
transport of staff and youth. During an emergency, the program will take all youth hard copy
records with them, which include the individual case management record, mental health, and
healthcare records.
Seven youth records were reviewed for critical identifying information. Each youth record
contained all required elements to include youth’s full name, Department of Juvenile Justice
Identification Number, admission date, date of birth, gender, race, name, address, and
telephone numbers for parent/guardian, name, address, and phone number of the persons with
who, the youth resides and his or her relationship to the youth, person(s) to notify in case of an
emergency and contact information, juvenile probation officer contact information, committing
judge, state attorney, and public defender contact information, committing offense and judicial
circuit where offense occurred, notation of whether or not the judge retains jurisdiction, victim
notification contact information if applicable, physical description of youth to include height,
weight, eyes and hair color, and any identifying marks, overall health status including chronic
illnesses, current medications and allergies, personal physician (if known), and photograph of
youth. The PD was interviewed and reported the COOP is accessible to staff and is in the PD’s
office, supervisors’ office, the staff training area, medical, clinical director’s office, and human
resources office.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains a policy and procedures addressing the storage and inventory of
flammable poisonous, and toxic items, and materials. The program’s policy and procedures
state all flammable, poisonous, toxic, and caustic materials must be stored in secure areas
which are inaccessible to youth. All materials were observed to be secured and within locations
inaccessible to youth. Documentation review confirmed inventories were maintained for all
flammable, poisonous, and toxic items and materials. The program maintains a list of facility
positions and titles authorized to handle these items. The program’s policy and procedures on
the disposal of flammable, toxic, caustic, and poisonous items state any hazardous materials
will be disposed of in accordance with local and state regulations. Direct care, administrative,
medical, education, and maintenance staff are authorized to dispose of these items. According
to documentation review, the program’s disposal procedures are in accordance with
Occupational Safety and Health Administration Standards 29. The program’s policy and
procedures on the disposal of flammable, toxic, caustic, and poisonous items state any
hazardous materials will be disposed of in accordance with local and state regulations. An
informal interview with the assistant program director was conducted and informed any
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materials needing to be disposed of are taken to the local waste management facility.
Prearrangements are not required. Documentation review confirmed hazardous waste is
disposed of in accordance with Safety Data Sheets (SDS), and hazardous liquid waste is stored
in a hazardous materials storage area. According to the program’s policy and procedures, liquid
waste such as dirty mop water and unused beverages are dumped in mop sinks located in the
back storage area of each dorm and in the kitchen. Residual grease is placed in a separate
container for disposal. There were no chemical spills reported by the program during the annual
compliance review period. The program’s policy and procedures include once becoming aware
of a chemical spill, staff shall immediately notify master control of the spill location, the shift
supervisor shall direct the shutdown of air handlers and ventilation system, and close windows
and doors at the discretion of the on-scene supervisor or program director (PD), and outside
assistance shall be contacted as necessary. A sample of inventory of ten items was conducted.
Documentation and visual observation review confirmed the actual count of each item and the
ending count on the inventory matched. All items were secured, and each item contained a
SDS. The PD was interviewed and was able to explain and provide policy and procedures for
the disposal practice of flammable, toxic, caustic, and poisonous items.
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 policy and procedures addressing youth handling and supervision for
flammable, poisonous, and toxic items and materials. The program’s policy and procedures
indicate youth are not allowed to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth will not be permitted to clean, handle, or dispose of any
person's biohazardous material, body fluid, or human waste. The program maintains strict
control of flammable, poisonous, and toxic items and materials. Youth access to areas where
items are used or stored is restricted. Observations of youth during daily cleaning activities was
unable to be made during the annual compliance review week due to none taking place. Each of
the seven interviewed youth reported not having used any chemicals or cleaning products.
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5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water related activities; therefore, this indicator is rated
as non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a policy and procedure addressing visitation and communication for
youth while in the program. The program’s visitation schedule is posted throughout the living
units within the activity schedules. Visitation schedules are also posted within youth handbooks
as well as within orientation packets which are provided to the parent/guardian upon youth
admission. The program’s policy and procedures related to visitation, youth correspondence,
and mail use is to promote, encourage, and enable visitation and communication between youth
in the program and their families or significant others. Youth will have an opportunity to visit with
family and their identified community- based support system. A review of the program’s
visitation log and schedule confirmed the program’s adherence. Visitation is scheduled for
Saturdays from 1:00 p.m. until 4:00 p.m. Special visitation may be made at the discretion of the
program director (PD). The program’s case managers maintain an approved telephone and
mailing/correspondence list for each youth assigned on their case load. Observations of these
lists were made during the annual compliance review week. According to an interview with the
lead case manager, incoming and outgoing mail is searched as required. Telephone calls for
youth are given once each week, and youth may have longer call times based on their level
according to the behavior management system. The telephone schedule is made for each youth
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 64 (Revised August 2025)
by the case manager based on a certain weekday youth are assigned. In addition, youth can
mail up to two letters each week. According to the lead case manager, the program utilizes an
outside provider translation service for a third-party language service when needed. For youth
who have a history of human trafficking, there was evidence the case manager requested
clarification from the youth’s juvenile probation officer to verify the parent/guardian and other
contacts for the youth. Seven interviewed youth confirmed they are able to call and/or send
letters to their parent/guardian. The PD was interviewed and reported the program uses
Language Line Solutions, a third-party language service entity, for youth whom English is not
their primary language.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a policy and procedures which addresses recreation and leisure
activities. The program’s activity schedule documents a range of supervised and structured
indoor and outdoor recreation and leisure activities to include large muscle activity for the youth
for at least one hour daily. According to documentation for the annual compliance review period
in the master control logbook, recreation was conducted as scheduled. Activities provided by
the program promote social and cognitive skill development, creativity, teamwork, healthy
competition, mental stimulation, and physical fitness. Recreational activities were observed
during the annual compliance review week to ensure the program takes precautionary
measures to prevent overexertion, heat stress, dehydration, frostbite, hypothermia, and
exacerbation of existing illness or physical injury. According to the program’s contract, a
recreational therapist is required. The program has a recreational therapist, whose credentials
meet all requirements. Seven youth case management records were reviewed. Each of the
seven records indicated recreational therapy was included in each youth’s individual treatment
plan. Seven youth were interviewed. Each youth reported physical activities are provided for at
least one hour. Youth stated they participate in activities such as walking, basketball, and
kickball. Seven staff were interviewed and were able to articulate the types of indoor and
outdoor activities youth participate in and the duration. Examples included basketball, kickball,
football, and board games.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated as non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated as non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 64 (Revised August 2025)
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated as non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 64 (Revised August 2025)

source: DJJ