summary: QI Residential - FY25-26 - 6 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Kissimmee Youth Academy BDD/DD/BIF
Youth Opportunity Investments, LLC
(Contract Provider)
2330 New Beginnings Road
Kissimmee, Florida 34744
Review Date(s): September 9-12, 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:
Tamara Mahl-Adkins, Office of Accountability and Program Support, Lead Reviewer (Standard
1)
Belinda Alexander, Office of Education, Central Education Coordinator (Standard 2)
Teresa Andersen, Office of Accountability and Program Support, Regional Deputy Supervisor
(Interviews, Video Observation, Standard 5)
Kara Brown, Office of Accountability and Program Support, Regional Deputy Supervisor
(interviews)
Jeremy Curvan, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Cheryl Francis, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Jamie Franz, Office of Education, Deputy Director of Postsecondary and Workforce Education
(Standard 2)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Amanda Nelson, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Bradley Taylor, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Jennifer Tummino, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Kissimmee Youth Academy BDD/DD MQI Program Code: 1426
Provider Name: Youth Opportunity Investments, LLC Contract Number: 10287
Location: Osceola County / Circuit 9 Number of Beds: 32
Review Date(s): September 9-12, 2025 Lead Reviewer Code: 156
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 64 (Revised August 2025)
T h e fo llo w in g lim ite d a
Lim ited R atings
2.18 E ducation A ccess (R esidential P rovider) *
5.04 Ten M inute C hecks *
5.09 S earches and Full B ody V isual S earches
n d /o r fa ile d in d ic a to rs re q u
5.18 S
ire im m e d ia te c o rre c tiv e a c tio n .
Failed R atings
5.13 Tool Inventory and M anagem ent
torage, Inventory, and D isposal of Flam m able, P oisonous, and Toxic Item s and M aterials
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
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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tin g in e a c h o f th e s e
a re a (d e te n tio n ,
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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
* 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
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
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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
* 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
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b
S a tis fa c to ry
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
a re a (d e te n tio n ,
le
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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
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 64 (Revised August 2025)
5555555555555555555555555 .0 1
C .0 2
.0 3
.0 4
.0 5
.0 6
.0 7
.0 8
.0 9
.1 0
.1 1
.1 2
.1 3
.1 4
.1 5
.1 6
.1 7
.1 8
.1 9
.2 0
.2 1
.2 2
.2 3
.2 4
.2 5
* T h e D e
p ro g ra m o
in d ic a to
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
Y o u th S u p e rv is io n *
o m p re h e n s iv e a n d C o n s is te n t Im p le m e n ta tio n o f th e B e h a v io r M g t S y s te m a n d S ta ff T ra in in g
U s e o f R o o m R e s tric tio n
T e n M in u te C h e c k s *
C e n s u s , C o u n ts , a n d T ra c k in g
L o g b o o k E n trie s a n d S h ift R e p o rt R e v ie w
K e y C o n tro l *
C o n tra b a n d P ro c e d u re
S e a rc h e s a n d F u ll B o d y V is u a l S e a rc h e s
V e h ic le s a n d M a in te n a n c e
T ra n s p o rta tio n o f Y o u th
W e e k ly S a fe ty a n d S e c u rity A u d it
T o o l In v e n to ry a n d M a n a g e m e n t
Y o u th T o o l H a n d lin g a n d S u p e rv is io n
O u ts id e C o n tra c to rs
F ire , S a fe ty , a n d E v a c u a tio n D rills
D is a s te r a n d C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P )
S to ra g e , In v e n to ry , a n d D is p o s a l o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
Y o u th H a n d lin g a n d S u p e rv is io n o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
E le m e n ts o f th e W a te r S a fe ty P la n , S ta ff T ra in in g , a n d S w im T e s t *
V is ita tio n a n d C o m m u n ic a tio n
R e c re a tio n a n d L e is u re
S e a rc h a n d In s p e c tio n o f C o n tro lle d O b s e rv a tio n R o o m
C o n tro lle d O b s e rv a tio n
C o n tro lle d O b s e rv a tio n S a fe ty C h e c k s a n d R e le a s e P ro c e d u re s
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 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
rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra
re s id e n tia l, p ro b a tio n ).
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
L im ite d
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
L im ite d
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
F a ile d
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
F a ile d
S a tis fa c to ry
N o n -A p p lic a b le
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
m a re a (d e te n tio n ,
Program Overview
Kissimmee Youth Academy-BDD/DD is a thirty-two bed program, for fourteen to nineteen year
old males, located in Kissimmee, Florida. The program is operated by Youth Opportunity
Investments, LLC, through a contract with the Department. The program provides the following
services: borderline intellectual functioning or developmental disability services. In addition, the
program fosters each youth by providing Impact of Crime (IOC), Skillstreaming the Adolescent,
Trauma-Focused Cognitive Behavioral Therapy, Teen Relationships Workbook, and Life Skills
Training. Additional treatment services provided include family/individual therapy, recreational
therapy, and Daniel Memorial Life Skills. Program administration is comprised of a facility
administrator, three assistant facility administrators, one administrative assistant, one business
manager, and one human resources manager. Case management services are provided by the
director of case management, six case managers, and two transition managers. Mental health
staff at the program include the clinical director, a contracted psychiatrist, two licensed
therapists, seven mental health and substance abuse clinicians, and one recreational therapist.
Medical services are offered twenty-four hours seven days a week and are provided by the
designated health authority, a health service administrator, and four registered nurses.
Educational services are provided by the Florida Scholars Academy and post-secondary
services are provided by the Florida Youth College. The layout of the program includes
administration, case management, medical, mental health and substance abuse departments,
as well as classrooms, modules, and a kitchen within one building. The program has 148
operating security cameras providing coverage. At the time of the annual compliance review,
the program had eleven vacant positions: seven safety and security specialists, two food
services workers, one master control operator, and one night nurse.
.
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
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures to address the initial background screening
requirements for volunteers, mentors, and interns who work with youth less than ten hours a
month requiring sight and sound supervision. An Annual Affidavit of Compliance with Level 2
Screening Standards was completed and sent to the Department’s Background Screening Unit
(BSU) on January 14, 2025 prior to the January 31st deadline. Twenty-three new staff were
hired since the last annual compliance review. The program did not have any volunteers,
mentors, or interns. All twenty-three staff had a background screening completed prior to
contact with youth and confidential youth records, including review of a criminal history report.
None of the staff required an exemption prior to working with youth. Two of the twenty-three
staff had a break in service as indicated in the Department’s Staff Verification System (SVS)
and a new background screening was completed. All twenty-three staff required and had a pre-
employment assessment tool administered and a passing score was documented in each staff’s
record. All the staff were added to the program’s Clearinghouse employee roster, and each had
signed a contraband attestation form.
1.02 Five-Year Rescreening Non-applicable
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.)
There have been no eligible staff to receive a five-year rescreening during the annual
compliance review period; therefore, this indicator is rated non-applicable.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 64 (Revised August 2025)
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to address child abuse reporting guidelines.
The program had no incidents involving staff physically, emotionally, or psychologically abusing
or neglecting youth during the annual compliance review period. A review of ten staff records
showed all reviewed and signed the code of conduct. The program had the Florida Abuse
Hotline and the Department’s Central Communications Center (CCC) numbers posted
throughout the facility, including in each youth module for youth and staff access. The program
completed a Trauma Responsive and Caring Environment (TRACE) self-assessment on March
12, 2025. The facility administrator (FA) was interviewed and stated the employee code of
conduct includes but is not limited to theft, violence in the workplace, improper conduct, dress
code, attendance, insubordination, and unethical or abusive behaviors. The program uses
progressive discipline starting with coaching and verbal warning, up to termination of staff.
Depending on the severity of the incident staff can be terminated on the first offense. The
program uses the TRACE assessment and provides trauma training to all staff, including crisis
response and mental health emergency procedures, as well as Prison Rape Elimination Act
(PREA), and child abuse reporting; all staff are mandatory reporters. The staff also receive the
youth handbook, staff handbook, and are required to complete human trafficking training
annually in the Department’s Learning and Management System (SkillPro). Staff know the
reporting requirements based on their training, as well as postings throughout the program.
Youth are made aware during the intake orientation, youth handbook, and the postings on the
modules regarding abuse reporting guidelines. The FA stated there were no staff in need of
disciplinary actions due to allegations of abuse towards youth since the last annual compliance
review. If the program has to take action, the area in which the alleged abuse has occurred is
secured, youth are secured and protected from retaliation, the Florida Abuse Hotline, the CCC,
law enforcement, and victim service advocate are contacted, and the staff is terminated.
Five staff were interviewed and all stated they allow youth to make a call to the Florida Abuse
Hotline or the CCC to report suspected abuse. Four also stated they notify the supervisor, three
said the staff are allowed to call as well, and one staff mentioned notifying the FA and letting the
supervisor make the call. The five staff also stated the telephone number of the Florida Abuse
Hotline are on the modules and youth can call anytime. Four provided a process on how to
handle the call. All five indicated they had never observed another staff telling a youth they
could not call the Florida Abuse Hotline. One stated they had never heard another staff using
profanity while speaking with youth. Four stated they had but reiterated it was in front of the
youth but not toward the youth.
Five youth were interviewed and stated they feel safe at the program, mentioning staff treat
them well, teach them things, and they are allowed to go outside and play football and
basketball. All five said they had never been stopped from reporting abuse to the Florida Abuse
Hotline or the CCC and they were aware of where to locate the Florida Abuse Hotline telephone
number. All five said the staff treat them respectfully when talking with them and other youth.
None of the youth have ever heard staff use curse words when speaking to them or other youth
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nor have they exchanged emails, telephone numbers, or social media contact information with
staff.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring., or within two hours of any program staff becoming aware of
the reportable incident.
The program had six incidents reported to the Department’s Central Communications Center
(CCC) during the annual compliance review period. A review of five CCC reports indicated four
were reported to the CCC within the required two-hour time frame. The remaining incident was
reported fifteen minutes late. The program provided disciplinary action taken against the staff
causing the report to be late. The program had no additional internal incidents/grievances,
which should have been reported to the CCC. The program experienced a decrease in the
number of reportable incidents to the CCC in the annual compliance review period.
The facility administrator (FA) was interviewed and stated CCC reports are required to be made
within two hours of an incident. All staff at the program have access to make a report to the
CCC, law enforcement, and the Florida Abuse Hotline. The program’s practice is when a
reportable incident occurs the staff advise the unit manager/shift supervisor, then the incident is
reported to administration to call the CCC. If administration is unavailable, the unit manager/shift
supervisor is authorized to make the report themselves. All staff are aware they are mandatory
reporters.
1.05 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program had six Right Interactions (RI) incidents during the annual compliance review
period. The program maintained and submitted monthly RI incident summaries to the
Department by the fifteenth of each month during the annual compliance review period. The RI
plan was updated on December 10, 2024 and approved by the Department on December 13,
2024. The program’s RI rate during the annual compliance review period was .68, which is
below the statewide residential RI rate of 2.57. A review of five RI incident reports showed all
were completed by the end of the staff’s workday and included statements from all staff
involved. None required the Mechanical Restraint Supervision Log, none resulted in injury to the
youth or staff, none of the youth alleged abuse, and none required a RI medical review. All five
RI reports were reviewed by a supervisor, and by an RI instructor. An administrator/designee
also reviewed the RI reports within seventy-two hours of the incident. The FA was interviewed
and stated following the use of physical intervention, a mediation is completed between the
youth and staff, the staff complete a RI report and turn it into the assistant facility administrator
(AFA) for review. The AFA reviews the RI report the following business day in the morning
meeting. Five staff were interviewed and stated they knew the RI process and were able to
explain it, which included de-escalation, using verbal interventions, and having to complete an
incident report.
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1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program considers all staff to be direct-care staff and are counted in the staff-to-youth ratio
other than the maintenance or kitchen staff, nurses, and master control operator. The master
control operators are cross-trained and can take on a shift but are not allowed to work master
control and count in ratio at the same time. A review of training documentation showed all
instructors are qualified to deliver the provided training. The program submitted a pre-service
training plan/calendar prior to implementation, and the training plan/calendar was approved by
the highest ranking official at the location, the Department’s assistant secretary for residential
services, and the director of the Department’s Office of Talent, Leadership, and Culture (TLC).
A review of five staff training records showed all completed a minimum of 120 hours of pre-
service training within 180 days of hire. All five staff completed the essential skills prior to any
contact with youth, which included child abuse recognition, reporting, and prevention, first-aid,
automated external defibrillator (AED), cardi-pulmonary resuscitation (CPR), emergency
procedures, program operating procedures, Prison Rape Elimination Act (PREA),
professionalism, interpersonal communication, and ethics, including standards of conduct, Right
Interactions (RI), and suicide awareness and prevention. Additional training was completed and
included Active Shooter Preparedness, adolescent development and behavior, balanced
approach to rehabilitative justice, the Department’s Central Communications Center (CCC)
incident reporting, civil rights, communication, Confidentiality/Health Insurance Portability and
Accountability Act (HIPAA), Department legacy/history, and equal employment opportunity
(EEO). The staff also completed gang awareness, human trafficking intervention, infection
control/bloodborne pathogens, Information Security Awareness, the Department’s Juvenile
Justice Information System, mental health and substance abuse, motivational interviewing (MI),
quality report writing, safety, security, and supervision of youth, sexual harassment, effective
and respectful treatment of youth, trauma responsive practices, grievance process, infection
control, exposure control plan, behavior management system, and the intended and safe use of
tools. Specialized and other trainings included mental health and substance abuse overlay
services, developmental disabilities treatment services, epinephrin-auto injector, Narcan, and
Massachusetts Youth Screening Instrument-Second Version (MAYSI-2). None of the staff were
supervisory staff. Three more staff were reviewed within their first 180 days of hire. All three
staff completed the required training prior to being in the presence of any youth, which included
child abuse recognition, reporting, and prevention, first-aid, AED, CPR, emergency procedures,
program operating procedures, PREA, professionalism, interpersonal communication, and
ethics, including standards of conduct, RI, and suicide awareness and prevention.
1.07 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a policy and procedures to address in-service training requirements.
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The in-service training was reviewed during the last annual compliance review period for the
same training year; therefore, during this annual compliance review the in-service training was
not reviewed. A review of training documentation showed all instructors were qualified to deliver
training. The program submitted an in-service training plan/calendar prior to implementation,
and the training plan/calendar was approved by the highest-ranking official at the location, the
Department’s assistant secretary for residential services, and the director of the Department’s
Office of Talent, Leadership, and Culture.
1.08 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures to address the grievance process, including training
requirements. The program’s grievance process included informal phase, formal phase, and an
appeal phase. The program did not have any grievances during the annual compliance review
period. The facility administrator (FA) was interviewed and stated the youth have a right to
grieve and have access to the grievance forms on the modules. Once the form has been
completed the youth will place the form in the grievance box in the hallway, which is checked
daily, and all forms are reviewed. The grievance is given to the appropriate staff to meet with the
youth within forty-eight hours. During the informal phase the assistant FA will review the
grievances and get back to the youth with a written response within forty-eight hours. In the
formal phase the FA will review the grievance, get back to the youth with a written response
within twenty-four hours or no more than five business days from the day the grievance was
originally completed. Five staff were interviewed, and all stated the grievance process included
a supervisor reviewing the grievance, four also mentioned a youth can request assistance in
completing the grievance form, and three said the FA reviews the grievances. The staff also
mentioned youth can ask for the form. Five youth were interviewed and two stated they are
provided grievance forms to complete, one of them stated the forms are placed throughout the
program. One youth mentioned they can speak to a supervisor and one said they would ask for
a request to speak form. The remaining youth stated they are not sure but would just ask the
staff how to complete a grievance. All five agreed they can ask for assistance in completing a
grievance form.
1.09 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff 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.
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1.10 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures addressing life and social skills activities offered to
youth. The program uses mainly primary groups; however, provides the Daniel Memorial Life
Skills program, which is an online assessment, with individual sessions provided by the
transition services manager (TSM). The life and social skills address communication,
interpersonal relationships and interactions, non-violent conflict resolution, anger management,
critical thinking, including problem-solving and decision-making, as well as addressing the
needs of the program’s targeted population. The facility administrator (FA) was interviewed and
stated youth participated in daily group sessions facilitated by trained mental health
professionals using evidenced-based curricula including Seven Challenges, Teen Relationship,
Trauma-Focused Cognitive Behavioral Treatment, Skillstreaming the Adolescent, and life skills
training. Youth also completed a cycle of Impact of Crime (IOC) facilitated by a trained case
manager. Five youth were interviewed and stated they receive different types of groups. They
mentioned Skillstreaming the Adolescent, setting goals, learning coping skills, box breathing,
how to introduce themself to people, manners, how to cope, role play, talk about what can help
them when they are home, how to avoid certain things, and skills to hang around more positive
peers. The clinical director (CD) was interviewed and stated licensed and non-licensed mental
health professionals provide group services at the program. During the intake process, the
licensed staff gather current information from the youth and collateral information obtained in
youth's Department records to complete the brief behavioral health status exam. Each youth
receives a comprehensive assessment within twenty-one days of intake based on their current
and past behavior which is conducted by a licensed/non-licensed mental health professional
and reviewed by the CD/designee. Based on the information gathered, evidenced-based
interventions are implemented to meet the youth's needs through individual, family, and group
counseling as a part of the youth's treatment. All youth are presented and encouraged daily
during group activities to practice the skills they have learned, as well as use and practice them
outside of the group environment.
1.11 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at this program. For details related specific to IOC service delivery, please refer
to the annual SPEP report. The program’s contractual requirement indicates IOC shall be
provided; however, states other services shall teach youth accountability, discipline, reinforcing
lawful behavior, develop their competency, self-discipline, respect for authority, understanding
consequences of their actions, and promoting responsibility. A review of documentation showed
youth had participated in a legal studies lecture, created a vision board, painted the facility,
made hygiene bags for the homeless, as well as wrote thank you cards to the local fire fighters.
The facility administrator was interviewed and stated all youth participate in daily group sessions
facilitated by a trained mental health professional using evidenced-based curricula, like Teen
Relationships addressing the need of the targeted gender group. Youth are required to
complete service projects like spot painting doors, walls, and living quarters, Hopes of Hands
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projects, get well letters for sick youth, inspirational cards for cancer patients, hygiene bags for
the homeless, and a vision board for for a local hospital. Five youth were interviewed and two
stated they had not yet participated in restorative justice groups/activities while at the program.
Two stated they had completed community service, and one stated they participated in IOC
where they talked about how crime can impact others. The three youth who had participated in
activities said they learned coping skills, like walking away, taking a few seconds to think, using
a stress ball, learned manners, and introducing themselves to people.
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 addressing the internal alert system and alerts. When
risk factors or special needs are identified during or following the classification process, staff
shall immediately update the internal program alert information and shall enter this information
into the Department’s Juvenile Justice Information System (JJIS). Only appropriate staff may
recommend downgrading or discontinuing a youth’s internal alert status. The policy states the
program alerts staff utilizing the JJIS alert list, the dietary alert list, and the alert communication
board. The mental health staff, as well as medical, case management, and operations input
alerts based upon type, and update the information when needed. During shift briefings alerts
are provided to staff. The medical team also has an alert log specific to medical conditions, and
the kitchen staff has the alerts specific to food allergies. A review of five youth confirmed each
youth was identified with alerts, totaling eighteen alert risks, and each were entered in the alert
system, as specified in the program’s written procedures. One of the eighteen alerts was
entered into JJIS seventy-five days late, and one alert was closed in the internal alert system
eleven days late. All other alerts were entered, updated, or closed as required in JJIS and the
internal alert system. Documentation indicated the required alerts were noted and updated in
the logbook. The facility administrator (FA) was interviewed and stated they discuss important
medical issues pertaining to the youth at the program during morning meetings and during shift
briefings, which are conducted daily. The medical team, the assistant clinical director (CD), and
the director of case management (DCM) are responsible for entering and closing alerts
pertaining to their areas of expertise. Changes in the medical alerts are emailed to the staff.
Five staff were interviewed and four stated they are informed of alerts by looking at the alert
board in the conference room, and one stated there is an alert book. One staff also stated if
youth wear red they are an escape risk, and four stated alert information is discussed during the
daily debriefings.
A nurse was interviewed and stated the registered nurses (RN) update the medical alert binder
daily.
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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 divides the youth records into two separate records: an Individual Healthcare
Record (IHCR) and an individual management record. The individual management records
contained the required elements of youth’s name, the Department identification number (DJJID),
date of birth, county of residence, and committing offense. The individual management records
contained legal information, demographics and chronological information, correspondence, case
management and treatment team activities, and miscellaneous section. All youth records were
labeled “Confidential”, were secured in a locked file cabinet or a locked room, and each file
cabinet or room was also labeled “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 community advisory board (CAB) meetings at least every ninety to 120
days, as indicated by a review of the agendas, meeting minutes, and video conference invites.
The facility administrator (FA) actively solicited involvement or recruited the following community
partners: law enforcement representative, judiciary community, other community partners,
business community, Florida Scholar’s Academy, faith community, victim/victim advocate/or
other victim services community representative, and a parent/guardian whose child was
previously, rather than currently, involved with the Department. A CAB member was interviewed
and stated she is very new to the board and just attended her first meeting in August 2025. The
services the program is providing were discussed during the meeting. She is a community
mental health provider, who already works with the Department, and her goal is to work with the
youth during the transition phase and provide outpatient services when the youth have returned
to the community. The FA was interviewed and stated the CAB meets on a quarterly basis. The
invitations are sent to the CAB members by mail and email with a calendar invite. A follow-up
telephone call for confirmation is also done if a response has not been received through the
invitations. The program recruits CAB members through invitations, referrals, mentors, guest
speakers, and staff recommendations.
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 addressing staff performance standards and
frequency of evaluations. Three job/position descriptions were reviewed, and each staff’s
performance standards were clearly identified. Six performance evaluations were reviewed, and
all were completed as outlined in the program’s policy at least annually. The performance
standards matched the job descriptions for each staff. The program’s contractually required
positions were maintained, other than one night nurse who resigned on July 13, 2025. The
program provided documentation they have been recruiting for the position since it has become
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vacant. A review of the staffing roster, schedule, and credentials for the recreational therapist
showed the program employed the one contractually required recreational therapist. The facility
administrator (FA) was interviewed and stated the program has partnered with Career Source
for employee referrals, utilizes staff referrals, and conducts daily interviews to hire new staff.
The program conducts meet and greets, bowling events, breakfast for staff, three-on-three
basketball games, waffle day, potlucks, and Christmas parties to boost morale and minimize
staff turnover. All staff have monthly coaching meetings with their supervisor, assisting staff to
know what needs improvement, and be acknowledged for a job well done. Each staff has an
annual evaluation, and new hires receive a ninety-day evaluation. Five staff were interviewed
and three stated they received formal evaluations based on performance standards annually
and monthly. Staff also mentioned receiving daily evaluations, as well as on an as needed
basis.
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 had two special contract conditions. One is the designated health authority (DHA)
shall be available twenty-four hours seven days a week, which was corroborated with the DHA
interview. The master control operators shall not fall under the staff to youth ratio as they do not
provide direct care and supervision to youth. An informal interview with the assistant facility
administrator (AFA) corroborated the program cross trains the master control operators as
safety and security specialist; however, when these staff work in master control they are not
included in the youth and staff ratio and do not supervise youth.
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.
A review of documentation indicated the provider utilizes satisfaction surveys in their monitoring
and verification activities as a part of the program's quality assurance. Satisfaction surveys are
provided at least quarterly and include youth surveys, family surveys, and staff surveys. The
surveys target admission activities, topic-specific assessments, and discharge satisfaction. The
survey data is reviewed and evaluated monthly on a program-level and during corporate
leadership meetings. Survey outcomes are collected and communicated as part of ongoing
program communication and quality improvement activities. Annual grievance and incident
analysis are completed and provided to the Commission on Accreditation of Rehabilitation
Facilities (CARF). The program staff and corporate leadership meetings include monthly quality
assurance review processes, which incorporate review of facility data, surveys, and findings of
formal monitoring and verification activities. Each meeting discusses progress to date, program
strengths, improvement needs, and corrective action. Recommendations are made by the team
with ongoing review and follow-up, and technical assistance is provided as applicable. Data
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gathered by the program and the Department is used for long-term planning, provisions for
staffing, and a system of communication to keep staff informed. The program indicated during
the current annual compliance review period they have not utilized any data trend analysis to
make any changes within the program.
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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.
A review of five youth case management records revealed each youth’s parent/guardian was
notified by telephone within twenty-four hours of admission, and in writing within forty-eight
hours of admission. Each of the five youth case management records revealed the court and
juvenile probation officer (JPO) were notified of each youth’s admission to the program within
five working days.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
A review of five youth case management records revealed each youth received an orientation
on the day of admission. The program’s orientation process includes services available, daily
schedule, expectations and responsibilities of youth, the program’s behavior management
system (BMS), availability of and access to medical, mental health, and substance abuse
services, and access to the Florida Abuse Hotline or the Department’s Central Communications
Center (CCC). Youth orientation included the program’s zero-tolerance policy regarding sexual
misconduct, including how to report incidents or suspicions of sexual misconduct. Special
accommodations are available to ensure all written information about sexual misconduct
policies, including how to report sexual misconduct, is conveyed verbally to youth with limited
reading skills or who are visually impaired, deaf, or otherwise disabled. Additionally, orientation
included the right to be free from sexual misconduct, right to be free from retaliation for reporting
such misconduct, the agency’s sexual misconduct response policies and procedures, items
considered contraband, including illegal prohibited items in which possession may result in the
youth being prosecuted, the performance planning process involving the development of goals
for each youth to achieve, dress code, and hygiene practices. Furthermore, orientation services
included procedures on visitation, mail and use of the telephone, expectations for release from
the program, including the youth’s successful completion of their Individualized Performance
Plan (IPP) goals, recommendation to the court for release based on the youth’s performance in
the program, and the court’s decision to release, community access, grievance procedures,
emergency procedures, including procedures for fire drills and building evacuation, program
tour, assignment to a living unit and room, treatment team, and if applicable, a staff advisor or
youth group. During the annual compliance review week, the program did not have any youth
admitted into the program; therefore, there were no youth observations of the program’s
orientation process conducted. Five youth were interviewed and each stated they received
orientation within twenty-four hours of their admission. Each youth stated they were explained
the program rules and/or provided a handbook explaining the rules.
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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.
A review of five youth case management records indicated none were applicable. Three
additional applicable records were requested; however, the program only had one applicable
youth. The one applicable youth case management record confirmed a written consent was
obtained before release of information related to the youth’s physical or mental health
screenings, assessments, or treatments.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a policy and procedures to address the classification process which includes a
classification system to promote safety and security, as well as effective delivery of treatment
services, based on the determination of each youth’s individual needs and risk factors, which
addresses, at a minimum, items outlined in Florida Administrative Code. The program’s policy
states the staff shall reclassify youth when warranted based upon changes in the youth’s
supervision status, new or updated alerts, behavioral concerns, and relevant information to the
treatment team to ensure safety and security of youth at the program. A review of the program’s
classification form revealed the form included physical characteristics of the youth, age and
maturity level, identified special needs, history of violence, gang affiliation, criminal behavior,
sexual aggression or vulnerability to victimization, youth’s perception of vulnerability, youth’s
history of potential or verified human trafficking, suicide risk, medical risk, escape risk and
security risk. Five youth case management records were reviewed. All five records contained an
admission classification form. Two of the five youth had suspected risk factors: one with a
medical risk and one with a security risk. Each youth had a review completed of the
Department’s Juvenile Justice Information System (JJIS) alerts and the program’s internal alerts
for any issues affecting each youth’s classification. Each of the five records contained
classification forms reflecting youth were classified for the purposes of assignment to a living
area, sleeping room, and youth group or staff advisor. Two of the five reviewed records required
and confirmed medical, mental health, substance abuse, security risk factors, and/or special
needs identified during or after the classification process were immediately entered into the
program’s internal alert system and JJIS. Each record revealed reclassifications were
completed prior to considering an increase in each youth’s 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 and were able to participate in off-campus
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activities. An interview with the facility administrator (FA) revealed the program takes in all
factors (mental health status, physical health, cognitive performance, age, and prior
victimizations) including the county the youth live in, or co-defendants when determining a
youth’s placement in the mod. The program also places youth with prior victimization in front
rooms on the mod.
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.
Five reviewed youth case management records indicated only one was applicable. Two more
examples were requested. The three applicable youth were identified as gang affiliated. The
program has a policy and procedures addressing gang identification including notification by the
program of the youth’s gang involvement to youth’s home county law enforcement and the
program’s county law enforcement. Additionally, gang alerts are entered into the internal alert
system and in the Department’s Juvenile Justice Information System (JJIS) upon identification
within twenty-four hours. The gang status is shared with the educational provider at the
residential program and the youth’s assigned juvenile probation officer (JPO). Each of these
requirements were completed regarding the three applicable youth. All three records
documented, prior to the annual compliance review seven-day notice, local law enforcement
was notified of youth’s gang involvement by either the program, detention staff, or each youth’s
JPO. None of the youth were applicable for notification to the youth’s post-residential counselor.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program maintains a policy and procedures regarding youth’s participation in gang
prevention and/or intervention activities. The program’s policy addresses providing youth an
opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang. Five
reviewed youth case management records indicated only one was applicable to be identified as
a gang member or affiliated gang member. Two more examples were requested. A review of
documentation revealed each of the three applicable youth participated in gang prevention and
intervention strategies. A review of each youth’s performance plan showed the inclusion of
relevant goals and objectives related to gang intervention strategies for each youth to complete
prior to release from the program. The program utilizes Arise curricula, 50+ Stories of Fractured
Lives and Impact of Crime (IOC) as the gang intervention strategies. A review of sign-in sheets
confirmed the delivery of groups. An interview with the facility administrator (FA) revealed the
youth who are flagged as gang members participate in monthly gang and
intervention/prevention services. Youth are usually given an assignment to complete and submit
to the program gang liaison. The FA also stated all youth participate in IOC.
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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.
Five youth case management records were reviewed, and each record indicated the Residential
Assessment for Youth (RAY) was completed within thirty days of admission and was maintained
in the Department’s Juvenile Justice Information System (JJIS). Three of the five records were
applicable for RAY reassessments, of which each was completed within ninety-days after the
completion of the initial RAY. All reassessment documentation was maintained in each youth’s
official case record. None of the youth were applicable for any other updates or reassessments
completed by the intervention and treatment team.
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.
Five youth case management records were reviewed. Each record indicated the youth needs
assessment summary (YNAS) was completed within thirty days of admission and documented
in the Department’s Juvenile Justice Information System (JJIS). In each of the five youth case
management records, the YNAS documented each 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.
Five youth case management records were reviewed. All five records indicated the
Individualized Performance Plans (IPP) were developed within thirty days of the youth’s
admission and after the completion of the initial Residential Assessment for Youth (RAY)/youth
needs assessment summary (YNAS). Each record contained signatures for intervention and
treatment leader, youth, administrative representative, living unit representative, treatment staff
and educational staff on the IPP. None of the reviewed records were applicable for Department
of Children and Families (DCF) waiver support coordinator signatures. The signature sheet was
filed in each youth’s case record. All five reviewed performance plans contained individualized
goals and based upon the prioritized needs reflecting the risk and protective factors identified
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Office of Accountability and Program Support Page 23 of 64 (Revised August 2025)
during the initial assessment process. All five records contained delinquency interventions on
the IPP and addressed each youth’s top three criminogenic needs. Target court-ordered
sanctions which could be reasonably initiated/completed while in the program, transition
activities targeted for the last sixty days of each youth’s anticipated stay, youth’s responsibilities
to accomplish goals, program staff responsibilities to enable youth to complete goals, and target
dates for goal completions were all listed on each youth’s IPP. A review of documentation
revealed a transmittal letter and copy of the plan was sent to the committing court, juvenile
probation officer (JPO) and the parent/guardian within ten working days for each youth. Five
youth were interviewed and reported they participated in the development of their performance
plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
Three of five reviewed youth case management records were applicable for Individualized
Performance Plan (IPP) revisions. Each IPP revision was completed when the Residential
Assessment for Youth (RAY) reassessment results warranted, and/or when youth demonstrated
progress toward completing a goal. None of the records were applicable for revisions based on
newly acquired/revealed information, for youth demonstrating lack of progress toward
completing a goal requiring revisions, nor to facilitate transition activities during the last sixty
days of a youth’s stay. Each youth was applicable for education/mental health treatment plans
which were incorporated into the IPP. None of the youth were applicable for a case plan through
the Department of Children and Families (DCF).
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.
Five youth records were reviewed for the completion of performance summaries. Three of the
five youth records were applicable for performance summaries and transmittals. Each of the
three applicable reviewed summaries were completed within the required time frame and
contained all required elements except each summary did not contain each youth’s academic
status, grades, and credits earned in the program, as well as two summaries were missing the
overall treatment progress. Each summary reflected the opportunity for youth to read and
comment prior to signing and each youth was provided a copy of the summary. All reviewed
summaries were signed by the case manager/treatment team leader, facility administrator (FA)
and youth. In the three applicable records the summary was sent to committing court, juvenile
probation officer, and each parent/guardian within ten working days. Each summary was filed in
each youth’s case management record. Three closed records were reviewed for discharge and
release summaries. All three records contained the original release summary which included the
justification for each youth’s release from the program. None of the three youth were a direct
discharge. All records contained a signed pre-release notification (PRN), completed at least
forty-five days prior to each youth’s release. A review of documentation revealed the program
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provided written notification to each parent/guardian regarding the planned release. Each of the
three records showed a completed Residential Assessment for Youth (RAY) exit assessment
was completed. No youth were applicable for the Sexually Violent Predator Program (SVPP).
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program maintains a policy and procedures regarding parent/guardian
involvement in case management services. A review of documentation showed the program
makes efforts to include the parent/guardian in the assessment process, development of the
youth’s performance plan, progress reviews, and transition planning. If unable to attend, the
parent/guardian is given the opportunity to participate by telephone/video conference or
provide verbal/written input prior to the meeting. The program provides the parent/guardian
dates and times of the next month’s treatment teams/other meetings each month when they
send out performance plan/treatment team letters. During the week of the annual compliance
review, an observation of three treatment team meetings was conducted. For each meeting, the
parent/guardian participated by telephone. The program allowed each youth’s parent/guardian
time to speak about youth progress, ask any questions, or voice any concerns. The facility
administrator stated in an interview the case management process is explained to the
parent/guardian at intake. The program provides the parent/guardian with a youth handbook by
mail. Monthly treatment team letters are mailed with the next treatment team review date and
time. Formal and informal treatment team reviews are conducted with the parent/guardian. The
parent/guardian is invited to quarterly family days and a family forum is held quarterly where the
parent/guardian can voice concerns and learn all the innovative approaches. Five youth were
interviewed, and each reported parent/guardian involvement in their case management, usually
by telephone during treatment team meetings.
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.
Five youth case management records were reviewed and each indicated formal reviews were
held at least every thirty days and informal bi-weekly alternating with the formal meetings. Each
of the formal meeting documentation included youth name, date of review, required attendees,
comments from treatment team members, brief synopsis of youth progress, progress on the
performance plan goals, positive and negative behaviors, an opportunity for each youth to
demonstrate skills acquired in the program, treatment progress, and Residential Assessment for
Youth (RAY) reassessment results. None of the youth exhibited behaviors resulting in physical
interventions. All formal treatment team documentation was contained in each youth’s record. A
review of documentation showed the program provided advance notification to each youth’s
juvenile probation officer (JPO), parent/guardian, and any other pertinent parties for participation
in the treatment team meetings. A treatment team meeting was observed during the annual
compliance review week, with all required staff present. Five youth were interviewed, and each
confirmed program staff talk about their performance to include progress on performance plan
goals, positive and negative behavior, and treatment progress. The five interviewed youth
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reported they can explain their progress, level of change, and future goals by completing a
document submitted during treatment team.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
A review of three closed youth case management records confirmed a transition conference
was held at least sixty days prior to each youth’s targeted release date. A review of
documentation confirmed the youth, treatment team leader, facility administrator (FA) or
designee, and other team members attended the transition conference in all three records.
Documentation confirmed the treatment team leader invited and encouraged participation of
each youth’s juvenile probation officer (JPO), parent/guardian, education staff, and any other
pertinent parties through advance notification. A review of documentation confirmed during the
transition conference, the participants reviewed transition activities on each youth’s performance
plan, revised performance plans, identified additional transition activities, identified target
completion dates, and identified persons responsible for completion. The treatment team leader
obtained attendees’ dated signatures representing their acknowledgment of the transition goals,
and accountability for completion. Each of the three records had documentation showing the
plans were transmitted electronically to the JPO with a return email acknowledgment receipt
printed and filed with the plan. In each of the three records, documentation revealed a
Community Re-Entry Team (CRT) meeting was conducted prior to each youth’s release with the
youth and case manager participation and evidence of an invitation to participate in the CRT
meeting was provided.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
A review of three closed youth case management records revealed the exit portfolio was
discussed and initiated for each youth during the transition conference. Two youth exit portfolios
contained a state-issued identification card, with notation in the third exit portfolio the
parent/guardian did not provide the state-issued identification card. None of the three closed
case management records contained a social security card or birth certificate; however, there
was a note in each of the records containing an explanation why the identification was not
included. Each youth portfolio contained each youth’s transition plan and a calendar with all
dates, times, and locations of upcoming community appointments, educational and vocational
certifications earned in the program, resume and a sample employment application. Each
youth’s case management record reflected the program staff forwarded the exit portfolio
information to the juvenile probation officer. The completed exit portfolio was provided to each
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youth upon release, and a plan was put in place as to who will be responsible for working with
the youth to obtain documents for employment. The program’s contract does not include any
additional requirements for the exit portfolio.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Three closed case management records were reviewed and each had documentation an exit
conference was completed. Each exit conference was conducted after the program notified the
youth’s juvenile probation officer (JPO) of the release and at least fourteen days prior to release.
A review of each youth’s exit conference documentation revealed the date of each conference,
signatures of participants, and a summary of pending transition goals was included. Each exit
conference had each youth’s date of admission and date of termination documented, matching
with the Department’s Juvenile Justice Information System (JJIS). During each exit conference,
the status of transition activities and provisions for continuation of education and/or employment
were reviewed, and plans were finalized for each youth’s release. Each youth’s exit portfolio
was reviewed during the exit conference and documentation showed parent/guardian and JPO
were aware of the vocational plan for each youth. Documentation revealed the intervention and
treatment team leader, parent/guardian, education representative, JPO, youth and other
pertinent parties participated in each exit conference. All three records indicated the exit
conference was held separately from the transition and community re-entry team (CRT)
meetings.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program’s formal process to promote constructive input from youth is conducted through
student council meetings and town hall meetings twice a month, and youth are encouraged to
utilize “Request to Speak” forms. A review of the youth advisory board binder showed the
program’s efforts to solicit input from the youth through avenues such as recreation/incentive
calendars, student council meeting minutes/sign-in rosters and “Request to Speak” forms. The
program provides youth with monthly recreation and incentive calendars. The student council
meetings are held bi-weekly. A review of the program’s sign-in sheets, agendas, and meeting
minutes confirmed the meetings are being held as required. Five youth were interviewed and
one indicated they can voice their input through the town hall meetings and two stated through
talking with staff. One youth stated they are unsure how to provide input and one youth said
youth are not able to provide input about what happens at the program. An interview with the
facility administrator (FA) revealed the program’s formal process to solicit input from the youth is
completed through a bi-monthly student council meeting. During this meeting, youth can provide
input about the facility, incentives, canteen and recreation calendar, and address concerns. The
youth are also able to complete a “Request to Speak” form. Town halls are also completed bi-
weekly, which also allows the opportunity for the program to provide updates to the youth on
any changes to the program.
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2.18 Educational Access (Residential Contract Provide) Limited 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 for educational access. The
program integrates education into the daily schedule. A sample of three days of videos and
coordinating logbook reviews showed youth missed the required amount of daily education
times seventy-one minutes, nine minutes, and seven minutes, respectively. In addition, logbook
reviews for one random day a month for the annual compliance review period were reviewed,
and youth were moved accordingly with little deviation. Five youth were interviewed and stated
there are no interruptions during the school day.
2.19 Contract Specific Career and Technical Education Services
Limited Compliance
(Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program’s contractually required career and technical education (CTE) services include
soft skill credentials in Florida Ready to Work, Occupational Safety and Health Administration
(OSHA) 10-hour training course, and first-aid/cardiopulmonary resuscitation (CPR) training. The
program shall serve as a collaborative partner who provides CTE services which lead to career
pathways with student outcomes which must include industry certifications earned from the
master credentials list and may include articulation agreements providing enrollment
opportunities into in-demand CTE programs at a local technical college. Fourteen youth
received certifications in Florida Ready to Work, and fifty-one in OSHA-10, as well as three in
CPR/first-aid. CTE services are scheduled and provided on Wednesdays and Fridays from
12:05 p.m. to 1:05 p.m. weekly. The program has five staff who provide CTE services; all had
their certifications to facilitate the services they are providing. At the time of the annual
compliance review week the program had forty-six youth enrolled in coursework towards
earning an industry certification. A review of five youth case management records indicated all
five youth received certifications on CPR/first-aid and OSHA-10. None of the five had received
the Florida Ready to Work certifications at the time of the annual compliance review. Five youth
were interviewed and all stated they do not receive any career or technical education services.
The facility administrator was interviewed and stated youth receive OSHA-10, OSHA-30, first-
aid, and CPR certifications as part of the career and technical education services offered at the
program.
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Office of Accountability and Program Support Page 28 of 64 (Revised August 2025)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program maintains a policy and procedures addressing the requirement for a designated
mental health clinician authority (DMHCA). The program has a clinical director (CD) who serves
as the DMHCA. The CD is a full-time position and on-site forty hours weekly as required by the
program’s contract to ensure appropriate coordination and implementation of mental health and
substance abuse services. The CD ensures consistent and appropriate services in addition to
being on-call twenty-four hours a day seven days a week for emergency consultation. The CD is
a licensed mental health counselor (LMHC). The license was reviewed and was free and clear
in the State of Florida with an expiration date of March 31, 2027. The program’s back-up CD
has a free and clear license in the State of Florida with an expiration date of March 31, 2027.
The previous CD had a clear and valid license in the State of Florida which expires on March
31, 2027. The interviewed CD stated their role in the coordination and implementation of mental
health and substance abuse services include conducting clinical supervision for non-licensed
mental health professionals, providing weekly group schedules, as well as monthly fidelity
monitoring to the mental health professionals who submit monthly service calendars of
scheduled individual and family sessions to the CD or designee. The program provides
individual, family and group therapy services. The clinical staff and the CD communicate daily.
Formal meetings include weekly supervision, and informal methods to ensure good morale and
open dialog fostering the effective functioning of the clinical department. Mental health
professionals are notified when staff complete a mental health substance abuse referral, which
is provided to clinical staff. The CD is on-call and can be reached twenty-four hours a day seven
days a week.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a policy and procedures ensuring established requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program’s
licensed clinical director (CD) serves as the program’s supervisor for on-site clinical staff. The
program’s staff roster was reviewed and confirmed there is one contractually required licensed
clinical staff, the assistant clinical director (ACD). The ACD is a licensed mental health
counselor with a free and clear license in the State of Florida, which expires March 31, 2027.
Additionally, the regional clinical manager is a licensed mental health counselor. The reviewed
license confirmed it was free and clear in the State of Florida with an expiration date of March
31, 2027. The regional clinical manager provides support and supervisory services to ensure
the licensed clinical staff working under their supervision are performing services they are
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qualified to provide based on education, training, and experience based on a review of job
description and an informal interview with the CD. The licensed mental health and substance
abuse clinical staffing is in accordance with the current contract and Florida Administrative
Code. Copies of all licenses were available on site; furthermore, the program maintains a binder
with licenses, training, policy and procedures. All licensed mental health professionals were
reviewed and were clear and valid.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a policy and procedures regarding non-licensed clinical staff. The
clinical director (CD) confirmed their responsibility for ensuring non-licensed clinical staff are
working under their supervision and performing services they are qualified based on education,
training, and experience. Reviewed documentation for the annual compliance review period
reflected each non-licensed mental health clinical staff received a minimum of one hour a week
on-site direct supervision by a licensed mental health professional for the purpose of overseeing
and directing the mental health services provided in the program. The program’s practice is to
complete group and/or individual clinical supervision for the non-licensed clinicians and the
recreation therapist. The clinical supervision was documented on the program’s form and
included all elements on the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. The program is
licensed under Chapter 397 by the Department of Children and Families (DCF) to provide
substance abuse services to adolescents. The Chapter 397 license expires October 15, 2025.
The license was displayed in the lobby with the program’s physical address listed. The
program’s non-licensed clinical staffing, based on the contract, requires one recreation
therapist, and seven non-licensed mental health clinicians. Documentation supported education
and service requirements were in accordance with the contractual requirements. The program
had no clinical staff vacancies since the last annual compliance review. The program had seven
non-licensed mental health clinicians providing therapeutic services during the annual
compliance review period. A review of the seven non-licensed staff’s education documentation
reflected each held a master’s-level degree from an accredited university or college in the field
of counseling, social work, psychology, or a related human services field. Each non-licensed
staff was providing clinical services under the program’s Chapter 397. Each of the seven non-
licensed clinical staff who conducted Assessments of Suicide Risks (ASR) completed twenty
hours of training 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.
The program has a policy and procedures to ensure mental health and substance abuse needs
of youth are identified through a comprehensive screening process ensuring referrals are made
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when youth have identified mental health and/or substance abuse needs or are identified as a
possible suicide risk. A review of the program’s policy confirmed a standardized screening
process, staff training in mental health and substance abuse issues, the administration of the
Massachusetts Youth Screening Instrument-Second Version (MAYSI-2) and a standardized
process for the referral of youth identified in need of further evaluation. Five youth records were
reviewed for mental health and substance abuse admission screening. Each record contained
screening documents completed upon each youth’s detention intake. Each record indicated
available information and screening documents were reviewed by staff upon receipt of each
youth. The MAYSI-2 was completed at intake, on the day of admission, for each youth and was
initiated within the Department’s Juvenile Justice Information System (JJIS). All MAYSI-2
screenings were completed in full, by trained staff as verified in the Department’s Learning
Management System (SkillPro). In three of the five records, the results of the MAYSI-2 indicated
a need for further assessment and the remaining two MAYSI-2 were marked override as all
program youth receive mental health services and are referred for further evaluation. Based on
the results of the MAYSI-2 in each record, the need for further assessment was required and
the appropriate referrals were made to the clinical director (CD) with notification to the facility
administrator (FA). The FA ensured an Assessment of Suicide Risk (ASR) was conducted within
twenty-four hours and a review confirmed each ASR was completed on the day of admission.
The screener for each youth made a referral to the mental health clinical staff for an ASR,
comprehensive substance abuse and mental health assessment and also documented the
reason for each referral. The interview with the facility administrator indicated each youth
admitted to the program receives the MAYSI-2, and all youth are referred for a comprehensive
assessment within thirty days. Also, the program has a contracted board-certified behavioral
analyst who provides additional services for youth as referred.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a policy and procedures to ensure youth identified by screenings, staff
observations, or behaviors post-admission as in need of further evaluation will be referred for a
combined Comprehensive Mental Health and Substance Abuse Evaluation. Five youth records
were reviewed for mental health and/or substance abuse evaluations. All five youth were
identified at admission and were referred for a comprehensive mental health and substance
abuse evaluation. The program completed a new comprehensive mental health and substance
abuse evaluation for each youth within thirty calendar days of admission. Each record contained
a substance abuse consent for services signed by each youth. All five reviewed youth were
applicable for completion of their comprehensive evaluation by non-licensed clinical staff. In
each record, the licensed clinical staff reviewed and signed the comprehensive evaluation within
ten calendar days. Each youth’s comprehensive evaluation contained all required elements. An
interview with the clinical director (CD) was conducted. The CD indicated the mental health
department provides individualized treatment through individual, family, and group therapy
services to address mental health and substances abuse concerns of the youth. The CD stated,
when youth complete the intake process, including classification, problem areas are discussed
with each youth and parent/guardian. The CD added, during the intake process licensed or non-
licensed staff gather current information from the youth and the therapist confirms youth's
reports by referring to collateral information obtained in the Department’s Juvenile Justice
Information System (JJIS) records to complete the Brief Behavioral Health Status Exam. Each
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youth receives a comprehensive assessment within twenty-one days of the intake based on
their current and past behavior by licensed or non-licensed mental health professional, which is
reviewed by the CD or designee.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures to ensure youth determined to have a mental disorder
and/or substance abuse impairment and are receiving mental health and/or substance abuse
treatment have an Initial or Individualized Mental Health and/or Substance Abuse Treatment
Plan. Five youth records were reviewed for mental health and substance abuse treatment. Each
record included an initial treatment plan completed within seven days of the initiation of
treatment, on a program form which contained all required elements. The initial treatment plan
was signed by the mental health clinical staff completing the form. All five initial treatment plans
were signed by all members of the treatment team who participated in the development of the
plan, except for the parent/guardian and the juvenile probation officer (JPO) who participated on
the telephone, which was noted on each initial treatment plan. Four of five initial treatment plans
were completed by a non-licensed mental health clinical staff, and each was signed by the
licensed clinical supervisor within ten days of completion; the remaining initial treatment plan
was completed by a licensed mental health clinical staff. Three of the five initial treatment plans
included each youth’s psychiatric needs, including medication and frequency of monitoring by
the psychiatrist. The remaining two were not applicable; however, these remaining youth did
have psychiatric services added to their individualized treatment plans after completing a
psychiatric interview. Four of five youth had an individualized treatment plan completed on a
program form which contained all required elements. The remaining youth had an individualized
treatment plan completed on a program form, which contained all required elements, with the
exception of the frequency of monitoring for psychiatric services. Treatment plan reviews were
completed for each youth at minimum every thirty days, with the exception of one treatment plan
review which was completed four days late. All five youth had individualized treatment plans
signed by all required parties, except for parent/guardian and JPO who participated by
telephone, which was documented on each treatment plan. All five individualized treatment
plans and reviews were completed by a non-licensed mental health clinical staff, and each was
signed by the licensed clinical supervisor within ten days of completion. Each individualized
treatment plan outlined services, goals and objectives specific to the needs of each youth,
including individual therapy, group therapy, family therapy, psychiatric services, and medication
management, if applicable. Five interviewed youth each confirmed they are participating in
individual and family counseling at least monthly. An interview with the clinical director (CD) was
conducted. The CD said licensed mental health professionals provide clinical supervision for
non-licensed mental health professionals, and they provide a weekly group schedule which
guides the implementation and execution of group therapy services to the youth. Mental health
professionals submit monthly service calendar of scheduled individual and family sessions to
the CD or designee. Mental health professionals utilize internal forms to track services provided
as well as completion of documentation for the services. The CD also provides monthly
monitoring of the calendar and services to ensure service fidelity.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 32 of 64 (Revised August 2025)
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
The program has a policy and procedures which address treatment and discharge planning.
Five youth records were reviewed for treatment and discharge planning. All five records
indicated the mental health orientation was held within fourteen days of admission and all
records indicated each youth required a treatment plan. Documentation revealed each youth’s
initial treatment plan was in place within seven days of the onset of treatment. All five youth
were assigned to a treatment team upon arrival to the program, and all required members
participated, with two exceptions; education who was not available for one treatment team and
parent/guardian who was not available for one treatment team; however, attempted contact was
documented in each youth record. A review confirmed each record contained a properly
executed Authority for Evaluation and Treatment (AET) form, a signed Youth Consent for
Substance Abuse Treatment form and all mental health and/or substance abuse treatment
notes were properly documented on a program form which contained all of the information of
the Department’s Counseling/Therapy Progress Notes form. The progress notes in all five
records validated each youth was receiving treatment services as stipulated on the treatment
plan. Three closed youth records were reviewed for discharge plans. Each reviewed discharge
plan was documented on the Department’s Mental Health/Substance Abuse Treatment
Discharge Summary form, which documented the future services needed; the discharge plan
was discussed with all required parties during the exit conference for each youth, and a copy of
the form was provided to each youth, juvenile probation officer (JPO) and each parent/guardian.
No youth were released while on suicide alert/precautions. An interview with the clinical director
(CD) was conducted. The CD indicated the mental health staff create master treatment plans
within twenty-five days of admission and treatment plan reviews are completed monthly, which
are reviewed by the CD or designee. Updates are also made using a treatment addendum if
treatment adjustments are needed. The CD added he meets with the facility administrator (FA)
daily.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program has a policy and procedures which require specialized treatment services to be
provided to youth. The delivery protocol includes borderline intellectual
functioning/developmental disability (BIF/DD) services. The program’s required clinical
treatment groups include Skillstreaming the Adolescent, Seven Challenges, Trauma Focused
Cognitive Behavioral Therapy, and LifeSkills Training. Five youth were interviewed, and all
confirmed they participate in family and/or individual counseling on a bi-weekly or monthly basis.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 33 of 64 (Revised August 2025)
Five staff were interviewed, and all confirmed direct care staff do not facilitate any mental health
or substance abuse groups. An interview with the clinical director (CD) was conducted. The CD
reported the program provides group, individual, and family counseling services to address the
mental health and substance abuse concerns of youth at the program. An interview with the
facility administrator (FA) was conducted. The FA stated the program provides specialized
treatment services and mental health and substance abuse services for the youth as identified
by contract. Documentation confirmed the CD was on-site for forty hours each week and
licensed mental health staff were on-site at least five days each week. The program met the
required counselor to youth ratio, which is not to exceed one counselor to ten youth for
developmental disabilities and not to exceed one counselor to twelve youth for borderline
intellectual functioning. Additionally, each non-licensed staff held a master’s-level degree. The
program met requirements to include individual therapy provided at least once every two weeks,
or more often as needed, family therapy provided at a minimum of monthly, as applicable, and
psychiatric services at least once every two weeks. The program has a licensed mental health
counselor to provide on-site services, as needed. Group therapy included four total mental
health and substance abuse groups each week for all youth. None of the youth at the program
missed any services due to being on medical quarantine.
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 ensuring the implementation of a Suicide
Prevention Plan. The plan included identification and assessment of youth at risk of suicide,
staff training, suicide precautions, levels of supervision, referral, communication, notification,
documentation, immediate staff response, and review process. The review process for suicide
attempts and mortality review included circumstances surrounding the event, procedures
relevant to the incident, all relevant training received by involved staff, pertinent medical and
mental health services involving the victim, possible precipitating factors, and recommendations,
if any, for changes in policy, training, physical plant, medical or mental health services, and/or
operational procedures. The Suicide Prevention Plan was reviewed on August 1, 2025, by the
facility administrator (FA) and the clinical director (CD). The CD meets with the psychiatrist to
discuss youth receiving psychiatric services bi-weekly by telehealth.
3.10 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
The program has a policy and procedures which governs suicide prevention services. The
program had a was assigned a previous deficiency, which was closed on June 12, 2025. Five
youth records were reviewed for suicide prevention services and none of the five were
applicable. A request for three additional records was made. The clinical director (CD) reported
there were no applicable records to review for suicide prevention services after the deficiency
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Office of Accountability and Program Support Page 34 of 64 (Revised August 2025)
was closed; therefore, there was no applicable video footage of precautionary observation to
review. An interview with the CD was conducted. According to the CD, suicide risk screenings
are conducted by the case manager and trained non-licensed mental health professionals as
well as licensed mental health professionals, which include the administration of the
Massachusetts Youth Screening Instrument-Second Version (MAYSI-2) to assess mental health
and substance abuse issues, and the Suicide Risk Screening Instrument (SRSI) to assist in
identifying youth at-risk of suicide. The CD indicated once the MAYSI-2 is administered, a
referral form is completed and given to mental health professionals during the intake process.
The CD added he is on-call and can be reached twenty-four hours a day seven days a week. An
Assessment of Suicide Risk (ASR) is completed for all youth at the time of intake, regardless of
MAYSI-2 results. If a youth appears to be acutely suicidal, a mental health/substance abuse
referral is completed, a licensed mental health professional is contacted, and the youth is
assessed using an ASR. Youth who are a potential suicide risk have an involuntary commitment
completed and law enforcement is called for secure transport to an off-site Baker Act facility.
The youth will be accompanied by program staff until intake at the facility is completed. When a
youth is potentially suicidal, they are assessed, placed on precautionary observation, an internal
alert is entered, and a new precautionary observation log is initiated for every shift. Also, during
each shift briefing, all staff are notified of any youth on precautionary observation and their
corresponding level of supervision. Prior to revising the supervision level of a youth, mental
health meets with the facility administrator (FA)/designee and this information is then
documented on the ASR and in the master control logbook. If mental health is on duty when a
youth is potentially suicidal or has attempted suicide, mental health notifies the parent/guardian
by telephone, and the youth's juvenile probation officer (JPO) by telephone or through email.
The CD indicated in the last six months, the program has not had any youth attempt to hurt
themselves.
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.
The program’s Suicide Prevention Plan requires staff to maintain one-to-one or constant
supervision of youth placed on suicide precautions. Five youth records were reviewed for
suicide precaution observation logs. None of the five youth were applicable. A request for three
additional records was made. The clinical director (CD) reported there were no other applicable
records to review for suicide precaution observation logs during the annual compliance review
period.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 35 of 64 (Revised August 2025)
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a policy and procedures which ensure 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. Eight pre-service staff training records were reviewed for
suicide prevention training. There was no in-service training records reviewed because the 2024
training was already reviewed during the prior annual compliance review. Documentation
supports completion of suicide prevention training for the eight applicable staff. The program
maintains two suicide response kits, including a knife-for-life, wire cutters, and needle nose
pliers, which were all observed during the annual compliance review week. One kit is located in
the East Wing sub-control and the other kit is in the West Wing sub-control, both of which were
co-located with the first-aid kits. Training records indicated mock suicide drills were held no less
than quarterly on each shift. There was one mental health drill conducted within the last thirty
days; however, video review was unable to be completed because the drill was conducted in an
area with no camera coverage. Additionally, the program staff completing the video review
indicated the drill was not simulated for the third shift. The program’s suicide training included
mock drills for all staff who encounter youth, including kitchen and maintenance staff. All mock
mental health drills were in response to a suicide attempt and/or incident of serious self-injury.
No youth were used in drill simulation related to mental health or substance abuse care. The
program conducted semi-annual training on emergency response procedures which included
mock training in emergency response to a suicide attempt or incident of serious self-inflicted
injury. Staff who were not present during any quarterly drills have the opportunity to review the
drill scenario and procedures to understand the process and receive necessary training to
respond. The interview with the facility administrator (FA) indicated the program conducts mock
drills monthly on all three shifts and the mental health drills are reviewed in the monthly All-
Team Meeting. Five interviewed staff indicated if a youth expresses suicidal thoughts, they are
responsible for calling a code, notifying mental health, keeping each youth under constant sight
and sound supervision, and informing their supervisor. Four of the five staff indicated suicide
response kits are located in sub control, one staff stated master control, and one staff added
medical. Three of five staff confirmed medical emergency and suicide drills are conducted on
their shift monthly, while the remaining two staff indicated often; however, were not sure of the
exact frequency of the drills.
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 maintains a policy and procedures to outline operating procedures for crisis
intervention. The program’s Crisis Intervention Plan addresses mental health crisis intervention
services and Crisis Assessments. A review of the plan confirmed it included a notification and
alert system, means of referral, as well as youth self-referral, communication, supervision,
documentation, and review. The facility administrator (FA) interview confirmed mock drills are
conducted monthly for all three shifts. Mental health drills are reviewed in the monthly All-team
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Office of Accountability and Program Support Page 36 of 64 (Revised August 2025)
meeting. Five staff were interviewed and stated medical emergency and suicide drills are
conducted on a shift at least monthly or twice a month.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a policy and procedures ensuring the program responds 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 program. 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. Five youth records were reviewed for crisis assessment and none of the
five youth were applicable for a crisis assessment. A request for three additional records was
made. The clinical director (CD) reported there were no other applicable records to review for a
crisis assessment during the annual compliance review period.
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 maintains a policy and procedures outlining the mental health and substance
abuse procedures for youth who are believed to be in imminent danger to themselves or others
because of mental illness or substance abuse impairment. The Emergency Mental Health and
Substance Abuse Services Plan includes immediate staff response, notifications,
communication, supervision, authorization to transport for emergency mental health or
substance abuse services, transport for emergency mental health evaluation and treatment for
Baker Act and Marchman Act, documentation, training, and review. The procedures for
notification of the facility administrator (FA), parent/guardian or other agencies regarding a
potentially suicidal youth or youth who has committed suicide involves the licensed professional
conferring with the FA, parent/guardian by telephone, and the juvenile probation officer (JPO) by
telephone or email. In the last six months, no youth have attempted to self-injure themselves.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 37 of 64 (Revised August 2025)
3.17 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker Act or Marchman Act procedures during the annual
compliance review period; therefore, this indicator is rated non-applicable.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedures to 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. Five youth records were reviewed for the safety planning process.
The five reviewed youth records confirmed each safety plan was completed within fourteen days
of admission and was jointly prepared by youth, parent/guardian or family member, the
program’s clinical staff and behavioral specialist, if applicable. All five safety plans incorporated
any recommendations from previous or current clinical assessments or screening instruments,
incorporated trauma responsive practices for each youth, and each plan was reviewed and
updated at least every thirty days. A review confirmed all five safety plans were updated
following any significant behavioral or mental health event identified by each youth’s intervention
and treatment team. Each reviewed safety plan included warning signs, youth’s baseline
behaviors, crisis recognition, jointly developed coping strategies, intervention strategies
preferred by the youth, and a debriefing process. All of the safety plans were reviewed by the
staff who have contact with each youth, which was confirmed by a review of the treatment team
reviews. Each youth’s mental health record contained their safety plans. Five interviewed youth
confirmed they contributed to the development of their safety plan. The interview with the facility
administrator (FA) indicated the safety plans are updated monthly during the treatment team
reviews.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 38 of 64 (Revised August 2025)
Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a policy and procedures addressing the responsibilities of the designated
health authority (DHA). The program has a board-certified physician who is an osteopathic
physician (DO) who meets all requirements for independent and unsupervised practice in
Florida to serve as the DHA. The DHA holds an unrestricted license which expires on March 31,
2026. The DHA is responsible for performing evaluations, sick call, reviewing the nursing
protocols, as well as establishing policies for providing medical care for the youth in the center.
The DHA did not have any disciplinary cases/public complaints on record. The program did not
have an advanced practice registered nurse (APRN) or a physician assistant (PA) providing
services during the annual compliance review period. A review of the sign-in and out logbook
confirmed the DHA was on-site as required by contract to meet with youth as needed. The
program has a back-up DHA who holds an unrestricted license which expires January 31, 2028;
however, the back-up DHA was not utilized during the annual compliance review period. The
program did not utilize tele-medicine/tele-health during the annual compliance review period;
however, each youth and parent/guardian signed a consent to participate in tele-health while in
the program. The DHA interview reported the role of the DHA is to conduct sick call, periodic
evaluations, review off-site visits, and policy and procedures development. The DHA is on-site
weekly and communicates with direct care staff through alerts and shift reports, and with
healthcare staff through weekly meetings to discuss youth records. The DHA is available by
telephone when not on-site. The DHA confirmed the process of off-site visits and follow-ups.
The DHA reported when on vacation another physician provides coverage.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a policy and procedures addressing the responsibility of licensed medical
staff. The program has one licensed practical nurse (LPN). The designated health authority
(DHA) provides directives to the LPN and reviews all medical cases daily with the LPN including
on-call consultation. The program had four registered nurses (RNs) and one licensed practical
nurse (LPN) who provided services during the annual compliance review period. Each of the
nursing staff had current cardiopulmonary resuscitation (CPR) and first-aid certifications. The
program has nursing staff on-site twenty-four hours a day seven days a week; however, at the
time of the annual compliance review had one night RN vacancy and these shifts were covered
by current staff to ensure coverage.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 39 of 64 (Revised August 2025)
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has a policy and procedures, and treatment protocols, which were written and
authorized by the DHA. A review of the policy, procedures, and treatment protocols confirmed
the facility administrator (FA) and designated health authority (DHA) signed and dated them all
on July 5, 2025. T. Each nurse reviewed, signed and dated the cover page on which all FOPs,
healthcare protocols, and other procedures were listed. The program did not have any newly
hired nurses during the annual compliance review period.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures to ensure each youth has a valid Authority for
Evaluation and Treatment (AET). A review of five youth Individual Healthcare Records (IHCRs)
was conducted and confirmed each IHCR contained a valid AET signed by the parent/guardian
and a department representative. None of the youth were over eighteen years old, needed a
court order for treatment authorization, nor were they in the care of the Department of Children
and Families (DCF). The nursing staff interview confirmed the program’s policy and procedures
to obtain an AET.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure parental notification/consent is obtained for
youth treatment beyond the scope of the Authority for Evaluation and Treatment (AET). A
review of five youth Individual Healthcare Records (IHCRs) was conducted. Three of the five
IHCRs confirmed new medication was ordered; the remaining two had no new medication. Each
IHCR contained documentation of the program’s notification to the parent/guardian prior to
youth receiving any treatment beyond the coverage of the AET, including when new medication
was ordered. The written notifications were sent utilizing the Department’s Parental Notification
of Health-Related Care: General or Parental Notification of Health-Related Care: Medications
forms or the Acknowledgement of Receipt of the Clinical Psychotropic Progress Note (CPPN)
when documented on the CPPN. Four of the five IHCRs contained parental notification and
consent for each youth to receive the treatment; the remaining IHCR contained a parental
decline of treatment at the time of notification. Three of the five youth were taking psychotropic
medication at admission, one of the remaining two youth was placed on psychotropic
medication after admission, and the remaining youth was not applicable for psychotropic
medication. Four of the five IHCRs contained a second staff signature as witness for all
progress notes for contact made with the parent/guardian regarding psychotropic medications;
the remaining IHCR was not applicable. Two of the five youth were applicable for
parent/guardian verbal consent of new psychotropic medication, an adjustment, or
discontinuation; the remaining three were not applicable. Both applicable youth had the required
documentation within the IHCR on the CPPN as required. None of the youth were in the care of
the Department of Children and Families (DCF). All five reviewed IHCRs contained
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Office of Accountability and Program Support Page 40 of 64 (Revised August 2025)
documentation of the verification of vaccinations within thirty days of admission. One of the five
vaccination records were verified to be missing a required vaccination, and the parent/guardian
was contacted for consent as required; the remaining four had all required vaccinations noted.
The parent/guardian was sent a notice of missing vaccination three times since admission;
however, there has not been an approval or decline received at the time of the annual
compliance review week. The nursing staff interview confirmed parent/guardian verbal consent
is required at the time of the doctor’s order and within twenty-four hours by mail for all
medications, activity restrictions, and medical procedures. For an emergency or life-threatening
illness/injury notification is made to the parent/guardian, facility administrator (FA), designated
health authority (DHA), and the Department’s Central Communications Center (CCC). When
new psychotropic medication is ordered, the parent/guardian is contacted by telephone and it is
documented on the CPPN, and then the CPPN is mailed to the parent/guardian. Vaccination
records are obtained through the Department of Health’s Florida Shots website and verified at
admission. Youth can receive vaccinations on-site, if needed.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures to ensure youth receive a health screening at
admission. A review of five youth Individual Healthcare Records (IHCRs) was conducted. Each
IHCR contained a Facility Entry Physical Health Screening (FEPHS) completed by a registered
nurse (RN) on the date of admission. None of the youth were out of the care and custody of the
program for greater than twenty-four hours. The nursing staff interview confirmed the program’s
procedures for youth health screenings at admission. The nursing staff receives an email
notification for each admission.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures to ensure all youth receive an orientation about the
program’s health services and health education. The orientation consists of the required topics:
access to medical care, sick call, definition of a medical emergency, medication process, right of
refusal, post-sexual assault steps, non-disciplinary healthcare staff role, and standard universal
precautions. The program’s contract was reviewed for topics and frequency of health education
requirements, which is monthly on a rotating schedule. The program’s health education
contained, at a minimum, the required topics: seatbelt use, substance abuse problems, sexually
transmitted diseases, tobacco use, dental care, basic hygiene, immunizations, infection control,
violence prevention, nutrition, physical fitness, self-examination, parenting skills, pregnancy
education, and chronic medication conditions.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 41 of 64 (Revised August 2025)
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to ensure the program’s designated health authority
(DHA) is notified regarding each admission. A review of five youth Individual Healthcare
Records (IHCRs) was conducted and each IHCR contained the DHA notification within twelve
hours of admission. Three of the five notifications included chronic condition(s); the remaining
two were not applicable. None of the youth required emergency care at the time of admission.
Three of the five notifications were made to the DHA and the psychiatrist for psychotropic
medications; the remaining two were not applicable. The nursing staff interview confirmed the
program’s DHA are notified at admission by the registered nurse (RN), and documentation in
the nursing admission progress note.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures to ensure all youth have a health-related history
(HRH) form completed after admission. A review of five youth Individual Healthcare Records
(IHCRs) was conducted and each IHCR contained an HRH completed within seven days of
admission. Each HRH form was completed prior to the Comprehensive Physical Assessment
(CPA) as evidenced by the signatures and date. The physician who completed the CPA made a
note of their review of the HRH form on the CPA. The nursing staff interview confirmed the
nurse completes the HRH at admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures to ensure each youth receives a comprehensive
physical assessment upon admission. A review of five youth Individual Healthcare Records
(IHCRs) was conducted. Each IHCR confirmed a physical assessment was completed by a
physician documented on the Department’s Comprehensive Physical Assessment (CPA) form.
Each CPA was completed within seven days of admission and contained all required elements
to include the Medical Grade at admission. Each element had the required marking and refusal,
if applicable, on the form. Each observed youth refusal was noted and had a completed youth
refusal form in the IHCR. All youth medical issues were noted on the Department’s Problem
listed as required. Each reviewed IHCR had at least one verified tuberculosis (TB) test, and the
TB results matched the notation on the CPA and the Infectious and Communicable Disease
(ICD) form. The nursing staff interview confirmed the program’s process for completing the
CPA, TB test/results, and documentation.
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4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures to ensure all youth are evaluated for sexually
transmitted infections (STIs), including human immunodeficiency virus (HIV). The policy and
procedures reflect HIV results are only disclosed to the youth and entities outlined in Florida
Statute. A review of five youth Individual Healthcare Records (IHCRs) was conducted and
confirmed each youth was evaluated for STIs/HIV on the date of admission. Each youth was
referred for a STI test and was tested at admission. The testing results were documented on the
Infectious and Communicable Disease (ICD) form and filed in each IHCR. None of the youth
were out of the Department’s physical custody. Each youth was offered HIV counseling, testing,
and if applicable treatment/referral. One of the five youth proceeded with the HIV testing and
had documentation of consent, results being filed in a sealed envelope marked “Confidential”
with proof of review by the practitioner, as well as the results not being noted in the alerts; the
remaining four youth declined. The program has a policy and procedures for HIV test results
and disclosure with all the required elements. HIV pre- and post-test counseling services are
provided by the designated health authority (DHA) or Department of Health staff. Five youth
were interviewed, and each confirmed they can request an HIV test. The nursing staff interview
confirmed the program’s policy and procedures for STI/HIV testing. At admission each youth is
tested for STIs and offered HIV testing. If further evaluation is required, the DHA will complete
the order. The results are documented on the Department’s ICD form and the lab results are
filed in the IHCR. HIV results are maintained in the IHCR within a closed envelope. When a
youth request HIV counseling and testing, a consent is signed by the youth, the request is noted
in the HIV log, and nursing staff schedules the testing and counseling. The counseling is
provided by a contracted service provider.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures to ensure all youth can request medical care within a
reasonable amount of time. A review of five youth Individual Healthcare Records (IHCR) was
conducted and confirmed none of the youth presented with similar sick call complaints three or
more times within a two-week period. There was a total of seven sick calls among the five
reviewed IHCRs. Each youth and a registered nurse (RN) completed a sick call request form for
each incident, and the forms were filed in the appropriate IHCR in reverse chronological order.
Four of the five youth were in restricted housing during the annual compliance review period;
the remaining youth was not. Each of the youth in restricted housing had documentation in their
IHCR regarding the nursing staff daily check of youth. The program’s policy instructs the nursing
staff to document the restrictive housing daily check on the episodic log. Each sick call was
documented on each youth’s Sick Call Index and the program’s Sick Call Referral Log, with
matching dates of service. The sick call forms or progress notes were documented in
accordance with The Health Service Rule. A review of the daily schedule, posted schedule, and
nurse interview confirmed sick call is conducted daily Monday to Sunday at 8:00 a.m. and
Monday to Friday at 2:45 p.m. Sick call hours are posted outside the clinic. Sick calls are
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conducted by RNs, and if an RN is not on-site the program does have procedures for
supervisory staff to review sick calls within four hours of the request. Youth can access sick call
forms from the staff’s binder located on each module and then place the form inside the sick call
box located on the modules. The medical clinic does have an examination table and equipment
to perform sick calls. A sick call was not observed during the annual compliance review week as
there were none placed while the annual compliance review team was on-site. Five youth were
interviewed about sick call access. Four of the five confirmed a sick call is addressed within one
day; the remaining youth said a sick call is addressed more than three days later. This youth
also stated sick call forms are torn up by staff and then they never get seen. The program
confirmed this youth had received sick calls as evidenced in the youth IHCR. The nursing staff
interview confirmed the program’s sick call process, procedures, and hours. Additionally, the
nursing staff noted in the interview any needed treatment would be ordered by the designed
health authority (DHA).
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures to ensure all youth have access to episodic/first-
aid/emergency care. A review of five youth Individual Healthcare Records (IHCR) was
conducted, and two IHCRs had documented episodic incidents; the remaining three did not.
One of the two applicable youth had two separate incidents, and the remaining applicable youth
had one incident. All three incidents used problem-oriented charting documented by a
registered nurse (RN) in each IHCR. An episodic care event was not observed during the
annual compliance review week. The program’s Episodic and Emergency Care procedures
were reviewed. The first-aid kits were located in the West and East sub control rooms with the
suicide kits, and one in the kitchen. There are two first-aid kits located in master control for use
during transportation. The nursing staff conducts monthly monitoring checks to ensure each kit
has all the required items and each item is not expired. A review of three first-aid kits was
conducted and found each kit contained all of the required items and all items had a future
expiration date. The program has one automated external defibrillator (AED) and it is located in
the break room, a central location in the facility. The AED procedures are located with the AED.
The licensed healthcare staff check the batteries and pads. The program staff conducted a self-
test of the AED in front of the annual compliance review team and there were no issues with the
test. The batteries and pads were last changed in March of 2024, and current batteries expire
December 26, 2025. The pads expiration date is October 31, 2025. The list of emergency
numbers was posted and accessible for non-licensed and licensed staff but not accessible to
youth. Each of the eight reviewed pre-service staff were appropriately trained on the
administration of the epinephrine auto-injector, episodic, first-aid, Narcan, and emergency care.
There were no episodic care incidents to observe during the annual compliance review week. A
review of medical drills was conducted and found the program conducted seven medical drills
on each of the three shifts during the annual compliance review period: twenty-one in total. Drills
were announced and unannounced and conducted at least quarterly. Documentation confirmed
direct care staff participated in at least one drill which included cardiopulmonary resuscitation
(CPR) and a “man-down” drill; however, video review was not available as none of the drills had
been conducted within the last thirty days. The program stated the staff simulate each drill. The
program has a policy and procedures for the use and access of Narcan. Staff are trained by a
registered nurse (RN) on recognizing and treating symptoms of overdose. The training includes
risk factors for overdose, strategies to prevent overdose deaths, and response. The program
has one box with two doses of Nacan in the locked medical cart, and seventeen boxes, with two
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doses each, in the locked medical storage room. The inventory is conducted weekly. The
supervisory and nursing staff have access to the Narcan. Eight supervisory staff have
documented Narcan training. Five youth were interviewed and confirmed they are able to ask to
see the dentist or the doctor. Five staff were interviewed and three stated they do not have
telephones on the floor, so they call a code or ask the master control staff to call 9-1-1; the
remaining two staff stated they are allowed to call 9-1-1. The nursing staff interview confirmed
the locations of the first-aid kits, the documentation process for episodic events including
transport and designated health authority (DHA) logs, AED location and check log, and medical
drill frequency.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures to ensure referrals and coordination of medical care
is completed in a timely manner. A review of five youth Individual Healthcare Records (IHCR)
was conducted, and two IHCRs had off-site care/referrals; the remaining three did not. One of
the two applicable youth had two separate incidents, and the remaining applicable youth had
one incident. All three incidents had a Summary of Off-Site Care Consultation Report form used
to document the event, each was filed in the appropriate IHCR, and was documented on the
Episodic Care Log. The documentation for each event included parent/guardian notification,
discharge documents, and the designated health authority’s (DHA) review of the documentation.
Two of the three reviewed incidents required follow-up care; the remaining one did not. Both
applicable incidents had the required follow-up noted in the IHCR; one of the follow-ups was
completed during the annual compliance review week. The nursing staff interview confirmed the
nursing staff utilize the transport and DHA logs when youth are sent off-site for care. The DHA is
notified upon the youth’s return to the program, then reviews the discharge information, and the
nursing staff flag the documentation for the DHA’s signature when they are on-site next. The
nursing staff utilize a calendar and the DHA log to track follow-up care.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure youth identified with chronic conditions are
scheduled for regular evaluations and follow-up. A review of five youth Individual Healthcare
Records (IHCR) was conducted, and three were applicable for chronic conditions; the remaining
two were not. All three applicable IHCRs had chronic conditions identified on the Facility Entry
Physical Health Screening (FEPHS). One of the three youth was identified as taking prescribed
medications on an on-going basis for a medical condition, one youth had a medical condition,
and all three were identified with food allergies. Two of the three youth had a Medical Grade
between 2 to 4; and the remaining youth had a Medical Grade of 5 due to the psychotropic
medication they were also taking. Each youth was placed on the program’s chronic illness list
and the Department’s Problem List was updated in each IHCR. Two of the three youth had the
required periodic evaluation prior to renewing medication; the remaining youth was not due for
the periodic evaluation as of the annual compliance review week. None of the youth were
applicable for anti-tuberculosis (TB) medication, communicable disease, undergoing treatment
for physical health condition, or pregnancy evaluations. The facility administrator (FA) was
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interviewed and confirmed medical staff are present each morning to speak about the
importance of medical issues pertaining to the youth, updating the alert board and alert binders,
and sending daily emails regarding alerts. The nursing staff interview confirmed the program’s
internal alert systems. The designated health authority (DHA) interview confirmed youth with
chronic conditions have an evaluation every ninety-days or less if needed and the medical clinic
utilizes a tracker to maintain the schedule.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a policy and procedures to ensure all medications are received, stored,
inventoried, and administered safely and effectively. A review of five youth Individual Healthcare
Records (IHCR) was conducted. Three of the five were admitted to the program with
medications as documented on the Facility Entry Physical Health Screening (FEPHS); the
remaining two youth were not. All three applicable records contained documentation, in the
chorological progress notes and on the required form, the medication was verified prior to
admission, and the designated health authority (DHA), and/or the psychiatrist, was contacted to
obtain an order to continue the medication. After admission, another of the reviewed youth was
placed on medication; the remaining youth was not. In all four applicable IHCRs, each
medication had a current and valid order. Two of the four applicable youth were placed into
restricted housing on multiple occasions as a result of behavioral incidents while in the program,
and each IHCR contained documentation to confirm both youth were still provided with their
medication as ordered. Two of the five reviewed IHCRs contained documentation of over-the-
counter (OTC) medications not listed on the Authority for Evaluation and Treatment (AET) were
administered according to the approved protocols; the remaining three IHCRs were not
appliable. All five reviewed IHCRs contained the Department’s Standard Medication
Administration Record (MAR) utilized to document all medication and treatment with all the
required elements completed in its entirety, to include the staff’s initials at each administration
and a minimum of weekly side-effect monitoring. There were no incidents of non-licensed staff
administering mediation nor any lapses or errors in medication administration observed. Each
youth refusal of procedures or medication administration was documented on the MAR and the
IHCR contained a completed youth refusal form. None of the reviewed IHCRs contained
documentation of parenteral medication ordered. The program does not have any standing, pro
re nata (PRN), nor emergency treatment orders for psychotropic medication. Medication
delivery is the sole responsibility of the nursing staff at the time of administration. An
observation of medication administration was completed during the annual compliance review.
Medication pass is conducted at the door of each module. The youth was escorted out of the
doorway into the hallway and stood in front of the nurse and the medication cart with a staff. The
nurse prepared and administered the medication to the youth after the youth confirmed their
name, date of birth, and the medication they were expecting to receive, and the nurse confirmed
any allergies and alerts. The nurse, with the staff present, watched the youth take the
medication and then observed the youth’s open mouth to check for cheeked medication. No
medication was pre-poured or removed from the original packing prior to the youth standing at
the cart. The Six Rights of Medication Delivery/Administration were verified. Five youth were
interviewed about the staff administering medication. Two of the five youth confirmed the nurse
provides their medication; the remaining three youth stated they do not take medication. The
three youth who stated they do not take mediation were referring to prescribed medication at the
time of med pass. The nursing staff interview was conducted and confirmed the program’s
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process for youth admitted with medications. The program utilizes the Department’s MAR form.
The nurse manager stated there are program administration and supervisory staff who can
administer medication; however, the program has twenty-four hours a day, seven days a week
nursing coverage when fully staffed. Currently the program has one night shift vacancy.
Medication pass hours were confirmed in the nurse interview: every day at 7:00 a.m., 1:00 p.m.
and 7:00 p.m. The nurse manager also confirmed the psychiatry services and time frames, and
a separate fee is not charged for each youth for services.
4.17 Psychiatric Services Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a policy and procedures to ensure psychiatric services are available for youth
with diagnosed mental disorders and youth receiving psychotropic medications. The program
has a psychiatrist with a clear and active license who is available, as required, twenty-four hours
a day, seven days a week. For each youth receiving psychiatric services, the psychiatrist
provides briefing of status and services rendered to the youth’s treatment team. The evaluation
and recommendation from the psychiatrist are utilized by the clinical mental health staff when
formulating and reviewing the youth’s treatment plan. The program utilizes a psychiatric
advanced practice registered nurse (APRN) with a clear and active license, and the required
education, experience, and certification, as a back-up. The APRN works under a Collaborative
Practice Protocol with the psychiatrist, and a copy is maintained on-site at the program. During
the annual compliance review period, the program has utilized two other psychiatrists, both with
clear and active licenses. A review of the sign-in/sign-out log for the annual compliance review
period confirmed psychiatric services were rendered in accordance with the contractual
requirements. The review of the documentation confirmed the psychiatrist is actively involved in
the management and supervision of the psychotropic medication services. The psychiatrist does
provide bi-weekly supervision of the APRN and is available by telephone and email when not
physically on-site. The contract was reviewed for tele-psychiatry requirements. The contract
does not include tele-psychiatry; however, the program did receive written approval from the
Department’s Office of Health Services to utilize tele-psychiatry services in lieu of on-site
psychiatry services. The psychiatrist interview was conducted and confirmed the psychiatrist is
providing the required services within the required time frames, is available as required,
participated in treatment team meetings, and meets with the clinical director (CD) at least
monthly. The CD interview confirmed psychiatric services are provided on a bi-weekly schedule
through tele-psychiatry. A review of five youth Individual Healthcare Records was conducted.
Three of the five were admitted to the program with current psychotropic medications; the
remaining two youth were not. All three applicable youth were referred for a psychiatric interview
and the medication continued. Each applicable youth had a diagnostic interview completed
within fourteen days of admission. Each diagnostic interview contained documentation of all
required elements and was documented on the required Department form. Each initial
psychiatric interview was documented on the Clinical Psychotropic Progress Note (CPPN) and
was clearly identified. All three applicable records continued documentation of medication
reviews at a minimum of every thirty days. When a psychotropic medication was added,
changed, or discontinued page three of the CPPN was completed in its entirety. All three
records contained a documented psychiatric evaluation within six months prior to admission and
an updated psychiatric evaluation was completed as required, and each updated evaluation
contained all the required elements, to include the documentation of the monthly Tardive
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Dyskinesia by the psychiatrist, psychiatric APRN and the nursing staff. All three applicable
IHCRs had the standard of psychiatric care delivered through telepsychiatry the same as
rendered in-person and it was only utilized for youth who agreed to participate in the
telepsychiatry session and the parent/guardian provided consent.
4.18 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures to ensure all medical sharps equipment and
medications are stored securely, correct inventory is maintained, and disposal is handled
properly. The program’s medications and sharps were observed to be secured in a designated
locked area, inaccessible to youth. Each medication and piece of equipment has a perpetual
and a weekly maintenance inventory. Medications were stored separately by delivery type. The
medication cart was observed to be clean and well organized by youth-specific medications.
The program had one controlled medication on-site, and this medication was stored separately
behind two locks and had a perpetual inventory. The controlled medication had a shift-to-shift
inventory maintained on the youth’s Individualized Controlled Medication Inventory Record as
required. The program did not have any refrigerated medication during the annual compliance
review week; however, a locked refrigerator designated for medication was observed. The
program utilizes medication destroying liquid for non-controlled medication which have expired
or were not returned to the pharmacist, which is stored in the locked medical closet. Controlled
medication is returned to the pharmacist for destruction. A review of training documentation
confirmed the program has seven supervisory-level, non-healthcare staff who received the
required training, by a registered nurse (RN), in delivery and oversight of medication self-
administration. A review of three over-the-counter medications, three sharps, and the one
available controlled medication was conducted. Each medication and sharp had documentation
to confirm the on-site inventory matched the inventory logs. An informal interview with the RN
manager confirmed any discrepancies located during inventory of medication or sharps will
prompt a recount for verification, and if the discrepancy is confirmed the program administration
and the Department’s Central Communications Center (CCC) are notified. The nursing staff
interview confirmed two RNs, or a RN and the pharmacist, sign off on all medication disposal
incidents; and controlled medications are delivered by the pharmacist, stored behind two locks,
and have a shift-to-shift inventory conducted by two RNs. The program has a current
agreement/contract with a local pharmacy, who maintains a properly licensed pharmacy
consultant, to ensure all medications are verified.
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 has a policy and procedures detailing the infection control plan which includes
prevention, containment, treatment, and reporting requirements related to infectious diseases
and is in accordance with the Occupational Safety and Health Administration (OSHA) federal
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regulations and the Centers for Disease Control and Prevention (CDC) guidelines. The
designated health authority (DHA) reviewed and signed the plan on January 1, 2025, and the
facility administrator (FA) reviewed and signed the plan on January 2, 2025. The infection
control and the exposure control plans are reviewed annually and were available for staff. The
infection control procedures included all required elements. Hepatitis B immunization is
available for staff and staff have access to protective equipment. The program did not have any
incidents in which the local health department, CDC and/or Department’s Central
Communications Center (CCC) should have been notified. There is a separate file maintained
for youth and staff who have experienced a facility/occupational exposure; however, the
program did not have any applicable. The program has a process for needle stick post-exposure
which includes documentation, collection/testing, counseling, communication and evaluations.
The nurse interview reported the Exposure Control Plan is available to the healthcare staff. The
infection control training is facilitated by the registered nurse (RN) or health service
administrator (HSA). The nurse reported youth at admission receive infection control training.
4.20 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures addressing how the programs maintains active
supervision of youth by closely observing youth behavior and changes in behavior, as well as
knowing the whereabouts of youth at all times, interacting positively with youth, engaging in
constructive activities and providing thorough observation of youth behavior while consistently
applying the program’s behavior management system. The program’s contracted supervision
ratio is one staff to six youth for the Borderline Intellectual Functioning/Developmental Disability
(BIF/DD) services during the day hours, and one staff to ten youth during sleep hours. Each day
of the annual compliance review week, program staff were observed to be actively supervising
youth during classroom activities, school breaks, head counts, movements, and outdoor
recreation activities. Staff were always positioned properly in a manner to supervise and interact
with all youth they were supervising and within the contractually required ratio. Interactions were
observed to be positive. Three staff were informally interviewed during these observations, and
all staff immediately knew the number of youth they were supervising. The program has a daily
youth activity schedule which was posted on all living units and throughout the program. During
the annual compliance review week, youth were observed to be engaged in a full schedule of
activities. The program did not have any escapes during the annual compliance review period.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program has a policy and procedures addressing the development, implementation, and
on-going maintenance of the behavior management system (BMS) by all appropriate parties,
including education. The policy also includes procedures where staff are provided with feedback
regarding the implementation of the BMS and wherein staff explain to the youth the reason for
any sanction imposed prior to the end of the staff’s work day, the youth is given an opportunity
to explain his or her behavior, and staff and the youth discuss the behavior’s impact on others,
reasonable reparations for harm caused to others, and alternative acceptable behavior. A
review of the program’s contract, policies, and BMS confirmed all appropriate parties, to include
education, were involved in the development, implementation, and on-going maintenance of the
BMS. The program and education provider have a joint plan related to the utilization of the BMS
in the classroom. Documentation and an informal interview with the facility administrator (FA)
confirmed the FA trained education staff on the combined BMS plan. A review of five youth case
management records confirmed each youth’s orientation included a review of the BMS. All
requirements of the BMS are also included in the youth handbook. Eighteen staff position
descriptions were reviewed for staff whose job functions include implementation of the BMS,
and all position descriptions included a requirement for the implementation of the BMS. Five
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pre-services training staff records were reviewed which confirmed each staff member received
training in the BMS. Observations during the week of the annual compliance review confirmed
the BMS was seen posted in all modules and in the multi-purpose room which is accessible to
youth and included the rules governing conduct and positive and negative consequences. The
program’s BMS has not been changed nor was in the process of being changed during the
annual compliance review period. The program’s written BMS includes four levels and
contained all required elements. The program has no contractually required special BMS
provisions. Observations made during the annual compliance review week confirmed positive
interactions between staff and youth and adherence to the requirements of the BMS. The
program provides a variety of rewards/incentives to include nightly privileges, “Super Monday,”
“Phat Friday,” and “Gotchas.” The BMS does not include an increased length of stay, denial of
youth’s basic rights or services, promotion of group discipline, punishment of youth by other
youth, or disciplinary confinement. All five interviewed youth were able to provide examples of
consequences the program has for bad behaviors. Four of five interviewed youth were able to
provide examples of rewards they can earn while at the program, the remaining youth indicated
they do not earn any rewards. Four of five interviewed youth stated staff are consistent in their
implementation of the BMS. The remaining youth stated different staff do different things. Each
of the five interviewed youth were able to articulate the difference between each level and how
to move from level to level. All five youth confirmed youth are not allowed to punish other youth.
Five staff were interviewed and all were able to articulate the programs BMS. Each of the five
staff were able to verbalize rewards which are provided as part of the BMS to include canteen,
pizza nights, snacks and gotchas. All five staff confirmed basic rights cannot be taken away
from youth as a consequence. Each of the five staff described ways youth are informed of
consequences and stated youth are able to explain their behaviors. The FA’s interview
confirmed the programs practice and implementation of the BMS.
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.
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 has a policy and procedures to ensure youth are observed at a minimum of every
ten minutes when youth are placed within their rooms. The program has 128 video cameras,
and all were operational during the annual compliance review week. Video coverage is stored
for thirty days. Staff are required to conduct room checks every ten minutes when youth are in
their rooms and document the check in real time along with the initials of staff conducting the
check. A random sample of ten-minute check sheets for each month of the annual compliance
review period found no more than ten minutes passed without the staff actively observing each
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youth and the staff completing the check initialed the check sheets. A video review of nine
different dates of ten-minute checks was compared to the ten-minute check logs. Eleven checks
were not completed as required. Two different youth rooms contained white paper covering the
window on the door, not allowing staff to observe the youth during a total of five ten-minute
checks, for four checks the staff member did not pause to look into the rooms, one check was
two minutes late, and one was not completed; however, the staff documented it was completed.
This falsification was reported to the Department’s Central Communications Center (CCC)
during the week of the annual compliance review. Five staff were interviewed and three stated
youth are checked every nine minutes while in their room and the two remaining staff stated
checks are completed every ten minutes. The facility administrator was interviewed and
confirmed the program has operational security cameras which store recordings for thirty days.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program has a policy and procedures which addresses population census, counts, and
tracking of youth. The policy requires counts to be conducted at a minimum at the beginning of
each shift and throughout the day to include after each outdoor activity and during any
emergency situations. The program tracks daily census information including at a minimum,
daily census count, new admissions, releases, transfers, and youth temporarily away from the
program. Observations during the annual compliance review week confirmed head counts were
conducted throughout the day. The program utilizes a master control logbook to document
youth counts, movements, and daily census. A review of program logbooks for one day each
month of the annual compliance review period reflected headcounts are being conducted at the
beginning of each shift, after recreation, total daily census counts, head counts, youth
movements, transfers, youth temporarily away from the program, and randomly throughout the
day. The program documented all census, counts, and tracking activities as required. Five staff
were interviewed, and all indicated how and when youth counts are conducted. Each of the five
interviewed staff were able to explain when emergency head counts are conducted and the
procedures when a youth count cannot be reconciled.
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5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures addressing logbook entries. The program maintains
one master control logbook which documents a chronological record of events. The program
logbooks are bound with numbered pages. All reviewed entries were made in ink with no
erasures or white-out area. None of the reviewed logbooks had any entries removed or
destroyed. All reviewed entries with errors were struck through with a single line and initialed by
staff as required. All reviewed entries included the dates and times of events, the names of staff
and youth involved, brief descriptions of the events, and the names and signatures of the staff
making the entries. Two dates had incidents reported to the Department’s Central
Communications Center (CCC), which were documented in the logbook. A review of shift
reports indicated the program maintains them in the modules for forty-eight hours, summarizes
the events, incidents, and activities documented in the program’s central logbook, and the
incoming staff sign and date the shift reports for the previous shift to document they reviewed or
were verbally briefed about its contents. Logbook entries required and documented two
emergency drills. There were no incidents including the use of mechanical restraints or escape
or escape attempts, and requests by law enforcement to access any youth. One sample
required and documented an incident of special instructions for supervision and monitoring of
youth. All reviewed samples had population counts at the beginning and end of each shift, and
any other population counts conducted during a shift, perimeter security checks and other
security checks conducted by direct care staff, three transports away from the facility, including
the names of the staff, youth involved, and the destination. The reviewed samples also included
two incidents of removal of youth from the mainstream population, and four admission/releases,
including the name, date, and time of anticipated arrival/departure and mode of transportation
were documented.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures to govern the control and use of keys. The program’s
policy and procedures include key assignment and usage, restrictions on usage, inventory and
tracking, secure storage of keys when not in use, procedures for missing or lost keys, and
reporting and replacement of keys. The program’s policy lists the position titles who can be
issued permanent keys with written authorization of the facility administrator (FA). An
observation during the week of the annual compliance review verified when entering the
program, master control staff are required to sign, date, and list the program key number on a
key log and secure the personal key in a lock box. When leaving the program, master control
staff are required to sign the log and key sheet to show the program key was returned. Any staff
who are issued permanent keys must sign the Key Responsibilities form prior to being issued
permanent keys. The policy details which staff can have access to restricted keys and which
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areas those keys can access. The policy states any damaged keys should be reported to the
shift supervisor and returned to the assistant facility administrator (AFA), who will be responsible
for discarding the key, updating inventories as applicable and issuing of replacement keys.
There were no incidents reported to the Department’s Central Communications Center (CCC) or
Program Monitoring and Management (PMM) system related to key control concerns. An
informal interview with the master control operator indicated the restricted keys are only
accessible to authorized staff who are assigned to specific job functions requiring restricted key
use. The program uses a sign in/sign out log for daily tracking and reconciliation of keys. The
program’s key storage includes three gray key lock boxes, which are not accessible when
locked, with hooks and labels for each key ring which corresponds to the key inventory. The
program’s key storage area is located in master control. A review of the key inventory and a
sample of five staff key rings revealed the key inventory correctly matched the keys on the five
reviewed key rings. An informal interview of three staff revealed all three staff were able to
correctly list the number of keys they had on their key ring and know the function of each key.
All five interviewed staff were able to articulate the process for storage of personal and program
keys from the beginning of shift until end of shift, where they are stored, and how program keys
are assigned.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures addressing program safety and security and to
control the introduction of materials considered contraband into the program. The program has
a system in place to prevent contraband from entering the facility and clearly describes those
items considered to be contraband. The program’s system and policy include all required
elements. The program’s policy specifies law enforcement will be contacted if any found item
would be considered illegal as defined by Florida Statutes or if there is any suspicion of unlawful
activity. The program’s facility visitor log contains a contraband attestation statement. All newly
hired staff are required to sign contraband attestation forms upon hire. A review of personnel
records for the twenty-four newly hired staff, since the last annual compliance review, confirmed
each staff member signed an attestation form upon hire. The program’s policy includes staff
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found in possession of contraband in the program are subject to disciplinary action up to and
including dismissal as outlined in Florida Administrative Code. A review of documentation
confirmed the program documents the confiscation and disposition of any contraband. The
program did not have any illegal contraband turned over to law enforcement during the annual
compliance review period. An informal interview with the assistant facility administrator (AFA)
indicated there was one incident during the annual compliance review period of non-illegal
contraband being discarded. The program followed all required protocols to include calling the
Department’s Central Communications Center (CCC), notifying law enforcement, and securing
the contraband; however, the AFA indicated law enforcement did not take possession of the
broken vape pen charger and it was later discarded off-site. A review of logbooks, incident
reports, and search reports confirmed the program completes searches of program areas daily.
An interview with the facility administrator (FA) confirmed the program’s practice involving
contraband. Five staff were interviewed and three stated searches are conducted daily, one
staff stated room searches are conducted at random and scheduled, the remaining staff
member stated searches are conducted supervisory staff and is not sure of the process.
5.09 Searches and Full Body Visual Searches Limited Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures to ensure the program performs searches and full
body visual searches. The program conducts searches as a method to prevent the introduction
of contraband and unauthorized items into the facility. The annual compliance review team
observed several youth searches during the week of the annual compliance review including
transition to and from school, moving from the module to treatment team meetings, to
recreation, and back to the module. The program did not have any admissions, transports,
visitations, off-campus activities, nor was there an observation of youth access or ability to
obtain tools during the annual compliance review week. Searches were conducted by staff of
the same gender as the youth, while a second staff member assisted with supervision. Search
procedures and expectations were properly explained to all youth before searches were
conducted. Searches were thorough and completed in a manner to minimize the youth’s stress
and embarrassment. Searches were conducted as required by the Right Interactions (RI)
training manual. Video review of five random days of staff and visitor searches found three days
searches were not completed as required. On two days two staff entered the search area of the
program, and their belongings were not thoroughly searched prior to entering the secure area,
and the remaining day a visitor’s bag was not searched prior to entering the program. Five staff
were interviewed, and all confirmed youth are searched before and after every movement. Five
youth were interviewed, and all youth confirmed youth are searched before and after every
movement.
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.
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The program has a policy and procedures to ensure any vehicle used by the program to
transport youth is properly maintained and documentation regarding the use and maintenance
of each vehicle is kept. The program utilizes one van for youth transports; however, the program
has two assigned vans. An informal interview with the assistant facility administrator (AFA)
indicated only one van has a safety screen and is the only one utilized to transport youth. A
random check of five staff vehicles and both program vans was completed to ensure vehicles
were locked when not in use. All vehicles were locked as required. Both vans passed their
annual inspections and documentation confirmed regular maintenance was completed. The
program is a high/secure program; therefore, a safety screen is required and only the youth
transport van had the safety screen. An observation during the annual compliance review week
confirmed both vans have all required equipment, which included the appropriate number of
seat belts, a seat belt cutter, window punch, and fire extinguisher. The AFA stated both first-aid
kits are maintained at master control to preserve the integrity of the supplies, and an
observation confirmed this practice. All seatbelts in the van were in proper working condition.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures to ensure the 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’s policy includes all requirements outlined
by the Department relating to transportation of youth and driver eligibility. A review of the
program’s policy and procedures, and interviews completed during the annual compliance
review week, confirmed the program provides a program issued cellular telephone for all
transports. There were no scheduled transports during the week of the annual compliance
review; therefore, an observation was unable to be completed. The program’s human resources
(HR) office completes driver’s license checks from the Department of Highway Safety and Motor
Vehicles (DMV) on all newly hired staff and subsequently obtain monthly driving record
information to ensure all staff operating a program vehicle have a current driver’s license and
reviewed documentation confirmed this practice. The policy states HR shall notate all staff
within the Department’s Staff Verification System as designated transportation staff. The policy
further states youth are not permitted to drive program or staff vehicles. Five youth were
interviewed and three confirmed they have never been handcuffed to any part of the vehicle
during a transport and the remaining two youth indicated they have never been on a transport.
None of the youth have seen anyone place contraband in a transport vehicle. Five staff were
interviewed and two had never completed a youth transport; therefore, they could not articulate
the procedures relating to youth transport. The remaining three staff stated youth are secured
within the vehicle by seatbelts and are handcuffed during transport, and the program provides
radios and cellular telephones for all transports. Additionally, the remaining three staff stated
emergency equipment to include first-aid kit, window punch, fire extinguisher, and seat belt
cutter are in the transport vehicles. All five interviewed staff stated staff cannot use their
personal vehicles to transport youth and all transport vehicles are searched for contraband prior
to and after each use. The three staff who had participated in transports were able to detail the
emergency response and the required staff to youth ratio during a vehicle transport. Four staff
indicated the vehicle used for transport does have a safety screen, the remaining one staff
stated they never been on a transport and was not sure. An interview with the facility
administrator (FA) confirms the program’s transportation practice.
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5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures requiring the program maintain a safe and secure
physical plant, grounds, and perimeter. The programs assistant facility administrator (AFA) is
responsible for conducting weekly safety and security audits and the implementation of any
corrective action warranted as a result of any deficiencies found during the weekly audits. The
weekly safety audits are kept in a binder in the AFA’s office. Findings are discussed and a
corrective action plan is implemented to fix any deficiency noted and submitted to the
Department. The program’s policy meets the requirements outlined in Florida Administrative
Code. During the annual compliance review week reviewed documentation confirmed weekly
safety and security audits were conducted during the annual compliance review period and any
identified deficiencies were documented on the reports including the status and due date of any
needed corrective action. All forms were reviewed and signed by the AFA. A review of the
program’s Preventative Maintenance Checklist forms for the annual compliance review period
indicated inspections were completed, as required, and documented deficiencies and repair
updates were conducted. The interview with the facility administrator (FA) indicated the program
completes a key performance indicator report based on the reported information from each
morning meeting report, and this information is totaled each month and compared to the
previous month. A meeting of the management team is conducted to plan how to reduce
deficiencies. The program also uses internal interviews completed by corporate staff to verify
deficiencies are being reduced.
5.13 Tool Inventory and Management Failed Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures addressing the issuance, inventory, and control of
equipment and tools, missing/lost tools, and dysfunctional tools and their disposal. The policy
confirms machetes, bowie knives, or other long blade knives are prohibited. The maintenance
supervisor indicated when a tool is dysfunctional, it is disposed of according to policy. He further
stated they have not had any lost or missing tools since the last annual compliance review. A
review of tool inventory for the program’s maintenance shed since the last annual compliance
review confirmed a perpetual inventory is kept anytime a tool is used and a daily inventory is
maintained. Ten tools were compared to the tool inventory and two were not able to be located
in the maintenance shed. Two screwdrivers in the toolbox drawer had no identification markings
and were not on the tool inventory. There were also multiple tools in the maintenance shed not
found on the tool inventory; specifically, two shovels, a drill bit set, and an Allen-wrench T-
handled set. Multiple tools had no label/inventory number or any identification markings on the
items and were not located on the inventory list. The current inventory was not completed on
Class A tools for two days of the annual compliance review week. An observation of
tools/kitchen utensils was completed. Multiple items in the kitchen had no label/inventory
number or any identification markings on the items. The program maintains an inventory of
knives, cooking spoons, spatulas, whisks, and pizza cutters; however, not all cooking spoons,
ladles, and whisks are documented on the inventory, despite they are the same utensil type.
Five kitchen tools were compared to inventory and found one of two spatulas were not on hand.
The kitchen’s perpetual inventory indicates only one utensil is used daily, making it unclear if all
items utilized each day are documented on the inventory as they are utilized. The daily kitchen
tool inventory did not contain all items which were on-site, specifically, three large knives, one
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small knife, and two metal peelers were not on the inventory list; however, were securely
maintained. The kitchen inventory was not completed on one day during the annual compliance
review week.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures including the issuance of tools, staff to youth ratios,
tool distribution, and search criteria involving work projects. The policy states the ratio is one
staff to five youth during a work project involving youth; however, the assistant facility
administrator (AFA) indicated the program does not utilize youth for any work project involving
class A tools. A review of five youth case management records confirmed each youth received
training in the intended and safe use of tools. Five staff were interviewed, and each stated youth
are only permitted to use scrub brushes, mops and brooms. One staff added youth are
permitted to use these items only after a youth is cleared as a safety risk. Five youth were
interviewed and four stated they are permitted to use mops and brooms. One youth further
stated youth need to be on a certain level before being permitted to use mops or brooms. The
remaining youth stated they are not permitted to use tools.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures establishing guidelines for outside contractors
regarding tool control and restrictions. The physical plant manager is responsible for monitoring
all tools and sensitive items at the facility. The policy states outside contractor tools are limited
to only those necessary, all tools are checked upon and prior to exiting the program, youth
access to work areas must be restricted, and all contractors must sign a written notification and
attestation form and tool inventory list upon arrival. The policy also includes a follow up if any
tools are missing and restrictions on personal cellular telephones and/or equipment capable of
taking pictures or video recording. Contractors are escorted and supervised by the physical
plant manager or designee any time they are within the facility. A review of three project
invoices showed the vendors signed contractor agreements and an inventory of tools was
completed and documented. Reviewed outside contractor logs confirmed the program reviewed
the inventory or equipment when the vendor arrived and left. The program's policy states the
facility administrator is responsible for providing approval and permissions for personal cellular
telephone and/or equipment/electronic devices capable of taking pictures and audio or video
recordings, including smartwatches.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a policy and procedures addressing fire, safety, and evacuation drills. A
review of the Continuity of Operations Plan (COOP) drills revealed the program was conducting
monthly drills on a rotating basis as required on each shift during the annual compliance review
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period. Each reviewed drill included the type of drill, date and time, participants, a brief scenario,
and recommendations. The program had twenty-four fire extinguishers. All fire extinguishers
had been inspected in the last six months and were valid, with another inspection due by the
end of September 2025. All inspections are conducted every six months, rather than annually.
Five of the twenty-four extinguishers observed had monthly checks missing. One fire
extinguisher located in a utility room outside, and the spare reserve fire extinguisher did not
have any monthly checks conducted. In another outside utility room and the two vehicles fire
extinguishers were missing two monthly checks each. Fire evacuation routes and egress plans
were posted throughout the facility. There were three identified locations which did not have
evacuation routes which were in two modules and the multi-purpose room. The program was
notified during the annual compliance review week of the issue and took corrective action
posting evacuation routes in all three locations which was observed and verified by the annual
compliance review team. An interview conducted with the facility administrator (FA) indicated
the program conducts monthly fire/medical/suicide drills on all three shifts, COOP and
operations drills monthly, and quarterly mental health drills on all three shifts. Five youth were
interviewed, and each confirmed they had been instructed on what to do in case of a fire and
had participated in fire drills. Two youth stated they participate in drills monthly, two youth stated
they participate in drills every few weeks, and the remaining youth stated most weekends. Five
staff were interviewed and all five stated they had participated in drills to include fire, weather,
escape and medical and mental health drills.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program has a policy and procedures addressing the Continuity of Operations Plan
(COOP). The program maintains a combined COOP and Emergency Disaster Preparedness
Plan. An informal interview with the assistant facility administrator (AFA) indicated the COOP is
readily available to all staff, and is in master control, the facility administrator’s (FA) office, and
conference room, and observations during the annual compliance review week confirmed this
statement as well as confirming it is readily available to staff. The plan addresses alternative
relocation sites approved by the applicable Department regional director/designee. The COOP
was last approved on January 10, 2025, and submitted for approval to the Department on
March 20, 2025. The COOP addressed the following: fire prevention and evacuation, severe
weather, disturbances or riots, bomb threats, hostage situations, chemical spills, flooding,
terrorist threats or acts, staff roles and responsibilities, any equipment and supplies needed,
information about youth which may be needed, alternative housing arrangements, provisions for
continuity of care and custody of youth, and provisions for public protection. An informal
interview with the AFA indicated the emergency supplies consist of batteries, flashlights, radios,
canned food, and gloves. The equipment and supplies required for continuous operation and
services during emergencies or disasters are in the administration office, medical office, and
kitchen. The program maintains identifying information on each youth in the program in the FA’s
office, and if the program must evacuate the youth record accompanies the youth to the
temporary location, or in the event needed information cannot be accessed electronically.
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Reviewed documentation confirmed the program maintains critical identifying information in
hard copy binders including case management, and medical information. The program’s hard
copy records are easily accessible and mobile in the event of an emergency resulting in the
program relocating quickly or in the event needed information cannot be accessed electronically
for all youth in the program. The equipment and supplies required for continuous operation and
services during emergencies or disasters were also observed in designated areas including in
the administration office, medical office, and kitchen. Five youth administrative hard copy
records were reviewed which contained each youth’s name, a photograph, Department
identification number (DJJID), admission date, date of birth, gender and race, overall health
status and physician information, address, and parent/guardian contact information which
included name, address, telephone number of the person with whom each youth resides and
their relationship to each youth, and person(s) to notify in case of an emergency. In addition, the
hard copy records contained the youth’s assigned juvenile probation office (JPO), committing
judge, state attorney, and public defender. Each record contained the committing offense and
judicial circuit where offense occurred, notation of whether or not the judge retains jurisdiction,
victim notification contact information, physical description of youth to include height, weight,
eyes and hair color, and any identifying marks. An interview with the FA confirmed a copy of the
COOP is in the FA’s office, and in master control.
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous,
Failed Compliance
and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures addressing the process for chemical spills, disposal,
storage, and inventory of flammable, poisonous, and toxic items and materials. The program
maintains a list of staff who are authorized to dispose of chemicals and who have access to
chemicals. The program’s policy and procedures related to the disposal of chemicals was in
accordance with the Occupational Health and Safety Act (OHSA) Standards. An interview with
the facility administrator (FA) confirmed the program uses all of the chemicals/cleaning products
in their entirety, requiring no unused chemicals to be disposed of by the program. As a result,
the program does not maintain a disposal log. The FA explained a local company disposes of all
kitchen grease, which is stored in a grease trap until the company arrives for pickup. All liquid
waste, such as dirty mop water, unused beverages and kitchen liquid waste are disposed of in
the program’s drains. The program did not have any chemical spills requiring them to activate
the program’s procedures regarding chemical spills. A review of all chemicals during the week
of the annual compliance review confirmed each was secure and inaccessible to youth. A
comparison of chemicals in the kitchen’s chemical cabinet to the kitchen’s chemical inventory
confirmed there were only four chemicals on the inventory list; however, there were nine
additional chemicals in the cabinet. The inventory form is pre-printed and a review of all
inventories, since the last annual compliance review, confirmed none of the nine additional
items were on any of the kitchen’s chemical inventory lists. Only one of the four observed
chemicals was documented accurately on the corresponding inventory. A binder was in the
same cabinet containing a Safety Data Sheet (SDS) for three of the four reviewed chemicals
located on the inventory. A review of the inside chemical closet confirmed there were six small
caddies, one for each module, containing three bottles of chemicals in each caddy. A review of
the chemical’s perpetual inventory confirmed the inventories were maintained for each bottle of
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chemical since the last annual compliance review. A binder was in the inside chemical closet
containing a SDS sheet for each of the three chemicals. There were also nine large bottles of
chemicals, two different types, not listed on the inventory located in the chemical closet. An SDS
sheet was in the SDS binder for both types of chemicals. A comparison of ten different
chemicals in the maintenance shed to the maintenance shed chemical inventory confirmed each
was listed: however, only two matched. The inventory is not documented when items are used;
therefore, the amount on the inventory was not accurate. According to the maintenance
supervisor, inventory is captured at the end of each month and then the following month any
new deliveries which arrive in the current month are captured; then all chemicals are counted
again at the end of the month. There is no way to tell how many chemicals are on-site at any
given time throughout the month, except for the last day of each month, when the inventory is
completed. Two of the ten reviewed chemicals did not have a SDS sheet. Further observation of
the maintenance shed found multiple chemicals in the drawer cabinet, where tools are kept,
which were not on the inventory.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures to ensure strict control of flammable, poisonous, toxic
items and materials. The program’s policy prohibits youth handling, using, or disposing of any
dangerous/hazardous chemicals, bio-hazardous material, bodily fluids, or human waste. All
chemicals are stored in a locked storage closet inaccessible to youth. The annual compliance
review team was unable to observe youth during cleaning activities involving chemicals due to
youth not being allowed access to any chemicals. The facility administrator (FA) was
interviewed and was able to explain the program’s disposal practice and indicated the program
only purchases what is used and has not disposed of any items. Five youth were interviewed,
and each confirmed they do not handle any chemicals to include cleaning supplies.
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;
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• 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
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures to ensure the program allows visitation and
communication for youth while in the program. The program’s visitation schedule is posted in
the lobby of the program and in each module. The program’s policy and procedures are
reviewed during orientation and are communicated to youth and parent/guardian within forty-
eight hours of youth’s admission to the program. A review of the logbooks and visitation sign-in
sheets confirmed the program allows visitation for approved family members. Visitation occurs
two days a week on Saturdays and Sundays from 1:00 p.m. to 4:00 p.m. The program’s
visitation policy indicated consideration for requests of alternative visitation arrangements with
parent/guardian, if needed. The program policy states any visitors or communication with youth
must be on the youth’s approved correspondence list which is maintained by the case manager.
The program’s policy also states mail is opened in front of youth and outgoing mail is searched
prior to leaving the facility. Youth can send letters or make a telephone call at least once a week
to approved family members. A review of the program’s telephone log reflected youth have
consistent telephone communication with approved family members. None of the reviewed
youth had a history of human trafficking. The program has an agreement with a third-party
language service to provide translation services. An interview with facility administrator (FA)
indicated the program does have a third-party translation agreement. Five youth were
interviewed, and each youth confirmed they can call and/or send a letter to their
parent/guardian.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a policy and procedures to ensure the program provides a variety of
recreational and leisure activities to youth. The program’s policy requires recreation activities to
be provided for a minimum of one hour a day. The youth have a variety of recreation and leisure
activities posted on a recreation calendar which promotes creativity, teamwork, healthy
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competition, mental stimulation, and physical fitness. The program’s schedule has structured
indoor and outdoor recreation and leisure activities which include large muscle activity for a
minimum of one hour each day. A review of the master control logbook during the annual
compliance review period indicated recreation was conducted as scheduled. The program’s
contract requires a recreation therapist. A review of documentation confirmed the recreation
therapist has the required credentials and is providing services as stipulated in the program’s
contract. A review of five youth mental health and substance abuse records confirmed each
youth record contained a wellness plan, which was incorporated into their individualized
treatment plan. Recreation was observed during the annual compliance review week, which
confirmed the program takes precautionary measures to prevent overexertion, heat stress,
dehydration, frostbite, hypothermia, and exacerbation of existing illness or physical injury. Five
youth were interviewed, and all five indicated physical activity is provided for at least one hour a
day, which included activities such as basketball, football or mini games. Five staff were
interviewed, and all five confirmed recreation occurs for a minimum of an hour a day and
includes activities such as football, basketball, kickball, working out, four square, and board
games. One interviewed staff indicated it also depended on the heat index.
5.23 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program has a policy and procedures to ensure youth searches and room inspections are
conducted prior to placing a youth in on controlled observation. Each room was a minimum of
thirty-five unencumbered square feet, had a metal door with a shatter resistant observation
window, had properly covered vents and lighting, and no electrical outlets or switches inside the
room. Mattresses in the program are fire retardant. Five controlled observation reports were
reviewed and found staff documented an inspection of the room and a search of each youth
before each youth was placed in the room, as required. Staff of the same gender searched each
youth before each youth was left alone in the controlled observation room.
5.24 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program has a policy and procedures to ensure youth are only placed on secure
observation when non-physical interventions would not be effective. The program had twenty-
five youth on controlled observations since the last annual compliance review. A sample size of
five were reviewed. None of the reports reflected youth in a mental health crisis or with suicidal
ideations. Each youth met at least one of the required criteria for controlled observation. All five
contained documentation of supervisory or higher-level staff authorizing placement. All five
youth were advised for the reason of placement in controlled observation and the expected
behavior for removal. None of the youth complained about injuries, nor were injuries observed,
and each had the health status checklist completed. Times of controlled observation ranged
from four hours to seven hours and thirty-five minutes, in which all five reports included the
facility administrator (FA) or designee granting approval for the extension of the two-hour
window and approval for continued placement at least every two hours.
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5.25 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program has a policy and procedures for controlled observation safety checks and release
procedures, based on the youth’s behavior, as well as staff designations for controlled
observation. A sample of five youth records was reviewed. All five reports confirmed the staff
making placement completed the first page of the Controlled Observation Report, submitted the
form to a supervisor, documented the safety checks at least every fifteen minutes, and observed
youth’s behavior. The facility administrator (FA) or designated supervisory staff, who had the
delegated authority gave written approval before a youth was released from controlled
observation, which was based on whether the youth was no longer an imminent threat to self or
others. It was determined an internal alert was warranted for each reviewed youth. The
Controlled Observation Report, Health Status Checklist, and Controlled Observation Safety
Check forms were maintained in an administrative record and individual case management
record for each youth. The FA or designated supervisory staff, approved each youth’s
Controlled Observation Report within fourteen days of the youth’s release from controlled
observation to determine if the placement was appropriate. In all five records reviewed, staff
decided whether an in-house alert was warranted when each youth was released from
controlled observation.
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report_type: QI Residential

rule: Indicator 2.18

rating: Limited Compliance

rule: Indicator 2.19

rule: Indicator 5.04

excerpt: Ten-Minute Checks (Critical)

rule: Indicator 5.09

excerpt: Searches and Full Body Visual Searches

rule: Indicator 5.13

excerpt: Tool Inventory and Management

rating: Failed Compliance

rule: Indicator 5.18