state: FL

facility_name: Duval Academy

summary: QI Residential - FY24-25 - 16 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Duval Academy
Wayne Halfway House
(Contract Provider)
7500 Ricker Road
Jacksonville, Florida 32244
Review Date(s): 3/11/2025-3/14/2025
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:
Michele Maynard, Office of Accountability and Program Support, Lead Reviewer (Standard1)
Jeff Campbell, Office of Education, Northeast Education Coordinator, (Standard 6)
LeAnn Gruentzel, Office of Accountability and Program Support, Deputy Supervisor, (Standard
6)
Kristin Hanson, TrueCore Behavioral Solutions, Regional Compliance Manager (Standard 2)
Forrest Hallam, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Kristine Harshaw, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Bradley Taylor, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Interviews)
Devon Whitten, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Duval Academy MQI Program Code: 1280
Provider Name: Wayne Halfway House Contract Number: 10796
Location: Duval County / Circuit 4 Number of Beds: 28
Review Date(s): 3/11/25-3/14/25 Lead Reviewer Code: 224
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, (5) Safety and Security, and (6) Educational
Services, which are included in the Residential Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 70 (Revised September 2022)
5.18 S
T h e fo llo w in g lim ite d a n d /o r fa ile d in
Lim ited R atings
1.08 In-S ervice Training
1.13 Internal A lerts S ystem and A lerts (JJIS )*
2.04 C lassification Factors, Procedures, and R eassessm ent for A ctivities
2.07 R esidential A ssessm ent for Y outh (R A Y )
2.11 Perform ance S um m aries and Transm ittals
2.12 Parent/G uardian Involvem ent in C ase M anagem ent S ervices
2.13 Treatm ent Team M em bers and M eetings (Form al and Inform al R eview s)
2.15 E xit Portfolio
3.06 M ental H ealth and S ubstance A buse Treatm ent*
3.13 S uicide Precaution O bservation Logs *
5.06 Logbook E ntries and S hift R eport R eview
5.16 Fire, S afety, and E vacuation D rills
torage, Inventory, and D isposal of Flam m able, Poisonous, and Toxic Item s and M aterials
6.08 Florida Y outh C ollege (Post-S econdary C ontract)
d ic a to rs re q u ire im m e d ia te c o rre c tiv e a c tio n .
Failed R atings
2.05 G ang Identification: N otification of Law E nforcem ent
2.06 G ang Identification: Prevention and Intervention A ctivities
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Limited
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Non-Applicable
1.13 Internal Alerts System and Alerts (JJIS)* Limited
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 70 (Revised September 2022)
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 70 (Revised September 2022)
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
2 .1 2
2 .1 3
2 .1 4
2 .1 5
2 .1 6
2 .1 7
* T h e D e p a rtm e n
o p e ra te s b e lo w D
F a ilu re to d o s o w
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
Y o u th O rie n ta tio n
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
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
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
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
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 )
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 )
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 *
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
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
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
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 )
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 )
E x it P o rtfo lio
E x it C o n fe re n c e
Y o u th In p u t
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 e d ia te a
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 v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th
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 a re a (d e te n tio n , re
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
F a ile d
F a ile d
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
L im ite d
L im ite d
L im ite d
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
tte n tio n if a p ro g ra m
e s e in d ic a to rs .
s id e n tia l, p ro b a tio n ).
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 70 (Revised September 2022)
3 .0 1
3 .0 2
3 .0 3
3 .0 4
3 .0 5
3 .0 6
3 .0 7
3 .0 8
3 .0 9
3 .1 0
3 .1 1
3 .1 2
3 .1 3
3 .1 4
3 .1 5
3 .1 6
3 .1 7
3 .1 8
3 .1 9
* T h e D e p a rtm e n
o p e ra te s b e lo w D
F a ilu re to d o s o w
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
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 *
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
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
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
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*
T re a tm e n t a n d D is c h a rg e P la n n in g *
S p e c ia liz e d T re a tm e n t S e rv ic e s *
P s y c h ia tric S e rv ic e s *
S u ic id e P re v e n tio n P la n *
S u ic id e P re v e n tio n S e rv ic e s *
S e c u re O b s e rv a tio n *
S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
S u ic id e P re v e n tio n T ra in in g *
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 *
C ris is A s s e s s m e n ts *
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 *
B a k e r a n d M a rc h m a n A c ts *
S a fe ty P la n n in g P ro c e s s fo r Y o u th
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 e d ia te a
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 v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th
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 a re a (d e te n tio n , re
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
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
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
N o n -A p p lic a b le
S a tis fa c to ry
tte n tio n if a p ro g ra m
e s e in d ic a to rs .
s id e n tia l, p ro b a tio n ).
Standard 4: Health Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 70 (Revised September 2022)
4 .0 1
4 .0 2
4 .0 3
4 .0 4
4 .0 5
4 .0 6
4 .0 7
4 .0 8
4 .0 9
4 .1 0
4 .1 1
4 .1 2
4 .1 3
4 .1 4
4 .1 5
4 .1 6
4 .1 7
4 .1 8
4 .1 9
* T h e D e p a rtm e n
o p e ra te s b e lo w D
F a ilu re to d o s o w
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e *
L ic e n s e d M e d ic a l S ta ff*
F a c ility O p e ra tin g P ro c e d u re s
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t
P a re n ta l N o tific a tio n /C o n s e n t
H e a lth c a re A d m is s io n & R e s c re e n in g F o rm
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e A d m is s io n N o tific a tio n
H e a lth -R e la te d H is to ry
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g
S e x u a lly T ra n s m itte d In fe c tio n & H IV S c re e n in g
S ic k C a ll P ro c e s s
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re
O ff-S ite C a re /R e fe rra ls
C h ro n ic Illn e s s /P e rio d ic E v a lu a tio n s
M e d ic a tio n M a n a g e m e n t
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s
In fe c tio n C o n tro l/E x p o s u re C o n tro l
P re n a ta l C a re /E d u c a tio 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 e d ia te a
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 v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th
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 a re a (d e te n tio n , re
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
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 le
tte n tio n if a p ro g ra m
e s e in d ic a to rs .
s id e n tia l, p ro b a tio n ).
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 70 (Revised September 2022)
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
5 .0 1 Y o u th S u p e rv is io n *
5 .0 2 C 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
5 .0 3 U s e o f R o o m R e s tric tio n N
5 .0 4 T e n M in u te C h e c k s *
5 .0 5 C e n s u s , C o u n ts , a n d T ra c k in g
5 .0 6 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
5 .0 7 K e y C o n tro l*
5 .0 8 C o n tra b a n d P ro c e d u re
5 .0 9 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
5 .1 0 V e h ic le s a n d M a in te n a n c e
5 .1 1 T ra n s p o rta tio n o f Y o u th
5 .1 2 W e e k ly S a fe ty a n d S e c u rity A u d it
5 .1 3 T o o l In v e n to ry a n d M a n a g e m e n t
5 .1 4 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
5 .1 5 O u ts id e C o n tra c to rs
5 .1 6 F ire , S a fe ty , a n d E v a c u a tio n D rills
5 .1 7 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 )
5 .1 8 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
5 .1 9 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
5 .2 0 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 * N
5 .2 1 V is ita tio n a n d C o m m u n ic a tio n
5 .2 2 R e c re a tio n a n d L e is u re
5 .2 3 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 N
5 .2 4 C o n tro lle d O b s e rv a tio n N
5 .2 5 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 N
* 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 e d ia te a tte n
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 v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e
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 a re a (d e te n tio n , re s id e
S a tis fa c to ry
S a tis fa c to ry
o n -A p p lic a b le
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
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
L im ite d
S a tis fa c to ry
L im ite d
S a tis fa c to ry
o n -A p p lic a b le
S a tis fa c to ry
S a tis fa c to ry
o n -A p p lic a b le
o n -A p p lic a b le
o n -A p p lic a b le
tio n if a p ro g ra m
s e in d ic a to rs .
n tia l, p ro b a tio n ).
Standard 6: Educational Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 70 (Revised September 2022)
6 .0 1
6 .0 2
6 .0 3
6 .0 4
6 .0 5
6 .0 6
6 .0 7
6 .0 8
* T h e D e p a rtm e n
o p e ra te s b e lo w D
F a ilu re to d o s o w
S ta n d a r d 6 - E d u c a tio n a l S e r v ic e s
C o n tra c t S p e c ific C T E S e rv ic e s (R e s id e n tia l C o n tra c t)
E d u c a tio n a l A c c e s s (R e s id e n tia l C o n tra c t) *
E d u c a tio n a l A c c e s s (E d u c a tio n C o n tra c t) *
C a re e r E d u c a tio n (E d u c a tio n C o n tra c t)
E d u c a tio n T ra n s itio n P la n (E d u c a tio n C o n tra c t)
Q u a lifie d In tru c tio n a l P e rs o n n e l (E d u c a tio n C o n tra c t)
F lo rid a Y o u th C o lle g e (E d u c a tio n C o n tra c t)
F lo rid a Y o u th C o lle g e (P o s t-S e c o n d a ry C o n tra c t)
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 e d ia te a
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 v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th
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 a re a (d e te n tio n , re
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
N o n -A p p lic a b le
N o n -A p p lic a b le
N o n -A p p lic a b le
N o n -A p p lic a b le
L im ite d
tte n tio n if a p ro g ra m
e s e in d ic a to rs .
s id e n tia l, p ro b a tio n ).
Program Overview
Duval Academy is a twenty-eight bed program, for fourteen to eighteen year old males, located
in Jacksonville, Florida. The program is operated by Wayne Halfway House, through a contract
with the Department. The program provides the following services: Mental Health Overlay
Services (MHOS) or Substance Abuse Treatment Overlay Services (SAOS). In addition, the
program fosters each youth by providing Cannabis Youth Treatment, Living In
Balance, Aggression Replacement Training, Impact of Crime, and Dialectical Behavior Therapy.
Additional treatment services provided includes individual, group, family, and recreational
therapy. Program administration is comprised of a facility administrator, an assistant facility
administrator (AFA), a human resources/administrative assistant, a food service manager, and a
physical plant manager. Case management services are provided by two case managers
supervised by the program’s designated mental health clinical authority (DMHCA). Mental
health staff at the program includes the DMHCA, two non-licensed therapists, a recreational
therapist, and a transition services manager. Medical services are offered daily from 7:00 am to
5:00 pm and are provided by a medical doctor who is the designated health authority (DHA), a
health services administrator (HSA), one full time registered nurse, and two part time registered
nurses. Educational services are provided by the Florida Virtual School. The layout of the
program includes: a main building which includes administration, staff offices, youth living areas,
a dining room, kitchen, a classroom, and large meeting area/pavilion. The program has thirty-six
operating security cameras providing coverage. At the time of the annual compliance review,
the program had no vacant positions
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 70 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures requiring all staff, volunteers, and contracted staff to
be background screened prior to contact with youth and confidential youth records. The
program did not have any applicable volunteers or interns who interacted with youth on an
intermittent basis for less than ten hours a month. An Annual Affidavit of Compliance with Level
2 Screening Standards was completed and sent to the Department’s Background Screening
Unit (BSU) on January 28, 2025. The teachers, who are paid by the Florida Virtual School
received their annual screening March 12, 2025. The program had eighteen new staff hired
during the annual compliance review period, and each new staff received a background
screening prior to hire. The program had no new volunteers during the annual compliance
review period. A criminal history report was reviewed for each staff, and all staff were added to
the Clearinghouse employment roster. A check of the Clearinghouse website did not support the
additional staff to the employment roster hired after January 1, 2025. The program provided
copies of the background checks for each new employee supporting their addition to the roster.
Upon further review, this appeared to be a systemic issue with Clearinghouse. None of the staff
required an exemption prior to working with youth or had a break in service as indicated in the
Department’s Staff Verification System (SVS). Documentation regarding a pre-employment
assessment was found in all new staff’s personnel records, and those scoring below the
threshold showed remediation and re-testing. The facility visitor log contains a contraband
attestation statement and all staff, including all newly hired, have a contraband attestation
included in their personnel records.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures in place requiring all staff and volunteers to receive a
background rescreening every five years from their hire date. A review of the staff roster found
there were no staff applicable for a five-year rescreening during the annual compliance review
period.
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1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures in place to promote an environment in which youth,
staff, and others feel safe, secure, and not threatened by any form of abuse or harassment.
According to the program’s policy, all staff are required to report any knowledge or suspicion
regarding an incident of abuse or sexual harassment which has occurred in the program
immediately and report any retaliation against youth or other staff who reported an incident, and
any staff neglect or violation of responsibilities which may have contributed to an incident or
retaliation. The telephone numbers for the Florida Abuse Hotline and the Department’s Central
Communications Center (CCC) are posted throughout the program. Staff adhere to a code of
conduct, which is agreed to, signed, and documented in each staff’s personnel record. A review
of five staff personnel records found each of the staff signed a code of conduct. The program
completed a Trauma Responsive and Caring Environment (TRACE) self-assessment on June
25, 2024. The program had five incidents of alleged staff abuse during the annual compliance
review period and one of these incidents of abuse was found to be substantiated. All five
incidents alleged physical abuse, three of the five alleged excessive force, two of the five
alleged improper supervision, and one alleged a failure to report. None of the incidents included
a potential human trafficking victim, commercial sexual exploitation, or labor trafficking.
Five youth were interviewed. All five youth indicated they feel safe while at the program citing
reasons to include nothing too crazy happens, staff are supportive, staff do not allow bullying,
staff make sure they receive all they need, and staff treat all the youth the way the youth want to
be treated. All five youth reported staff are respectful when speaking to them or other youth in
the program and have never heard any staff use curse words when speaking to them or other
youth. All interviewed youth denied having ever exchanged emails, telephone numbers, or
social media contact information with staff. None of the five youth indicated they have been
stopped from reporting abuse to the Florida Abuse Hotline or CCC and they all reported should
they need to report any abuse, they either know or know where to find the number to make the
necessary call. Five staff were interviewed and confirmed the process to allow youth and/or staff
to make abuse reports to the Florida Abuse Hotline or CCC. Staff notify their supervisor and
allow youth to make the call. The staff either makes the call, if there is coverage, or the
supervisor calls for them. All five staff denied ever seeing another staff deny a youth an abuse
call. Two of the five staff indicated they have heard other staff use profanity but not towards a
youth. The facility administrator was interviewed and stated both youth and staff have access to
the abuse registry or the CCC if the youth is over eighteen years of age.
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1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program has a policy and procedures regarding management response to allegations of
abuse. The program had five incidents of alleged physical, psychological, or emotional abuse
during the annual compliance review period with one of the five incidents being substantiated.
All five were also reported to the Department’s Central Communications Center (CCC) and after
investigation required immediate action on behalf of management. In all five instances, there
was evidence management took immediate action to address the allegations of physical,
psychological, and emotional abuse. Documentation was reviewed identifying applicable
corrective action taken by management for follow-up to the allegations. According to the facility
administrator (FA) and reviewed documentation, three staff received disciplinary action for the
allegations. The remaining staff received some type of retraining. The FA reported they are
responsible for ensuring training is provided to all staff and will review all accepted Florida
Abuse Registry contacts for further disciplinary action towards staff, volunteers, and/or
contracted personnel. The FA will contact the Department’s regional director to report the
incident and receive consultation concerning the further action needed to provide a resolution
and complete an Administrative Notification of the CCC reportable incident for documentation to
the provider senior leadership team.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a policy and procedures in place to ensure the Department’s Central
Communications Center (CCC) is notified within two hours of the incident occurring, or within
two hours of any program staff becoming aware of the reportable incident. The program had a
total of thirty-one reports to the CCC during the annual compliance review period. Five reports
were selected for review. All of the incidents were reported within the required two-hour
timeframe. With the exception of one incident, all otherincidents were documented in the
logbook,A review of the program’s internal incidents and grievances found there were no
additional incidents which should have been reported to the CCC and were not. The program
has experienced a decrease in the number of reportable incidents to the CCC.
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
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than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program has a policy and procedures in place requiring a Protective Action Response/Right
Interactions model (PAR/RI) Report to be completed any time staff uses a physical intervention
technique.There were fifty-three PAR/RI incidents during the annual compliance review period
which was more than the forty-nine reported during the previous annual compliance period. The
program was unable to locate the PAR/RI reports for June, July and August of 2024 but
supplied the PAR/RI Monthly Summary for tallying the total number of PAR/RI incidents from
the last annual compliance review. The program’s RI Plan was updated on December 11, 2024
and approved by the Department on March 11, 2025. During the annual compliance review
period, the program documented fifty-three PAR/RI events which is an increase from forty-nine
the previous annual review period. The program’s RI rate during the previous quarter was 4.28,
which is above the statewide Residential rate of 1.71. The facility administrator was interviewed
and reflected compliance with the program policy and procedures. Five interviewed staff had all
used RI techniques. Staff confirmed verbal interventions are utilized and in the event a
maneuver is needed, a report needs to be completed. Four staff indicated it is done immediately
or at least by the end of their shift. One staff stated it is done within twenty-four hours.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has a policy and procedures for pre-service training. Five staff training records
were reviewed for pre-service training. A review of both the Department’s Learning
Management System (SkillPro) and on-site training records was conducted due to the
Department’s Juvenile Justice Information System (JJIS) being offline during a portion of the
annual compliance review period. All five staff completed a total of at least 120 hours of training
in all the mandatory topics with the exception of Motivational Interviewing and all were
completed within 180 days of hire. All reviewed staff records documented completion of the
essential skills trainings of cardiopulmonary resuscitation (CPR), first-aid, automated external
defibrillator (AED), forty hours of Protective Action Response (PAR)/ Right Interactions (RI),
professionalism and ethics including standards of conduct, suicide prevention, emergency
procedures, program operating procedures, child abuse recognition, reporting and prevention,
and Prison Rape Elimination Act (PREA) and all were completed prior to contact with youth
Four of the five staff were scheduled for an upcoming instructor-led training in Motivational
Interviewing, which is scheduled for next month with one staff member having previously
completed the training. All instructors were qualified to deliver the trainings provided. The
program submitted a pre-service training plan/calendar prior to implementation, and it contained
approval/signatures of the facility administrator, the Department’s Residential Services, and the
Department’s Office of Talent, Leadership and Culture.
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1.08 In-Service Training Limited 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 for annual in-service training. Five staff training
records were reviewed for in-service training. A review of both the Department’s Learning
Management System (SkillPro) and on-site training records was conducted due to the SkillPro)
being offline during a portion of the annual compliance review period. Two of the five reviewed
staff did not complete the required hours and only completed fourteen and eighteen hours
respectively, the remaining three staff completed the required twenty-four hours of in-service
training. Three of five staff did not complete active shooter training. Four of the five staff did not
complete information security awareness and mental health and substance abuse. Three out of
five staff did not complete professionalism, interpersonal communication, and ethics. One staff
did not complete sexual harassment. Two out of five staff did not complete suicide prevention
and trauma responsive practices. All five staff completed or were currently certified in
cardiopulmonary resuscitation CPR/first aid/automated external defibrillator (AED), Protective
Action Response/Right Interactions (PAR/RI), Prison Rape Elimination Act (PREA), and human
trafficking. One of the five staff was not current in PAR/RI when the review team arrived on-site
and was taken off the floor until the refresher could be completed. Two of the five staff reviewed
were supervisory staff and neither staff completed any of the required eight additional hours of
supervisor training completed. All instructors were qualified to deliver the trainings provided.
The program submitted an in-service training plan/calendar prior to implementation, and it
contained approval/signatures of the facility administrator, the Department’s Residential
Services and the Department’s Office of Talent, Leadership and Culture.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures which include the training requirements for the
grievance process.The program has a grievance process which includes an informal phase, a
formal phase, and an appeal phase. The informal phase includes encouraging the youth to
resolve questions, disputes, and complaints through informal communication with program staff
and use of a conference request form. Documentation correlated the program’s practice with
their process. The program maintained copies of all grievances submitted for the last twelve
months and a sample of seven grievances were reviewed and found in compliance with
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appropriate phases and resolution time frames. None of the five interviewed youth ever had to
submit a grievance; however, all were able to articulate how they would submit one should they
ever need to and all stated if they needed help doing so they could ask a staff member for
assistance. Five staff were interviewed about the program’s grievance process for youth. All five
staff were aware of the grievance forms and making sure the youth is able to fill it out before
submitting it to a supervisor or in the grievance box for review; however, were unaware of the
three phases or what occurs once the grievance is submitted. The facility administrator was
interviewed and reflected knowledge and compliance with program policy and procedures
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program provides instruction focusing on developing life and social skill competencies in
youth. Youth are provided the opportunity to volunteer for community services projects inside
and outside of the program. The youth are provided health and wellness training from the
nursing staff regularly, and participate in community service, including Habitat for Humanity,
working at the local food bank, and helping out in the independent living center for special
needs adults. Partnerships with Verbkind Mentoring and the Hopewell Church bring in
programming to develop effective communication skills and positive character development
strategies. All of the youth are involved in the Boselli Foundation Mentoring program, a
leadership development program designed to encourage young men to become functional
leaders through empowerment and mentorship. Documentation, including sign in sheets,
agendas, photos, press releases, awards and certificates of participation were observed. Five
youth were interviewed and stated they participate in groups every day to include Living in
Balance, Cannabis Youth Treatment, and mental health groups. Youth learn topics such as
maintaining goals and the steps to reach them, substance abuse recovery, coping skills, anger
management, and other life skills. The facility administrator was interviewed and reflected on the
community-based initiatives and partnership for youth involved activities. The designated mental
health authority (DMHCA) was interviewed and reported youth have the opportunity to practice
skills learned in Living in Balance and other groups during daily facility activities and off campus
outings.
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1.12 Restorative Justice Awareness for Youth Non-Applicable
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at Duval Academy. For details related to the IOC service delivery, please refer
to the annual SPEP report.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Limited 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.
According to the program’s written policy, the program’s internal alert system is updated on a
continual basis and all staff have access to alerts. A review of five youth records was
conducted. All of the youth had alerts placed in the Department’s Juvenile Justice Information
System (JJIS). Each of the alerts were removed or downgraded by medical or mental health
staff, as required. Each applicable alert was documented in the program’s logbook. The
program utilizes an alert board as a direct way of informing staff of any updated alerts for all
youth. The alert board updates were found to be inconsistent and not current. Youth were listed
who had been discharged from the program and youth who needed to be included on the alert
board were not. The alert board was not organized in a cogent manner where a staff looking at
it would be able to easily discern the information being relayed. According to the facility
administrator (FA), upon entry to the program all youth alerts are to be documented and
evaluated as needed. Any discrepancies will be documented and all youth with medical grades
of 2-5 shall be placed on the program’s medical alert system. Open internal alerts will also be
posted on the Alert board in the administration hallway identifying which youth are on the
specific alerts. Nursing staff interviewed stated the nurse on duty is responsible to enter alerts
into JJIS. Five interviewed staff indicated they are informed of youth alerts by reviewing the alert
board located in the administration hallway. Two staff also indicated youth alerts are reviewed
during shift briefing meetings.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
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The program maintains an Individual Healthcare Record and a separate individual case
management record. The reviewed individual management records contained the youth’s name,
Department identification number, date of birth, county of residence, and committing offense.
The individual management records contained sections labeled legal information, demographics
and chronological information, correspondence, case management and treatment team
activities, and miscellaneous. All reviewed youth records were labeled confidential and secured
in a locked file cabinet.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a policy and procedures to ensure the program has a community advisory
board meeting at least every ninety to 120 days. Sign-in sheets and agendas were reviewed for
the advisory board meetings, and documentation confirmed board meetings have been at a
minimum of every 120 days. A review of the list of attendees, the board roster, and letters from
the program found the facility administrator (FA) solicited involvement from all required parties.
The FA actively solicits involvement of interested community partners including, but not limited
to, representatives from law enforcement, the judiciary, the school board or district, the business
community, faith community, victim, victim advocate, or other victim services community
representative, and a parent whose child was previously involved in the juvenile justice system.
All meetings are available for members to attend virtually. Meetings are held bimonthly, and
board members are frequently involved in the program. The president of the board was
interviewed and expressed involvement and interest in the well-being of youth at the program.
The interviewed FA confirmed the process for advisory board meetings and involvement of its
members.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures to ensure staff are evaluated, at least annually, based
on established performance standards. Five position descriptions were reviewed, and staff
performance standards were clearly identified in each. Performance evaluations were reviewed
for five staff, and each was completed as outlined in the program’s policy, and the performance
standards for each evaluation matched the job description for each staff. Each of the five staff
position descriptions reviewed were for staff implementing the program’s Behavior Management
System (BMS). A copy of the evaluation is maintained in the staff’s personnel file. The
program’s contractual key positions were reviewed, and all were maintained by the program.
The program’s contract requires a recreational therapist and the current staff member’s
credentials were approved by contract management. Five staff were interviewed regarding the
frequency of their performance evaluations. Two staff indicated they occur quarterly, one staff
stated they were done two times annually, one staff stated they had been hired seven months
prior and had received one thus far, and the remaining staff had only been hired within the last
month and had not received one; however, stated they get one once they have been on staff for
ninety days.
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1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program has contract requirements detailing services to be provided to youth while in the
program. The program is to provide the following: three snacks a day; the ability to attend career
and technical education programs and work in the community; learning opportunities for youth
who have completed secondary education and wish to pursue post-secondary education, where
youth have the opportunity to earn an associate degree or to begin coursework towards a
bachelor’s degree; high school equivalency test preparation and on-site testing; peer-to-peer
mentoring; a behavior modification process called the D-Board process; a youth advisory board;
religious services; the transitional services manager follows up with all youth post commitment
weekly for thirty days; the opportunity for youth to attend Narcotics Anonymous (NA)/Alcoholics
Anonymous (AA); ServSafe certification; Microsoft Office certification; first aid and
cardiopulmonary resuscitation (CPR) certification; Heating, Ventilation and Air Conditioning
(HVAC), welding, or electrical applications program; The Occupational Safety and Health
Administration (OSHA) certification; and access to self-paced online courses such as business
management or accounting. Documentation provided confirmed the program is providing
community activities, D-board process, youth advisory board, and post release follow-ups,
career certifications. The program established post-secondary resources, which one youth was
applicable for and took a tour and enrolled at the Edward Waters University and can provide
resources through the Tulsa Welding School and Acelius Academy. The program is not
completing the items dependent on the county school board, as education has moved to Florida
Virtual School this fiscal year. The program encountered a resistance to a partnership for Youth
in Urban Agriculture program and is seeking an alternative program as this was also tied to the
county school board. The program has not provided Narcotics Anonnymous/Alcholics
Anonnymous services as it continues to seek a consistent volunteer for program provision. The
clinical director provided email documentation to support ongoing efforts to solidify this
resource. The interviewed facility administrator replied to refer to the contract regarding
negotiated items. Five youth were interviewed and each confirmed snacks are being given as
required and religious services are available to attend.
1.18 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program includes the review and analysis of data in decision-making practices and shares
the data among administrators and staff to proactively make policy, practice, and programming
changes designed to foster system and program improvement. The program tracks data trends
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such as reportable incidents to the Department’s Central Communications Center (CCC),
physical managements, abuse reports, and employee turnover through monthly reports, and
trackers. The program conducts regular internal leadership meetings in which these items are
discussed and reviewed. These leadership meetings occur, minimally, on a weekly basis. The
program conducts monthly staff meetings during which time critical issues and trends are
reviewed and discussed. Facility administrators participate in both weekly and monthly
leadership meetings across programs to review data trends. The program shares relevant trend
information with providers and stakeholders, such as the community advisory board, through
regular advisory board meetings. These practices were documented in meeting minutes for
community, staff, and board meetings.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a written policy and procedures in place to address initial contact to the
youth’s parent/guardian as well as the committing court. The policy stipulates guidelines for
initial contacts to parent/guardians for youth upon admission. The youth’s parent/guardian is
contacted by phone and followed up with an admission packet which includes program
information and a questionnaire to assist in treatment planning. Parents/guardians are asked to
complete and send back in the provided self-addressed envelope provided by the program. The
assigned case manager staff notifies the youth’s committing court, assigned juvenile probation
officer (JPO), and post-residential services case manager, as applicable, in writing upon
admission. Five youth case management records were reviewed, and all records contained
documentation the parents/guardians were contacted by telephone on the day of admission. All
records indicated parents/guardians were mailed a parent admission letter on the day of
admission. All reviewed records contained a copy of the Judge Notification of Admission Letter
sent to the committing court informing them of the youth’s placement which was mailed on the
day of admission. The documentation further indicated the youth’s assigned JPO was copied on
the notification and if known at the time of admission, the youth’s post release counselor.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a written policy and procedures in place to address youth orientation. Five
youth case management records were reviewed, and all contained documentation showing the
youth participated in an orientation on the day of admission. The youth’s assigned case
manager completed the Orientation Checklist which addresses the program’s rules,
expectations and goals, as well as services applicable to the youth. This orientation includes a
review of all requisite information and the following information: assignment to a treatment team,
introduction to key staff and their roles, assignment of a living unit, group leader, and primary
counselor, review of the program goals, services, responsibilities, and expectations, review of
the behavior management system and disciplinary actions, review of disaster preparedness
procedures and emergency building evacuation procedures and routes to include advising youth
of areas which are off-limits, student area search procedures, contraband policy and
consequences for possession, review of the daily facility schedule guidelines, dress code and
hygiene expectations, review of resident rights, grievance and abuse reporting, access to
emergency medical, dental, and mental health/substance abuse services including hours of sick
call, performance planning and eligibility for release criteria, visitation schedule, telephone and
correspondence policies and procedures, release criteria and anticipated length of stay, review
of personal property/valuables guidelines, criteria for off-campus activitie,; rules and regulations
regarding youth conduct, review of the program’s gang pamphlet, and a review of the student
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handbook. Information contained on the orientation checklist is discussed with the youth by the
case manager on the day of admission. Once all information is reviewed, completed forms are
signed and dated by both youth and the case manager. All records contained a signed
acknowledgement attesting each youth had received a copy of the program’s handbook for
youth. Additional information reviewed with the youth at admission included a review of rewards
and consequences, Prison Rape Elimination Act (PREA) information, information on how to
access outside victim advocates for emotional support services related to sexual abuse, and
items deemed unauthorized when in possession of youth. During the annual compliance review
the program did not have any admissions to observe. Five youth were interviewed and all five
indicated they participated in the orientation process on the day of their admission, were
provided with the aforementioned materials, and were encouraged to ask questions if they had
any.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a written policy and procedures which addresses written consent of any youth
eighteen years of age or older and outlines steps for the assigned case manager. Language
which addresses the program’s expectations for written consent are contained within their
orientation policy. Five youth case management records were reviewed to determine if the
program obtained written consent for providing youth information with the parent/guardian,
Department of Children and Families, or other applicable agencies. None of the five records
reviewed were applicable. The program provided three additional case management records for
youth over the age of eighteen. All three records contained an Authorization to Release
Information form which was signed by the youth on their eighteenth birthday or upon admission
to the program for those youth who were already eighteen years of age at the time of
placement. All Authorization to Release Information forms were signed and dated by the youth
as well as a witness. There were no incidents observed where information was sent to a
parent/legal guardian without consent.
2.04 Classification Factors, Procedures, and Reassessment for
Limited Compliance
Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a written policy and procedures in place which addresses a classification
system,is implemented in accordance with Florida Administrative Code, and promotes safety
and security as well as the effective delivery of treatment services. The system is designed to
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ensure the safest room and dorm assignment for the arriving youth. Upon being admitted to the
program the youth is assessed for youth demographic information, physical characteristics, level
of maturity, background information, key indicators or abnormal behaviors, such as medical
needs and mental health/substance abuse needs, youth’s skill level, current committing
offense(s), demonstrated behavior at intake, the youth’s prior history, security risk, gang
affiliation/involvement, internal alert classification, and vulnerability and or level of aggression.
Missing from the program’s classification form and screening process was the youth’s
perception of vulnerability as well as a review of the youth’s history of potential or verified
human trafficking. The form classifies youth based on their risk. Five case management records
were reviewed. All five reviewed records demonstrated the classification meeting was
completed at the time of the youth’s admission. Two youth were admitted with verified medical
alerts in the Department’s Juvenile Justice Information system (JJIS) which were not identified
on their classification forms. Another youth was admitted as a designated gang member on the
classification information; however, JJIS and other screening documents did not support this.
None of the aforementioned designations were transferred to the program’s internal alert
system. According to the program, each youth is placed on an internal security level known as
“orientation” level; however, two of the records demonstrated contradictory information relating
to this. Three youth were placed on orientation level, while two other youth were placed on
security alert for reasons not supported in JJIS or internal screening documents. The program
maintains a separate binder of risk assessments which the program’s policy states are
completed at “regular intervals”. The risk assessments reviewed demonstrated an ongoing
review of each youth’s review of potential increase in movement and/or privileges, participation
in possible work projects or off campus activities. None of the youth reviewed were eligible for
work projects; however, the youth were granted the ability to utilize class B tools such as mops
and brooms. An interview with the program director revealed ”all rooms are double youth
occupancy. Youth prior victimization is assessed using the Vulnerability and Sexually
Aggressive Behavior screening (VSAB) and youth identified as having prior victimization are
placed strategically away from peers identified as aggressive on the VSAB. Housing
assignments are a collaboration between the operational and clinical teams.
2.05 Gang Identification: Notification of Law Enforcement Failed Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a written policy and procedures in place which outlines notification of law
enforcement regarding youth entering the program with suspected gang affiliation, or
documented gang membership, as well as for youth who are observed engaging in gang
activities during their commitment to the program. Five case management records were
reviewed; however, only one was applicable for gang affiliation or membership. The program
was able to provide two additional records for review of gang identification and notification. Each
of the youth were admitted with previous gang alerts from their home counties confirmed in the
Department’s Juvenile Justice Information System (JJIS), as well as completed gang
questionnaires. None of the identified youth had any documentation to support local law
enforcement or law enforcement in the youth’s home county were contacted. Two of the three
applicable youth records contained notifications to the school system and all three applicable
youth had notifications to the juvenile probation officer (JPO).
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2.06 Gang Identification: Prevention and Intervention Activities Failed Compliance
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a written policy and procedures in place which addresses the implementation
of gang prevention and intervention strategies. During the admission process, youth are
screened for gang involvement with the gang questionnaire and cross referencing the youth’s
face sheet and alerts page in the Department’s Juvenile Justice Information System (JJIS). The
policy stated the use of Impact of Crime curriculum (IOC) will be a component of the intervention
strategies used. The policy further stated the program will also seek out “education and guest
speakers”. The program provided a “gang binder” which offered “Gang 50 Stories” as an
additional intervention activity, not mentioned in their policy; however, the program could not
provide any completed assignments for any of the youth identified as gang members. Five
records were reviewed and one youth was applicable. A review of the JJIS alerts and closed
record samples revealed two additional samples. The one youth identified in JJIS was not
identified as such in the program’s “gang binder”. Each of the identified youth had delinquency
intervention goals related to completing IOC; however, none of the youth had any specific
identified goals or objectives related to gang prevention/intervention. A review of sign-in sheets
revealed each youth was participating in or had completed the IOC curriculum. The program’s
internal alert system failed to identify all three youth as gang involved, but did identify one youth
who was not affiliated with a gang according to JJIS as gang affiliated on their alert board. The
program’s policy as well the program director’s interview indicated a youth will be provided the
opportunity to “dis-affiliate” from their identified criminal street gang should they choose.
2.07 Residential Assessment for Youth (RAY) Assessments and
Limited Compliance
Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures in place to ensure a Residential Assessment for
Youth (RAY) is completed within thirty days of the youth’s admission to the program and the
RAY re-assessments are completed within ninety days after completion of the initial RAY . Five
youth case management records were reviewed, and all five records contained an initial RAY
completed within the required timeframe. All initial RAYs were completed with the Department’s
Juvenile Justice Information System (JJIS). Five records were also reviewed for eligibility of
RAY re-assessments. Four youth were eligible. All four records demonstrated the youth’s RAY
re-assessments were completed beyond the ninety-day requirement. One record only had a
modified initial RAY within the required timeframe. The remaining three records were twenty-
three, nine, and one day late. None of the printed RAY re-assessments had corresponding
comparative reports.
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2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures in place to ensure the Youth Needs Assessment
Summary (YNAS) is conducted within thirty days of the youth’s admission to the program. The
youth’s assigned case manager is responsible for gathering information from all members of the
treatment team as well as collateral documents and incorporating this information into the YNAS
report. Five youth case management records were reviewed, and all contained a YNAS report
which was completed with the required timeframe. All YNAS reports were completed prior to the
youth’s Individualized Performance Plan (IPP) in the Department’s Juvenile Justice Information
System (JJIS).
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program has a written policy and procedures which addresses the intervention and
treatment team, including the youth and the need to meet and develop the performance plan
within thirty days of admission. The program’s policy outlinesthe required members of the
treatment team, which include, youth, juvenile probation officer (JPO), and parents/guardians to
be involved in the development of the youth’s Individualized Performance Plan (IPP) within thirty
days of admission to the program. Parents/guardians are provided a questionnaire at
admission and encouraged to provide feedback in the development of the plan accordingly.
Other disciplines provide input in order to create the youth’s IPP. Five youth case management
records were reviewed. All five contained documentation of the IPPs were developed within the
required timeframe and developed following the youth’s Youth Needs Assessment Summary
(YNAS) and initial Residential Assessment for Youth (RAY), as required. The youth’s
intervention and treatment team were present during the development of the IPPs and included
participation from the following parties: treatment team leader (youth’s case manager), youth,
program administration, direct care/living unit representative, mental health treatment staff,
education/vocation staff, and medical staff. All IPPs contained individualized goals based on
the prioritized needs of the youth. The top three criminogenic needs were identified in each
performance plan reviewed. One of the plans did not address delinquency interventions and two
did not address court ordered sanctions. The remaining plans met all required elements. All five
IPPs had corresponding transmittals within ten working days to the juvenile probation officer,
courts and parents/guardians requesting their review and signature. None of the five reviewed
records contained returned signature pages. Each IPP listed the responsibility of staff in
completing the goal, responsibility of youth in completing the goal, start date, and projected
completion/end date. All five interviewed youth indicated they participated in the development of
their performance plan.
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2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a policy and procedures in place which addresses performance plan revisions.
The program meets formally as a multidisciplinary team to review the youth’s performance plan
goals every thirty days and determine whether revisions are necessary. In addition, every ninety
days after completion of the initial Residential Assessment for Youth (RAY), case management
staff complete a RAY re-assessment and should the results warrant, will revise the youth’s
performance plan goals. Five youth case management records were reviewed andfour were
applicable. The youth reviewed each had at least one RAY re-assessment completed. Two of
the four reviewed records reflected changes when warranted due to progress, while the
remaining two had behavioral issues noted and a lack of progress. Each of the four applicable
records reflected the incorporation of both academic and treatment plans within the youth’s
performance plan. One youth warranted inclusion of their Department of Children and Families
(DCF) case plan and demonstrated the plan was incorporated into their respective performance
plans. Three closed records were reviewed and one open record contained documentation
showing the youth’s performance plan was updated to facilitate transition activities during the
last ninety days of the youth’s commitment.
2.11 Performance Summaries and Transmittals Limited Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program has a policy and procedures in place to ensure performance summaries and
transmittals are completed within required timeframes. At each ninety-day interval, beginning
ninety days from the signing of the youth’s Individualized Performance Plan (IPP), the
intervention and treatment team meets to create a performance summary. In addition, prior to
the youth’s release, discharge, or transfer from the program, the intervention and treatment
team will meet in order to create the performance summary. Five open and three closed youth
records were reviewed for the completion of performance summaries. Three of the open youth
and all three closed youth records were applicable for performance summaries. A total of eight
summaries were reviewed. Seven of eight performance summaries reviewed were completed
within timeframe requirements and the remaining one was twenty-three days late. Three of the
five open youth performance summaries did not capture any youth comments, instead noting
the section was “not applicable”. Each of the open youth summaries had corresponding
transmittals to required individuals; however, the closed records did not have any corresponding
transmittals. All performance summaries included the youth’s status on each performance
andtreatment plan goal, the youth’s overall adjustment and progression in the residential
commitment program, the youth’s overall progress during the rating period, youth’s interaction
with peers, interaction with staff, overall behavior adjustment to the program, and any significant
positive and negative events. Two performance summaries did not note the youth’s readiness to
change and two summaries did not document the youth’s grades or academic status. The
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completed performance summary was signed and dated by the staff member preparing the
performance summary (case manager), who was also the treatment team leader; program
director or designee, and the youth. A review of the three open records found the three
applicable youth did not receive a copy of their performance summary. Three closed records
were reviewed for discharge and release summaries. All three records contained the original
release summary which included the justification for the youth’s release from the program. All
records contained a Pre-Release Notification (PRN), completed at least forty-five days prior to
the youth’s release. All summaries and PRNs were signed by the appropriate parties and
maintained in the youth’s closed case management record. None of the closed records
contained notification to the parents/guardians confirming the youth’s release date once the
program received the approved PRN from the committing court. All three closed records
contained documentation supporting the exit Residential Assessment for Youth (RAY) was
completed for each youth following approval of their release. No youth were applicable for the
Sexually Violent Predator Program (SVPP).
2.12 Parent/Guardian Involvement in Case Management
Limited Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to encourage and facilitate the involvement of the
youth’s parents/guardians in the case management process. The policy outlines how parent
participation is facilitated throughout the entire youth’s length of stay in the program. If the
parent/guardian is unable to attend any of the meetings in person, they are given the
opportunity to participate by telephone and can provide verbal or written input as well. Five
youth records were reviewed and reflected the youth’s parent/guardian are contacted at the time
of admission and mailed an admission letter which is inclusive of a handbook and a
questionnaire asking for input into treatment planning. There were no formal treatment teams
scheduled or observed during the annual compliance review week. None of the five youth
records indicated the parents/guardians were provided any advance notice of the youth’s formal
treatment teams. Additionally, there was no correspondence inviting the parents/guardians to
participate in the youth’s transition. The formal treatment teams reviewed indicated many
parents/guardians participated by phone; however, there were no comments noted to confirm.
The program reported they provide weekly visitation; however, documentation of visitation was
sporadic. The facility administrator was interviewed and advised family sessions are offered
monthly. Five interviewed youth stated their parents/guardians are involved in their case
management through weekly telephone calls, case management communicating with them,
family therapy, visitation and/or video calls, and treatment team meetings.
2.13 Treatment Team Members and Meetings (Formal and
Limited Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a policy and procedures in place to ensure each youth and their intervention
and treatment team meet on a bi-weekly basis to review the youth’s performance, to include
Residential Assessment for Youth (RAY) re-assessment results, progress on individualized
performance plan (IPP) goals, positive and negative behaviors, including behavior resulting in
physical interventions, and treatment plan progress. Five youth case management records were
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reviewed and a twenty-three formal treatment team reviews were reviewed. Each meeting was
held at thirty day intervals and contained components which addressed a review of the
Performance Plan Progress Report , performance plan goal focus for the month, stages of
change, physical and medical progress report, education progress report, review of progress
reports, mental health/substance abuse progress report, issues/concerns with peers or staff,
overall program adjustment, and program behavior and performance progress report. The
documentation contained evidence participants who actively participated could sign. This
included the youth’s parents/guardians and juvenile probation officer (JPO). The reviews
documented if the parent/guardian and JPO participated, it was by phone and there were no
comments or signatures confirming their participation. Each record also contained informal
treatment team meetings held every thirty days. None of the informal reviews had any evidence
the youth participated in the meeting. Only the case manager’s signature was present. The five
youth records reviewed did not contain any evidence the youth’s parent/guardian and JPO
received advance notice of the meetings. The program was able to provide two chronological
notes which contained phone notifications to parents and one email to a JPO. There were no
scheduled treatment teams to observe during the program’s annual compliance review week.
Five interviewed youth stated staff talk about their performance to include their progress on
performance plan goals, positive and negative behavior, and treatment progress during
treatment teams. All five youth indicated they are able to show the skills they have learned by
self-reporting during their treatment teams about what they are working on, what they need to
work on, and what they want to work on.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has a policy and procedures in place addressing the program’s transitional
planning process, to include participation of the program and the youth in the Community Re-
Entry Team (CRT) meeting. A review of three closed youth case management records revealed
two out the three records contained evidence a transition conference summary being completed
at least sixty days prior to the youth’s targeted release date. One transition conference summary
was one day late. Each record also contained evidence of documentation each transition plan
was developed by the youth, case manager (treatment team leader), administrative
representative, clinical services representative, education representative, medical
representative, juvenile probation officer (JPO), and the youth’s parent/guardian. Documentation
in all three closed records verified all attendees signed and dated the transition plan. Two of the
three records did not show evidence of the plan being sent with a request for return with
signature to the parent/guardian and JPO. None of the plans had a signed and returned
signature page from their JPO or parent/ guardian. Additionally, none of the closed records
contained evidence any plans sent electronically had a return email acknowledgment from the
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youth’s assigned JPO. All three youth records contained evidence of the youth and assigned
case manager participating in the CRT held prior to the youth’s release. The program was able
to provide email notification from the assigned JPOs inviting participation to the CRT. Records
further contained evidence the treatment team members reviewed transition activities listed on
the youth’s Individualized Performance Plan, identified additional transition activities, identified
target completion dates, and the person responsible for completion.
2.15 Exit Portfolio Limited Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures in place addressing the program’s exit process to
include assembling an exit portfolio for each youth to assist them once they are released back
into their home community. A review of three closed youth case management records found all
contained elements of an exit portfolio. None of the records verified the exit portfolio was
initiated during the youth’s transition conference. None of the portfolios contained state issued
identification cards, social security cards, or birth certificates; however, there was evidence
these documents were solicited from the parents/guardians at admission. None of the exit
portfolios contained a calendar with all dates, times, and locations of upcoming community
appointments. All three exit portfolios contained a copy of the youth’s transition conference. Two
of the three portfolios contained the following: vocational certificates, educational records,
school transcripts, and resumes. Only one youth portfolio contained a sample of employment
application. None of the youth’s portfolios contained evidence they were verified at the youth’s
exit conference, provided to the youth upon their release, or forwarded to the youth’s juvenile
probation officer. A review of the program’s contract did not reveal any additional requirements
for the youth’s portfolios.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures in place which addresses participation of the youth
and treatment team in the exit conference. Three closed youth case management records were
reviewed for the completion of an exit conference. All three records contained documentation an
exit conference was conducted after the juvenile probation officer (JPO) was notified of each
youth’s release. Each of the records reflected the meetings were conducted at least fourteen
days prior to the youth’s release in which the status of goals developed at the transition
conference were reviewed and release plans were finalized. A summary of the conference was
found in all of the records and included the date, signatures, names of participants by phone,
and a summary of pending transition goals. As required, each exit conference noted the
required treatment team members participated in person or by telephone. Exit conferences were
held separately from the transition meeting and Community Re-Entry Team (CRT) meeting.
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2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has written policy and procedures which promotes constructive input by youth.
The program uses informal “SSpeak Out” forms, grievance procedures, community meetings,
and the student council meetings (youth advisory board). The student council meeting process
outlines participation which is contingent upon the youth’s consistent display of leadership,
civility, and positivity skills as well as demonstrate community service. Members of the board
meet with the administration and treatment team monthly for cohesion. Meeting minutes for the
annual compliance review period reflected youth input. The program’s policy did not specify
frequency of meetings, but there were minutes demonstrating they were held at least monthly.
Speak Out forms were reviewed for the annual compliance review period and reflected
communications between youth and treatment team members for a variety of reasons. Most
communication related to programmatic requests such as the need for more hygiene, level-ups,
or informal conflict resolution. All five interviewed youth stated the program holds town hall
meetings monthly and youth are also able to speak to staff about what happens at the program
as well as utilize speak out forms. The facility administrator was interviewed and confirmed
youth advisory board, speak out forms, grievance forms, youth surveys, youth meetings with
facility administrator, and assistant facility administrator, and Monthly Town Hal meetings” are
utilized for youth input.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program has a designated mental health clinician authority (DMHCA) who is a licensed
mental health counselor. The DMHCA has a current and valid license in the State of Florida.
The DMHCA’s license expires March 31, 2025. The program utilized one other DMHCA during
the annual compliance review period, whose license expires March 31, 2025 and now serves as
the state clinical director and back-up DMHCA when needed. The DMHCA was on-site weekly
to ensure appropriate coordination and implementation of mental health and substance abuse
services were taking place as required. A copy of the DMHCA position was provided and
reviewed. The DMHCA is responsible for the coordination and implementation of mental health
and substance abuse services at the program. The DMHCA was interviewed regarding their role
which included clinical services and communication with clinical staff at the program. The
DMHCA reported their role includes the monitoring of services provided through supervision,
audits, and fidelity check of services. The DMHCA consults with the state clinical director as
needed,facilitates a review of Department site visits, and reviews the findings of compliance
reviews. The DMHCA maintains a caseload of three to five youth and completes new intakes as
needed to assist the clinical team as well as participating in treatment teams. The DMHCA
facilitates the Cannabis Youth Treatment (CYT) groups weekly and other groups as needed for
coverage. The DMHCA provides supportive counseling upon request through Speak Out and
Volcano Passes. The DMHCA reviews all Assessments of Suicide Risk (ASR) completed by
non-licensed clinicians and provides supervision to the non-licensed staff as well. The DMHCA
completes ASRs for youth on Precautionary Observation and/or as needed to determine risk.
The DMHCA also provides Suicide Prevention training to new staff, initiates Baker Acts as
needed, and provides on-call support 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 did not have any other licensed staff throughout the annual compliance review
period. The designated mental health clinician authority (DMHCA) and back-up DMHCA were
the only licensed staff at the program during annual compliance review period.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) is the clinical supervisor at the
program. The DMHCA ensures the non-licensed staff working under their supervision are
performing services they are qualified to provided based on education, training, and experience.
Documentation revealed each non-licensed mental health clinical staff is working under the
direct supervision of a licensed mental health professional and received a minimum of one hour
each week of on-site, face-to-face direct supervision by a licensed mental health professional
for the purpose of overseeing and directing mental health services provided in the program
during the annual compliance review period. The supervisions were recorded on the
Department’s Licensed Mental Health Professionals and Licensed/Certified Substance Abuse
Professionals Direct Supervision Log. The program maintains a Chapter 397 license. The
Chapter 397 license expires May 9, 2025. Staffing for licensed and non-licensed clinical staff
were in accordance with the current program contract. There were no vacancies in clinical staff.
Two non-licensed staff records were reviewed for credentials. Both staff hold a master’s-level
degree from an accredited university or college in the field of counseling, social work,
psychology, or related human services field. Both non-licensed staff are qualified to deliver
substance abuse services. Both non-licensed staff administered Assessments of Suicide Risk
and they completed twenty hours of training and supervised experience in assessing suicide
risk, mental health crisis intervention, and emergency mental health services.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Five youth mental health records were reviewed for mental health and substance abuse
admission screening documentation. All five youth records included documentation a
Massachusetts Assessment-2 (MAYSI-2) was completed. The records included documentation
the screeners reviewed the available information to include the commitment packet and reports
available. All five MAYSI-2 screenings were completed in full by the assigned case manager at
the program on the day of each youth’s admission. All staff completing the MAYSI-2 screenings
had completed the required training in the Department’s Management Learning System
(SkillPro) to be able to administer the assessment. The MAYSI-2 screenings were printed from
the Department’s Juvenile Justice Information System (JJIS) and were located in the youth
mental health records for review. All five MAYSI-2 screenings indicated a need for further
assessments and all records included a referral was completed for further evaluation to the
designated mental health clinician authority (DMHCA) and all required parties were notified. All
youth referrals documented the reasons for the referral being completed. One of the five
MAYSI-2 screenings indicated the youth was a potential suicide risk. An Assessment for
Suicide Risk (ASR) was necessary; however, it is standard procedure for all youth to receive an
ASR upon admission to the program and all five youth had an ASR completed as required. It is
also standard procedure for all youth to be placed on Precautionary Observation at intake until
the ASR is completed. The program maintains a policy and procedures for mental health and
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substance abuse admission screenings. The policy and procedures include a standardized
screening process which includes review of commitment packet information, reports, records,
administration of the MAYSI-2 in JJIS, and referral of youth identified by screenings as in need
of further evaluation. The policy and procedures also included staff training requirements in
mental health and substance abuse issues, administration of the MAYSI-2, and a standardized
process for referral of youth identified as in need of further mental health and/or substance
abuse evaluation to an appropriate service provider/professional or, when immediate attention is
needed, to a hospital, Baker Act, or Marchman Act facility. The facility administrator was
interviewed and explained the policy and procedures for the program’s mental health and
substance abuse admission screening process.
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.
Five youth mental health records were reviewed for mental health and substance abuse
assessments and evaluations. All five reviewed records included documentation the program
completed a combined mental health and substance abuse evaluation for each youth. All
evaluations were new and completed within thirty calendar days of admission. All five
evaluations were completed by the designated mental health clinician authority (DMHCA). All
five youth records included documentation a consent was obtained for substance abuse
services. Each evaluation included the required elements of identifying information, reason for
evaluation, relevant background information, behavioral observations, mental status
examinations, interview or procedures administered, discussion of findings, diagnostic
impression, including the diagnoses from the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5), patterns of alcohol and other drug abuse, impact of alcohol
and other drug abuse in major life areas, risk factors of continued alcohol and other drug abuse,
and recommendations.
3.06 Mental Health and Substance Abuse Treatment (Critical) Limited Compliance
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.
Five youth mental health records were reviewed for mental health and substance abuse
treatment. All five records included documentation the initial treatment plan was developed
within seven days of initiation of treatment. Each initial treatment plan was documented on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Two records were
applicable for psychiatric services to be included on the initial treatment plan and both were
missing documentation of those services. All five initial treatment plans were signed by the
clinical staff who completed the form and signed by the licensed clinical supervisor within ten
days of completion. Four of the five initial treatment plans were signed by all required members
of the treatment team who participated in the development of the plan and included
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documentation of the initial treatment plan being mailed to the parents/guardians. The remaining
plan did not have documentation the initial treatment plan was mailed to the parent/guardian.
Four youth mental health records were applicable for review of Individualized Treatment Plans
and reviews. One youth had not been in the program thirty days at the time of the annual
compliance review. Three records were applicable for psychiatric services. All three records
were missing documentation of the frequency of monitoring by the psychiatrist, but did include
the youth were to receive psychiatric services. All four IndividualizedTtreatment Plans were
developed on the Department’s Individualized Mental Health/Substance Abuse Treatment Plan
form. In the four records reviewed, two of them contained documentation of the treatment plan
reviews being completed every thirty days as required. The remaining two records had
treatment plan reviews being conducted late; one record had ten applicable reviews, with seven
being between one and three days late; the other record had four applicable reviews, with one
being one day late. All four of the Individualized Treatment Plan reviews were signed by the
clinical staff completing the plan and three of the four records had documentation the reviews
were reviewed and signed by the licensed clinical supervisor within ten days of completion. The
remaining record was missing documentation in three out of four reviews of being signed by the
licensed clinical supervisor. Three of the four individualized treatment plans were signed by all
required members of the treatment team who participated in the development of the plan and
included documentation of the Individualized Treatment Plans being mailed to the
parents/guardians. The remaining plan was missing documentation of being mailed to the
parent/guardian. All four of the reviewed Individualized Treatment Plans included documentation
of the prescribed services. All four treatment plans included the same prescribed services which
included four individual sessions, group sessions, and family counseling. Three treatment plans
were applicable for psychiatric services, and they all contained the prescribed psychiatric
services; however, they did not specify how often these services were to occur. All reviewed
Individualized Treatment Plans included goals and objectives individualized for the youth. Video
observations and sign-in sheets were reviewed for non-primary mental health groups conducted
at the program. A comparison of video to the logbooks and sign-in sheets, verified the facilitator
and groups were conducted at the required group time and length. Three days of groups were
observed on video which confirmed all groups were being held for the appropriate amount of
time.
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.
Five youth mental health records were reviewed for treatment and discharge planning. All five
youth records included documentation the youth were assigned a treatment team upon arrival to
the program. This was evidenced by the initial and Individualized Treatment Plans. The mental
health records do not include a separate form for treatment teams. The Individualized Treatment
Plan reviews are the documentation for treatment teams. The following treatment team
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members were documented in attendance of treatment plan updates: youth, mental health staff,
and parent/guardian. Five youth mental health records were reviewed for mental health and
substance abuse treatment services. All five youth records included documentation on their
Initial Treatment Plans to need individual therapy, group therapy, and family therapy, to be
provided by a licensed qualified professional or a non-licensed substance abuse clinical staff.
One of the reviewed youth records lacked documentation of family counseling being provided in
one of the two months required. Four applicable youth had a properly executed Authority for
Evaluation and Treatment (AET) form located in each youth’s medical record. One youth was
under the custody of the Department of Children and Families (DCF) and had a signed court
order from the judge authorizing medical treatment. All five youth records included
documentation each youth provided consent through a signed Youth Consent for Substance
Abuse Treatment as well as signed a Youth Consent for Release of Substance Abuse
Treatment Records forms. All five youth records included documentation treatment notes were
documented on progress notes form which contained all the elements as the Department’s
Counseling/Therapy Progress Notes form. The mental health and substance abuse group
therapy included individual psychotherapy or counseling and psychosocial skills training. All five
reviewed records verified each youth received group and individual therapy as prescribed on the
Initial Treatment Plan. Four of the five reviewed records verified each youth received family
therapy as prescribed, with the remaining reviewed record missing documentation of one of two
required family sessions.
Three closed youth records were provided to review the Mental Health/Substance Abuse
Treatment Discharge Summary. All three closed records included documentation of the youth’s
discharge plan documented on the Department’s Mental Health/Substance Abuse Treatment
Discharge Summary form. None of the youth were released on suicide alert or suicide
precautions. The Mental Health/Substance Abuse Treatment Discharge Summary documented
the future services needed. All three youth records included documentation the discharge plans
were discussed with the youth, parent/guardian, and juvenile probation officer (JPO) during the
exit conference. All three records included documentation a copy of the Mental
Health/Substance Abuse Treatment Discharge Summaries were provided to the youth,
parent/guardian, and assigned JPO.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program provides specialized treatment through substance abuse overlay services (SAOS)
and mental health overlay services (MHOS). The program’s required clinical groups according
to the contract are Cannabis Youth Treatment (CYT), Living In Balance (LIB), Aggression
Replacement Training (ART), and Dialectical Behavior Training Skills (DBT). Five youth were
interviewed and reported they receive individual counseling. Four of five youth receive family
counseling. Individual counseling ranges between every week to every other week and family
counseling happens twice monthly. The remaining youth who does not participate in family
counseling stated because they are nineteen years old, they do not require it; however, they do
speak to a family member weekly. Five staff were interviewed regarding facilitation of mental
health and substance abuse groups. All five staff reported they do not facilitate mental health or
substance abuse groups. The designated mental health clinician authority (DMHCA) was
interviewed regarding mental health and substance abuse services provided at the program.
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The DMCHA reported the program provides CYT, LIB, and Processing Group for SAOS, and
DBT for MHOS. All youth receive individual and family therapy. The facility administrator was
interviewed and stated the specialized treatment services include individual, group, and family
substance abuse treatment. Mental health treatment is also provided through individual, group,
and family sessions.
The program provides MHOS and SAOS services through individual, group, or family therapy at
least five days a week. Based upon the review of documentation, the DMHCA is on-site for
forty-hours each week. Licensed mental health staff were on-site at least five days each week.
The counselor-to-youth ratio for MHOS youth at the program is one-to-ten and one-to-fifteen for
SAOS youth. The non-licensed staff held a master’s-level degree. The program is providing
individual therapy at least once every two weeks, or more often as needed and the psychiatrist
provided services at least once every two weeks. Four of the five reviewed youth received
monthly family therapy, the remaining youth was missing one of two applicable months. A
licensed psychologist/licensed mental health counselor/board certified behavior analyst
provided on-site services as needed. Four mental health group therapy sessions were being
held each week for all youth. No youth missed mental health services due to being on medical
quarantine.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a licensed psychiatrist with a valid license which expires January 31, 2027.
The psychiatrist is available for emergency consultation twenty-four hours, seven days a week.
The psychiatrist’s evaluation and recommendations for the youth are incorporated into the
youth’s individualized mental health or substance abuse treatment plans. The program does not
utilize a psychiatric advanced practical registered nurse (APRN). The sign-in/out logs were
reviewed and confirmed the psychiatrist was on-site weekly, as required, during the annual
compliance review period. The psychiatrist actively participates in, manages, and supervises
psychotropic medication services in the program. The program does not utilize a back-up
psychiatrist. The program does not utilize tele-psychiatry. The psychiatrist was interviewed and
reported they provide an intake evaluation on all youth who enter the program. They provide
ongoing medication management for those who enter on meds and provide evaluations for any
youth who the treatment team has mental health concerns for at the program. They are on-site
weekly and will participate in treatment team meetings as necessary. They meet with the
designated mental health clinician authority (DMHCA) on a weekly basis or as needed. All
services are provided face-to-face. They do not have any concerns with the program's mental
health or substance abuse services. The DMHCA was interviewed regarding psychiatric
services. The DMHCA advised they meet with the psychiatrist weekly or as needed to staff any
youth receiving psychiatric services.
All youth who are admitted to the program receive an Initial Diagnostic Psychiatric Interview. All
five reviewed records contained an Initial Diagnostic Psychiatric Interview completed within
fourteen days of admission. All five records contained an initial interview with all required
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elements of history, a mental health status examination, the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) diagnosis, and treatment recommendations. The initial
diagnostic interview was documented on the Department’s Clinical Psychotropic Progress Note
(CPPN) form, including page three, which was clearly identified as the Initial Diagnostic
Psychiatric Interview. Two of the five reviewed records indicated the youth entered the program
on medications and were continuously prescribed psychotropic medication. The two applicable
youth initial interviews also contained prescribed medications, explanation of the need for
psychotropic medication, target symptoms, initial treatment goals, potential side effects, risks
and benefits of taking the medication, and frequency of medication monitoring/management. An
additional youth was placed on medication by the psychiatrist four months after arriving to the
program. Three applicable youth records documented medication reviews by the psychiatrist at
least once every thirty days. One record had a medication review completed in the past the
thirty days; however, the youth was off-site at a Baker Act facility when the review was due.The
medication review was completed as soon as the youth returned to the program. The psychiatric
evaluations were documented on the CPPN which included the youth’s identifying data,
diagnosis, target symptoms of each medication, evaluation and description of effect of
prescribed medication on target symptoms, prescribed psychotropic medication, side effects,
and the youth’s adherence to the medication regime. All three CPPNs indicated there was
telephone contact with the parents/guardians to discuss medication when necessary. The
psychiatrist signed and dated each of the reviewed CPPNs. Monthly monitoring of Tardive
Dyskinesia was also documented for all three youth.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program maintains a written plan detailing suicide prevention procedures. The program’s
Suicide Prevention Plan was reviewed and included all required elements of identification and
assessment of youth at risk of suicide, staff training, suicide precautions, levels of supervision,
referrals, communication, notification, documentation, immediate staff response, and a review
process for suicide attempts and mortality reviews. The suicide attempts and mortality review
process included the following elements: circumstances surrounding the event, facility
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. The Suicide Prevention Plan was reviewed by the facility administrator and
the designated mental health clinician authority (DMHCA). They signed the plan on October 21,
2024.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
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Five youth records were reviewed and only one was applicable for suicide prevention services;
however, this youth had two applicable incidents which were reviewed. One additional
applicable record was provided and reviewed. In one record reviewed, the youth was
determined to be at risk through staff observation; in the other reviewed record, both incidents
indicated the youth was determined to be at risk by self-representation. All three incidents had
Assessments of Suicide Risk (ASR) completed on the Department’s ASR form. All three
incidents resulted in the youth being placed on Constant Supervision. All three incidents had
documentation showing both the parents/guardians and juvenile probation officers (JPO) were
notified of the youth’s potential suicide risk. Each incident had documentation of mental health
staff providing supportive services. The designated mental health clinician authority (DMHCA)
completed all three incidents. The record reviewed for one incident showed documentation the
ASR resulted in a recommendation to continue precautionary observation. The reviewed record
with two incidents showed documentation the ASR resulted in one recommending to continue
Precautionary Observation and one to transition to Close Supervision. All three ASRs were
completed within twenty-four hours of screening/concerns and all were completed by licensed
staff. The record reviewed for one incident documented the youth was on Precautionary
Observation and was transferred to another facility for placement. The reviewed record with two
incidents had documentation of the facility administrator documenting the discontinuation of
close supervision in the facility logbook as well as documentation of the actual date/time
clinician conferred with program director or designee and licensed mental health professional
recorded on the ASR in the date/time sections. All three reviewed incidents confirmed the ASR
was conducted immediately if the youth was in crisis. The reviewed record with two incidents
had documentation of both incidents having a follow-up ASR completed prior to the removal of
the youth from Precautionary Observation and the follow-up ASR was completed on the
Department’s Follow-Up ASR form. In both incidents, the youth was maintained on suicide
precautions and either one-to-one or Constant Supervision until the follow-up ASR indicated
suicide precautions could be discontinued. In both reviewed incidents, after the follow-up ASR
indicated suicide precautions could be discontinued, the youth was stepped down to Close
Supervision prior to transition to normal routine and Standard Supervision. Both reviewed
incidents confirmed Close Supervision was maintained until it was no longer determined
necessary by the DMHCA, there was documentation of a conference held by the program
director and licensed mental health professional to reduce the level of supervision, and the
discontinuation of Close Supervision was documented in accordance with the program’s Suicide
Prevention Plan. In all three reviewed incidents, the program entered a suicide alert into the
Department’s Juvenile Justice Information System (JJIS) for the youth placed on suicide
precautions. In all three incidents, the suicide risk alert was accurately closed following the
recommendations of the ASR or follow-up ASR. In all three incidents, there was documentation
in the facility logbook indicating administration or supervisory staff provided instructions related
to the ASR findings and suicide precaution decisions. In all three incidents, while on
Precautionary Observation, each youth was allowed to participate in select activities with other
youth in designated safe housing/observation areas of the facility. There were two incidents of
videos to review to verify Precautionary Observations. Both reviewed incidents showed the staff
stayed in constant supervision with the youth.
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated “Non-
Applicable.”
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3.13 Suicide Precaution Observation Logs (Critical) Limited 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.
Five youth records were reviewed and only one was applicable for Suicide Precaution
Observation (PO) logs; however, this youth had two applicable incidents which were reviewed.
One additional applicable record was provided and reviewed. In all three reviewed incidents, the
PO logs were maintained for the duration the youth was on suicide precaution. In one record
reviewed, the appropriate level of supervision and observations of the youth’s behavior was
documented in real time and did not exceed thirty-minute intervals. In the second record
reviewed, a total of twenty-one Precautionary Observation Logs were reviewed for all incidents.
Sixteen of the twenty-one logs had one or more late checks documented; one log had a three-
hour gap and another had a four-hour gap. Nine logs were missing a supervisor signature
and/or the date and time.Nineteen of the twenty-one logs had no notation of warning signs
being observed, and there was no documentation of notification to the program director or
designee and mental health clinical staff. One log had indication of pre-populated times being
documented. One log was missing a mental health clinical staff signature. None of the logs
reviewed documented safe housing requirements.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Five in-service and five pre-service training records were reviewed for suicide prevention
training. Three of five in-service training records indicated the suicide prevention training was
completed. All five of the pre-service training records indicated the suicide prevention training
was completed. The program maintains two suicide response kits. One is located in the Medical
Office, and one is located in a Mechanical Closet. The suicide response kits are co-located with
first-aid kits. Mock suicide drills were reviewed for the program. Mock suicide drills were held no
less than quarterly. Video review indicated drills were simulated. All mock mental health drills
were in response to a suicide attempt and/or incident of serious self-injury simulated. None of
the program youth were used in the drill simulations. The program provided documentation
showing semi-annual training on emergency response procedures which include mock training
in emergency response to a suicide attempt or incident of serious self-inflicted injury with the
use of cardiopulmonary resuscitation (CPR). Any staff who were not present during a quarterly
drill had the opportunity to review each drill scenario and procedures in an effort to understand
the process and receive the necessary training to respond to an incident of a suicide attempt or
incident of serious self-inflicted injury in the program. The facility administrator was interviewed
and advised training and mock drills for staff are completed monthly. Five staff were interviewed
about frequency of medical emergency and suicide drills conducted on their shift. Three staff
indicated they are done monthly, one staff stated they have participated in at least four or five
since being hired in July, and the remaining staff had only been hired less than a month and had
not yet participated in a drill.
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3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has an integrated mental health crisis intervention and emergency mental health
substance abuse services plan. The plan included all required elements of notification and alert
systems, means of referral including youth self-referral, communication, supervision,
documentation, and review.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
Five records were reviewed for Crisis Assessments. One of the five youth were applicable for
Crisis Assessments. Only one additional record was requested and provided for review. Both
reviewed records included documentation a Crisis Assessment was completed timely based on
the needs of the youth. Both Crisis Assessments included the following documentation: reason
for assessment, Mental Health Status Examination and interview, determination of danger to
self and others, initial clinical impressions, supervision recommendations, treatment
recommendations, and recommendations for follow-up or further evaluation. Both
parents/guardians were notified of follow-up treatment. The designated mental health clinician
authority (DMHCA) conducted the Crisis Assessments for both youth. The youth were not
placed on suicide precautions after completion of the Crisis Assessment; therefore, a mental
health alert was not necessary to be put into the Department’s Juvenile Justice Information
System (JJIS). Both youth were part of an alleged Prison Rape and Elimination Act (PREA)
event and a Crisis Assessment was completed for both youth. The youth received on-going
mental health treatment services.
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3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written emergency mental health and substance abuse plan. The
emergency mental health and substance abuse services plan included the following elements:
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 under Chapter 394, transport for emergency substance abuse
assessment and treatment under Chapter 397, documentation, training, and review.
3.18 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Five youth records were reviewed and only one was applicable for Baker and Marchman Acts;
however, this youth had two applicable incidents which were reviewed. One additional
applicable record was provided and reviewed. When the youth was determined to be in need of
emergency care, the staff entered a mental health alert, placed the youth on Precautionary
Observation (PO), and referred the youth for placement under Baker Act in all three records.
The notification was made by the program’s licensed mental health professional (LMHP). Mental
health staff was involved in all three records and all three youth were taken out of the program
and transported by law enforcement, which was authorized by the program’s facility
administrator (FA). Upon return to the program from the Baker Acts, the youth was placed on
Constant Supervision in all three records. A mental health referral was completed indicating a
Mental Status Examination (MSE) to be conducted for all three records. An Assessment of
Suicide Risk was completed by the LMHP in two of the records, the third was completed by a
non-licensed mental health staff and was reviewed by the LMHP. All three records reflected the
youth supervision levesl were not lowered until an appropriate assessment was conducted.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Five records were reviewed for the Safety Planning Process for youth. In all five records, the
safety plan was completed within fourteen days of admission. In four of five reviewed records,
the plans were jointly prepared with the youth, parent/guardian or family member, the program’s
clinical staff, and behavioral specialist, if applicable. The remaining record did not have
parent/guardian involvement in the preparation of the plan. In four of five reviewed records, the
safety plan incorporated recommendations from previous or current clinical assessments or
screening instruments; one record did not include this documentation. Only four of the five
reviewed records were applicable for safety plan updates, one youth had not been at the
program for thirty days. In the four applicable records reviewed, the plan was not reviewed or
updated as required. Ten out of twenty reviewed plans were not updated in the required
timeframe, ranging from one day to nine days late. There were no significant behavioral or
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mental health events in any records reviewed warranting an update. In five reviewed records,
four of the safety plans included warning signs, youth’s baseline behaviors, crisis recognition,
jointly developed coping strategies, intervention strategies preferred by the youth; the remaining
record did not include baseline behaviors.
All five records reviewed confirmed the safety plans are reviewed by staff who have contact with
the youth. The safety plans are maintained in the youth’s mental health records as well as in a
safety plan binder. Five youth were interviewed, and all confirmed they contributed to their
safety plan. The facility administrator was interviewed and stated safety plans are updated every
thirty days.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a licensed medical doctor (MD) with specialty training in Family Practice who
serves as the designated health authority (DHA). The DHA holds an unrestricted license and
meets all requirements for independent and unsupervised practice in Florida. The DHA has a
clear and active license, expiring January 31, 2026. The DHA did not have any disciplinary
cases or public complaints on record for the period of the annual compliance review. The
program does not utilize a physician’s assistant (PA) or advanced practice registered nurse
(APRN). The DHA is contracted to be on-site one time each week. A review of sign-in/out logs
for the duration of the annual compliance review period showed the DHA was on-site as
required. The program utilizes a back-up DHA, who has an active license, expiring on January
31, 2026. This doctor is not the official DHA back-up as there is no contract with the
Department; however, the back-up DHA was not utilized throughout the review period. The
program does not utilize tele-health services.
An interview with the DHA revealed their role covers policy and procedure review and/or
development. The DHA also conducts comprehensive physical assessments (CPA), focused
reviews, sick call, chronic disease management and periodic evaluation. The DHA also provides
twenty-four hour a day, seven days a week phone consultation. The DHA is also on site once a
week and utilizes charting, care plans, and verbal communication with program staff. All outside
care is reviewed once a week for further medical planning. Care plans are charted and
discussed at the time of the visit and follow-ups are entered on a calendar and tracked in a
binder.
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 registered nurses (RN) on-site for nursing coverageas required . The program
has not utilized any licensed practical nurses (LPN) during the annual compliance review period.
The program had four RNs, which provided medical services during the annual compliance
review period. Each of the four RNs had clear and active licenses in accordance with the Florida
Department of Health. Each of the four nurses had current cardiopulmonary resuscitation (CPR)
certifications. The program’s required on-site hours for the nursing staff were in accordance with
contract; seven days a week for forty hours each. The program’s nursing staff were found in
compliance with contract requirements which include the provision of four nurses.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOP) for all health-related procedures and
nursing protocols, all of which were developed and approved by the designated health authority
(DHA). The DHA, program director, and nursing staff all completed an annual review of the
policies and protocols. The DHA signed on February 25, 2025, the psychiatrist signed on
February 26, 2025, and the facility administrator signed on January 23, 2025. Each of the four-
nursing staff signed on February 26, 2025. All newly employed health care personnel received a
comprehensive clinical orientation to the Department’s health care policies and procedures
which was conducted by a registered nurse (RN). The approval of treatment protocols or
standing procedures are written and authorized by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of
the Authorization for Evaluation and Treatment (AET). Four of the five youth had an AET filed
within their IHCR. One record was applicable for being under the care of the Department of
Children and Families (DCF), and had a court authorization for treatment and procedures. Each
of the four AETs were signed by the parents/guardians. There were no AETs found where a
parent/guardian refused to sign. Each of the four AETs were valid and did not need a court
order. Each of the four AETs reviewed had a signature by a Department representative. None of
the youth were eighteen years or older.
An interview with the nursing staff revealed the program obtains a new AET from the
Department’s Juvenile Justice Information System (JJIS). If the AET is greater than one year
old, they notify the juvenile probation officer (JPO) for a current AET. If the youth is in DCF
custody, there needs to be a court order authorizing medical care. For youth who are eighteen
or older, the youth will sign a release of information form. The original AET is also kept in the
medical chart.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of
parental notification/consent. Four of the five IHCRs reviewed were applicable for parental
notification for over-the-counter (OTC) medications beyond those covered by the Authority for
Evaluation and Treatment (AET). Four of the five records documented consent provided by the
parent/guardian and was stored in the IHCR. One youth was under the care of the Department
of Children and Families (DCF). A review the youth’s record revealed documentation of a court
order for authorization for treatment and procedures. Each of the five records reviewed were
applicable for having new medication ordered, with four of the five records having
documentation of attempted contact made to the parent/guardian in progress notes, along with
the Parental Notification form being completed. Two youth records indicted youth were on
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psychotropic medication at the time of admission. For the youth on psychotropic medication,
there was documentation staff witnessed all telephone call attempts and conversations. For any
significant changes to the youth’s medications, parent/guardian verbal consent was received
and documented on the Parental Notifications form and the nurse progress notes. Each of the
five youth IHCRs reviewed had documentation where the program received and verified
vaccinations within thirty days of the youth’s admission to the program. None of the youth were
applicable for obtaining new vaccinations or requests for religious exemption. The health
services administrator (HSA) reported all youth came in with their immunization records. If the
records are not with the youth at admission, the program uses Florida Shots to obtain new
records or to verify the records on hand. The HSA revealed parental notifications are required
when there are changes in the youth's health condition, when there are changes in medication,
recommended treatment, dental treatments, and when the youth returns to the facility from an
outside appointment. These are sent out as soon as the order is received by the nurse. In an
emergency, verbal notification must be made, along with written notification. The designated
health authority (DHA) and facility administrator (FA) will be notified immediately, along with the
Department’s Central Communications Center (CCC) within two hours, if the youth requires off-
site emergency care. For new medications, the parent is contacted by the psychiatrist to explain
the purpose and possible side effects of any new medication or discontinuation of medication.
These calls are also witnessed by the nursing staff. Immunization records are obtained through
Florida Shots and are reviewed upon admission. If a parent claims exemption and does not give
consent for vaccinations, then they are required to complete the Religious Exemption form and
submit to the facility.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of a
Facility Entry Physical Health Screening (FEPHS). Each of the youth had a FEPHS completed
by a registered nurse (RN) on the day of admission. One of the reviewed IHCRs showed the
youth had a change in physical custody greater than twenty-four hours. The program completed
a new FEPHS upon the youth’s return to the program each of the six times the youth was out of
the custody of the program.
An interview with the nursing staff revealed all youth are seen by nursing staff first upon arrival
to the facility. Nursing staff are notified by email from the commitment manager about youth who
are scheduled to arrive. The RN on duty completes the admission screening. If the screening is
completed by direct care staff, nursing staff will review the screening and sign the form. Any
time there is a change in custody for a youth, the program will complete a new FEPHS form.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of a
youth orientation to healthcare services. Each youth record had documentation of receiving a
general care admission orientation. Each orientation included all required topics. The program
requires each youth to sign an orientation completion sheet which is located in the IHCR. The
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program conducts health education at the time of admission and as needed. The health
education covers all required topics and is documented on the Department form. Prenatal,
postpartum, and parenting education is not applicable in the health education for this program.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion for
notification of the designated health authority (DHA) and/or designee. Two of the five youth
were applicable for known suspected chronic conditions. An additional record was requested,
and received, to ensure a sample of three records were applicable for chronic conditions. Each
youth record had evidence of a referral to the DHA upon admission. There were no youth in
need of emergency care upon admission. All six records included documentation the DHA was
notified of the youth’s admission to the program within twelve hours. Two of the six records
indicated a youth was taking psychotropic medication at the time of admission and the
psychiatrist was notified.
An interview with the nursing staff revealed the DHA is notified, by the registered nurse (RN) on
duty, immediately if a youth is admitted with a serious or chronic condition. This communication
is documented in the nursing progress notes.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of a
Health-Related History (HRH) forms. Each of the five reviewed IHCRs showed a completed
HRH within seven calendar days of admission. Each of the five HRHs were completed prior to
the Comprehensive Physical Assessment (CPA) and were reviewed by the Designated Health
Authority (DHA). An interview with the nursing staff revealed the HRH is completed immediately
upon the youth’s arrival, during the admission process, by the registered nurse (RN) on duty.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
A review of five Individual Healthcare Records (IHCR) was conducted for completion of a
Comprehensive Physical Assessment (CPA). Each of the youth had a new CPA completed
within seven days of admission by the designated healthcare authority (DHA). There was no
indication of any missing or incomplete elements on the reviewed CPAs. All sections of the CPA
were completed in full utilizing an “O” and/or “X” markings. Four of the five youth refused the
genital examination and subsequently documented the refusal which included the youth’s
signature. One youth was not-applicable, with the DHA notating an exam was not needed. Each
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of the IHCRs had the Department’s Problem List updated as required. Additionally, results of
each youth’s Tuberculosis Skin Test (TST) were documented on the CPA and Department’s
Infectious and Communicable Disease (ICD) form. An interview with nursing staff revealed the
CPA is completed within seven days of the admission by the DHA and annually if the
medication grade is greater than two. Upon admission, the purified protein derivative (PPD) is
checked, and the next tuberculosis screening date is documented. These screenings are done
annually.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
A review of five Individual Healthcare Records (IHCR) was conducted for completion of sexually
transmitted infections (STI) screening. Each of the youth was screened and four of the five
IHCRs documented the youth was sexually active and was referred to the designated health
authority (DHA) for further evaluation. Each of the four youth were screened and evaluated. One
reviewed youth required further evaluation, which was documented on the screening tool.
Testing for this youth was ordered, completed, and results were documented on the Infectious
and Communicable Diseases (ICD) form. There is evidence each youth was offered counseling,
testing, and if indicated, treatment/referral for human immunodeficiency virus (HIV). One of the
five IHCRs reviewed indicated a youth received HIV testing with the other four youth not
consenting to testing. There is documented consent for the HIV testing and the results were
filed in a sealed envelope marked “Confidential”. There is evidence of documentation of
pre/post-test counseling documented in the IHCR and nurse progress notes. The youth’s
confidentiality was protected by not including the youth’s HIV status and any other STI diagnosis
on the program’s internal alert system. The program maintains policy and procedures which
reflect HIV test results are only disclosed to the youth and other entities as described in Florida
Statute, Chapter 381. The health services administrator (HSA) reported the DHA provides HIV
pre and post-test and counseling services for the youth at the program.
Each of the five interviewed youth reported they can request a HIV/AIDS test at any time. An
interview with nursing staff revealed all youth are screened utilizing the STI Screening form
upon admission and the DHA decides if testing is needed during their initial comprehensive
evaluation. Results for any testing are filed in the lab section of the chart and noted on the ICD
form/STI screening. If a youth is out of the program for more than thirty days, they will complete
a STI form upon re-entry. The HIV results are kept in a sealed envelope and stamped
“Confidential”. They are placed in the lab section of the chart. If the youth consents to HIV
testing, pre- and post-counseling services are provided by the DHA. The counseling will be
documented under the youth's individual education record in the youth's chart.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
A review of five Individual Healthcare Records (IHCR) was conducted for a review of the sick
call process. None of the youth had similar sick call complaints three or more times within a two-
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week period. Each of the five youth and the nurse completed a sick call request form. Each of
the five youth’s sick call request forms were filed in the IHCRs. No youth were placed on
restricted housing. Each of the five IHCRs had documentation of sick call forms or progress
notes documented as required. Each of the five youth’s sick calls were documented on the Sick
Call Index and Sick Call Referral Log. The dates listed on each Sick Call Index corresponded to
the completed Sick Call forms located in each IHCR. A review of the daily schedule, posted
schedule, and nurse interview confirmed sick call was conducted daily. Sick call hours and
forms are posted outside on youth dorms and in the common area (pavilion). The sick call times
for the program are daily from 7:00 a.m. to 8:00 a.m. and from 2:00 p.m. to 4:00 p.m. According
to the health service administrator (HSA) only licensed nurses conduct sick call. The program
has written policy and procedures identifying review of sick call requests for non-medical staff if
there are no licensed medical staff on-site. An examination table was observed in the medical
clinic. During the annual compliance review week, a sick call was not able to be observed as
none were requested.
Five youth were interviewed. Each of the youth indicated the nurse will conduct sick calls within
one day of a sick call request being submitted. An interview with nursing staff revealed the youth
complete a sick call form and put it in the secured sick call box in the pavilion, which is checked
twice a day. Sick call is conducted in the clinic by the registered nurse (RN) or designated
health authority (DHA) if they are on-site during sick call hours. If a youth presents with the
same complaint three times within a two-week period, the youth must be referred to the DHA.
The DHA approves treatment protocols. The program does not utilize restricted
housing/confinement.
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.
A review of five Individual Healthcare Records (IHCR) was conducted for a review of the
episodic/first-aid/emergency care process. Two of the five records were non-applicable. All
three applicable records indicated the youth required on-site first-aid or episodic care. Each of
the three applicable IHCRs had documentation the on-site care was provided by licensed
healthcare staff and was documented either in problem-oriented or standard narrative charting.
There were no instances of youth receiving episodic, first-aid and/or emergency care by non-
healthcare staff. An episodic care event was not observed during the annual compliance review
as no event took place while the team was onsite.
The program maintains episodic and emergency care procedures. There are a total of nine first-
aid kits located throughout the program. The first-aid kits are in the sub control for modules A
and B, master control, kitchen, maintenance, van one, van two, classroom one, and classroom
two. Two of the nine kits are utilized for transportation. The registered nurse (RN) conducts
weekly checks on each first-aid kit and documents it in the first-aid kit logbook. A review of the
logbook was conducted and found no issues. Each first-aid kit contains a sheet at the front with
designated health authority (DHA)-approved contents and expiration dates. The RN will replace
expired contents and re-seal the kits as needed. If a first-aid kit is used, the staff will bring the
used first-aid kit to medical for inventory and to be re-sealed. A review of three first-aid kits was
conducted with no issues. The program has one automated external defibrillator (AED), located
in the pavilion (common area), along with the written procedures. The health service
administrator (HSA) is responsible for ensuring the AED batteries and pads are operable.
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Nursing staff conducted a self-test of the AED with no issues observed. A review of
documentation confirmed the AED batteries are set to expire October 31, 2027, while the AED
pads are set to expire on July 19, 2026. The AED batteries were last changed in March of 2022
and the pads were last changed in August of 2024. While conducting the facility tour, a list of
emergency numbers was observed posted in the medical clinic and was accessible to non-
licensed and licensed staff. The numbers are not accessible to youth.
A review of five staff records showed each of the staff were missing components of episodic,
first-aid, and emergency care which was documented in staff training. Four out of five staff had
not completed training in Infection Control, Blood-borne Pathogens, and Exposure Control Plan.
All staff were certified in cardiopulmonary resuscitation (CPR) and first-aid. A review of the
program’s episodic, first-aid, and emergency care drill documentation, reflected drills were
completed on each shift. The drills were completed quarterly, at a minimum, during the annual
compliance review period. The drills consisted of both announced and unannounced type drills.
Not all drills conducted included the administration of cardiopulmonary resuscitation (CPR)
techniques but frequency of inclusion met the threshold of the program’s policy and procedures.
A review of the staff list showed four of thirty-three staff did not participate in a medical drill
utilizing CPR/AED with the annual review period. In addition, each of the reviewed drills
included the initiation of emergency procedures and addressed the application of first-aid
practices. Each drill is documented and stored in the program’s drill logbook. Video was
reviewed for one drill. The drill was simulated and utilized staff in real time, including the use of
CPR and the AED.
The program has policy and procedures which outline the use, access, and inventory of
Naloxone. All staff will be trained to recognize general signs and symptoms of opioid overdose
and to administer Naloxone nasal spray. Naloxone will be available to trained staff twenty-four
hours a day. All Naloxone use, by staff, will be documented and reported to program director,
who will then notify the appropriate chain of command. Nitrile gloves will be stored with
Naloxone. Daily medication counts, including Naloxone, is conducted.
Five interviewed staff reported if they witness a youth having a medical emergency, they are
allowed to call 9-1-1, depending on coverage. If they are unable to leave the area due to ratio,
they notify a supervisor and the supervisor contacts emergency services. All five interviewed
youth confirmed if needed, they are able to see a dentist and/or a doctor. An interview with the
nursing staff confirmed the location of first-aid kits. Episodic care is provided by the RN. A note
is placed in the chart. If episodic care is conducted by non-health care staff the Department form
is completed and a follow up is conducted by the RN within 24 hours. Off-site care is tracked in
the calendar and the episodic logbook. The program has an AED and AED procedures are
located in the pavilion. The RN is responsible for checking the batteries and pads are operable.
The nurse also confirmed procedures for the emergency drills.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of
off-site care referrals and two were applicable. One additional record was requested and
provided for review. For the three applicable IHCRs, each indicated the youth required off-site
care. Each of the three IHCRs indicated the Summary of Off-Site Care Consultation Report was
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utilized and filed. Each of the three incidents were logged on the Episodic Care Log. Each of the
three IHCRs contained parental notifications, discharge documents, and documented review of
discharge documents by the designated health authority (DHA). One of the three applicable
records indicated a need for follow-up testing, referrals, or appointments, and had documented
evidence of completed follow-up visits.
An interview with the nursing staff revealed the program utilizes calendars and episodic logs to
track off-site care for first-aid or emergency care needs. When hospital orders are received, the
nurse calls the DHA for a telephone order to continue the orders. The orders are then faxed to
the pharmacy and transcribed to the Medication Administration Record (MAR). The medication
pass list is then updated and the parent is notified by phone and mail. Off-site summaries with
all attachments are placed in the DHA book to review and sign during the next visit to the
program. Follow-up testing, referrals and appointments are tracked on the appointment tracker,
book, calendar, and episodic log.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of
chronic condition/periodic evaluations. Two of the five youth were applicable for having a
chronic condition. A third record was requested and provided for review. None of the youth were
identified as having a communicable disease. Each of the three applicable youth were actively
taking prescribed medication on an on-going basis. One of the three youth was undergoing
treatment for a physical health condition. Two of the three youth were classified with medical
grade two to four. Each of the three youth were applicable for periodic evaluations. Two of the
three youth have not been at the program for ninety days; therefore, they were not due for a
periodic evaluation. One youth was applicable for periodic evaluations. Two of the four
evaluations were completed within the required timeframe, the remaining evaluations were one
and two days late. None of the youth received evaluations off-site. There were no indications of
lapses in care. Each of the three IHCRs confirmed the Department’s Problem List was updated
in accordance with the Health Services Rule.
The facility adminsitrator was interviewed regarding the program’s formalized procedures for
communication with healthcare staff for important youth medical issues. The facility
administrator revealed the program utilizes daily morning meetings, medication management
meetings, and the psychiatrist attending clinical supervision as formalized procedures to review
important youth medical issues. An interview with the designated health authority (DHA)
revealed periodic evaluations for youth with chronic conditions are completed every thirty to
ninety days depending on stability. They are tracked on a calendar and in the binder. An
interview with the nursing staff revealed all youth with chronic conditions are seen every three
months. This is monitored by all nurses on the medical tracker and in the chronic clinic book.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of
medication management practices. Two of the five IHCRs was applicable for being admitted on
psychotropic medications. For the applicable records, the Facility Entry Physical Health
Screening (FEPHS) form and progress notes were completed, indicating the youth was
admitted with medications. Documentation confirmed the medication was verified and
documented in the Chronological Progress note in the IHCR. Documentation confirmed the
designated health authority (DHA) and the psychiatrist were contacted to obtain the prescription
to resume the specified medications prior to admission. Each of the medications for the
applicable records had a current and valid prescription. No youth were placed in restricted
housing. Three of the five youth reviewed were provided over-the-counter (OTC) medications
which were administered according to the approved protocols. Each of the five IHCRs had start
and stop dates for medication on the individual Medication Administration Record (MAR). None
of the reviewed records indicated any non-healthcare staff assisted in the administration of
medication. There were no lapses or errors in medication administration for the annual
compliance review period. Weekly side-effect monitoring was documented on the MAR. One of
five youth refused medications by signing the refusal of treatment form and on the MAR. Each
of the MARs had the correct youth’s name, Department identification number (DJJID), date of
birth, allergies, precautions, medical grade, medical alerts, and current photo of the youth. None
of the reviewed youth required parenteral medication. Two of the five youth was applicable for
being prescribed psychotropic medication at the time of admission. Documentation in the IHCR
confirmed the DHA and psychiatrist were notified upon admission. The youth received an initial
diagnostic psychiatric interview within fourteen days of admission and received a
monitoring/review within every thirty days. There were no standing orders, emergency treatment
orders, or pro re nata (PRN) orders for psychotropic medication. Medication delivery shall be the
sole responsibility of the nurse/staff person during the time of administration. A medication pass
was observed during the annual compliance review. The youth approached the nurse
individually and was escorted by the floor supervisor. The nurse identified themselves, verified
the Six Rights of Medication Administration, prepared and administered the medication, and
checked to ensure the youth utilized the topical medication. The youth received OTC
medication, which was documented on the MAR. There were no medications observed to be
pre-poured.
Four of the five interviewed youth reported they took medications; however, all five youth were
able to articulate the medication distribution process to include verifying demographic
information and verifying the correct medication is being given. An interview with the nursing
staff revealed all youth medications are verified upon admission using the Prescription
Medication sheet. If the youth did not come from a detention center, all medications must have a
pharmacy label intact with the youth's name on it. Non-health care staff would use the
Department form as well, along with assistance by the on-call nurse. The program utilizes
preprinted pharmacy MARs. The health service administrator (HSA) or registered nurse (RN)
trained the non-licensed healthcare staff for medication administration as evidenced by the list
maintained in the medical office. Medication pass is conducted daily at 7:30 a.m. and 5:00 p.m..
The program maintains a modified Class II permit. Ninety-eight percent of the medications are
procured through the contracted vendor, while the other two percent are procured through the
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community vendor. The program has a psychiatrist who comes on site every week, who
conducts initial psychiatric evaluations, medication management and side effect monitoring.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
An observation of medical equipment classified as sharps confirmed the items are secured and
inventoried utilizing a routine perpetual inventory descending count as each sharp was utilized
and disposed. Additional observation confirmed all medications are identified and secured in the
locked area designated for storage of medications. The medication cart was observed as clean
and organized. During the time of the annual compliance review, the program did not have any
controlled substances. An observation of the medication cart showed if the program does have
controlled substances, they are stored separately within the medication cart, behind an
additional lock. All medications were locked and inaccessible to youth. The program had no
medications which required refrigeration at the time of the review. A refrigerator which is used
for medication storage purposes was observed. The program has a pharmacist who comes on-
site monthly and destroys any expired or discontinued medications which was verified on the
disposal log. Observation also confirmed perpetual and weekly inventories of all sharps and
over-the-counter (OTC) medications was completed along with shift-to-shift inventory count of
all controlled substances. Six training records were reviewed for non-healthcare staff who were
trained by the registered nurse (RN) annually in the administration of medication. A count of
three over-the-counter (OTC) medications and three sharps was completed, with no issues in
inventories. The health service administrator (HSA) reported if there is a discrepancy it will be
verified with another person present (supervisor or medical staff). If the discrepancy is
confirmed, it is reported to the facility administrator, the prescribing doctor, and the
Department’s Central Communications Center (CCC). A search will be conducted. Corrective
action and follow-up training is then conducted, as needed. The HSA revealed the program is
utilizing "Drug Buster" to destroy medicine. Two staff/nurses must dispose of medication. All
controlled medication disposals require the pharmacy consultant and the nurse. This is done on
a weekly basis as required. All controlled substances/narcotics are kept in the medication cart
and double locked. The pharmacy consultant monitors medication care, MARs, medication
disposal, storage of medication, and medication management. The pharmacy consultant license
is maintained on site. The process for secure storage and inventory of medications include the
medication cart is locked behind two locked devices. Medication counts are conducted before
and after over-the-counter (OTC) medication is given and all OTC is inventoried at the end of
the shift. Closet stock medications are counted weekly and kept behind two locked doors.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
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The program has an infection control procedure in place which include prevention, containment,
treatment, and reporting requirements related to infectious diseases, as according to
Occupational Safety and Health Administration (OSHA) federal regulations and the Centers for
Disease Control (CDC) and Prevention guidelines. The policy was reviewed by the designated
health authority (DHA) on February 25, 2025 and the facility administrator on January 23, 2025.
The infection control procedures include all required elements. Staff have access to protective
equipment and hepatitis B immunizations. There were no instances in which the local county
health department, CDC, and/or the Department’s Central Communications Center (CCC)
should have been notified of an infectious disease. The Exposure Control Plan was written in
accordance with OSHA standards and is available to all staff. The plan was reviewed and
signed annually by the facility administrator on January 4, 2025. The plan includes a process for
needle stick post-exposure evaluation. The facility administrator has established a separate file
in the event of any instances of exposure. The program did not have any instances of infectious
diseases which needed to be reported to the local county health department and/or CDC.
The facility administrator was interviewed and revealed the exposure control and infection
control plan is stored in master control and reviewed monthly. An interview with nursing staff
revealed the exposure control binder is in master control, nursing office and in the lobby for all
employees to review. The nursing staff conduct infection control training for staff. Infection
control training is provided to the youth upon admission and annually. The health service
administrator (HSA) and registered nurse (RN) are responsible for providing training to staff for
the program's Exposure Control Plan. The county health department does not provide any
services to the program.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicatr is rated as non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains policy and procedures requiring all program staff to promote safety and
security by maintaining active supervision of youth to include interacting positively with youth,
engaging youth in a full schedule of constructive activities, closely observing behavior of youth,
and consistently applying the program’s behavior management system (BMS). The program
staff are required to account for the whereabouts of youth under their supervision and ensure
staff-to-youth ratios are in compliance with contract requirements. The program’s contract
requires staff-to-youth ratios to be one-to-eight during awake hours and one-to-twelve during
sleep hours. The ratio for off-site activities, transportation, and visitation is one staff to five
youth. Observations of staff supervision for four days during the annual compliance review
included classroom activities, line movement, school breaks, youth head counts, mental health
groups, youth searches, and outdoor/indoor recreation activities. The observations verified staff-
to-youth ratios were maintained, as required. A program tour confirmed the daily youth activity
schedule was posted throughout the program and is designed to keep youth engaged in a full
schedule of activities. The program common areas and living units were clean, well maintained,
and graffiti free. Observations of youth rooms confirmed windows were not covered by any
means which would affect the direct line of sight of youth. A perimeter check was conducted,
and fencing appeared to be in good repair. Staff and youth were appropriately attired. During
classroom activities and/or movement, observations confirmed staff were strategically
positioned to ensure proper supervision of youth. Observations of interactions between program
staff and youth reflected the interactions were positive and consistent with the program’s BMS.
An informal interview with three staff verified each knew the number of youth they were
supervising. Video observations of youth supervision during sleep hours was conducted. The
observations verified youth-to-staff ratio was in compliance, staff were awake and alert, and
conducting ten-minute checks as required.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program maintains policy and procedures addressing the implementation and training of
the program’s behavioral management system (BMS), which included all required parties in the
development, implementation, and on-going maintenance of the system. The policy includes a
protocol where staff are provided feedback of the implementation of the BMS. There is an
agreement between the program and the contracted education provider related to the BMS.
Documentation reflected both the program and education staff were trained in the BMS. A
sample of five pre-service staff training records reflect newly hired staff completed training in the
program’s BMS. Five youth case management records were reviewed confirming youth
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orientation included a review of the program’s BMS. Eight position descriptions were reviewed
verifying each job’s functions includes implementation of the program’s BMS. Displays of the
program’s BMS, which incorporates the rules governing conduct and positive and negative
consequences, were posted throughout the facility in areas accessible to youth to include the
dormitories, cafeteria, and meeting spaces. The BMS is presented to youth in the youth
handbook and includes all the required elements. The BMS does not include increasing lengths
of stay, denial of a youth’s basic rights, promotion of group discipline, punishment of youth by
other youth, or disciplinary confinement. Staff and youth interactions were observed during the
review week for adherence to the elements of the BMS, including rewards and negative
consequences. Documented negative consequences appear to be in direct relation to the
severity or seriousness of the inappropriate behavior exhibited. The program’s BMS includes a
process wherein staff explain to the youth the reason for any sanctions imposed, the youth is
given an opportunity to explain his behavior, the staff and the youth discuss the behavior’s
impact on others and reasonable reparations for harm caused, as well as alternative acceptable
behaviors. The program offers a variety of rewards and incentives, including canteen, mega
Mondays, movie privileges, outings, and the ability to work on facility projects.
Five staff were interviewed about the BMS. Four out of five staff were able to articulate the
program's process of points and levels. The program has rewards such as scholar awards,
canteen, snacks, mega Monday, pizza, movies, game room, and extra outings. All staff verified
youth cannot have any basic rights taken away as a form of consequence. When youth are
given consequences, they are informed either verbally or through writing and they are given the
opportunity to explain their behavior to include having a discipline board meeting.
Each of the five interviewed youth confirmed the program has a system of consequences and
rewards consistently given. Consequences include level restrictions such as a phase-up request
being denied and level freeze, early bedtime, more treatment to address the behaviors, and
write-ups. Rewards include canteen, mega Mondays, movie privileges, outings, and the ability
to perform kitchen duty. Youth are not permitted to punish other youth. The program uses a
point and level system based on behavior. When youth demonstrate good behavior, no write-
ups, and the required amount of points, youth are able to level up each week. Levels begin at
orientation phase then level one which has three sub levels before progressing to level two.
Level two and each subsequent level has six sublevels to progress through. Transition can be
requested in level three, sublevel four and, if approved, a youth enters transition at level four
sublevel two.
The facility administrator was interviewed and stated the program utilizes daily point cards
giving the youth opportunities to earn daily and weekly incentives, “Mega Mondays”, admission
to the honors dorm, and monthly incentives. The youth can earn weekly canteen containing
snacks and upgraded hygiene, and a monthly fast-food canteen. The program utilizes incentive
and level freezes for inappropriate behaviors using a special treatment team form. Emergency
treatment team (ETT) forms, daily point cards, and phase-up requests are reviewed daily in
morning management meetings.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
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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) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program maintains a policy and procedures to ensure ten-minute checks are conducted
when the youth are asleep or in their rooms. The program has a total of sixty-one cameras
which were all operating at the time of the annual compliance review. The program’s video
recording has a thirty-day storage capacity. Staff are required to conduct room checks every
ten-minutes and document the time of the check on the Ten-Minute Check Log when youth are
sleeping. Checks are documented on the program’s Ten-Minute Check Logs with the time of
each check noted in real time along with the initials of the staff conducting each check. A review
of samples of three nights of video footage of both dormitories and Ten-Minute Check Logs,
documented by staff, reflected no discrepancies. An interview with the facility administrator (FA)
and on-site observations confirmed all the cameras were functional during the week of the
annual compliance review. Five staff were interviewed and indicated they conduct checks every
nine minutes on youth who are sleeping in their room or are placed in their room for non-
punishment reasons.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program maintains a policy and procedures to ensure youth are always accounted for
through a system of physically counting youth at various times throughout each day. The
program’s policy is to conduct formal head counts each hour and after outdoor activities. In
addition, the policy indicates counts are conducted during power outages, escapes, program
disturbances, or any other disruptions which may occur. A review of the Continuity of
Operations Plan (COOP) verified program staff must always account for the whereabouts of the
youth in the care and custody of the program. This includes the need for continual head counts
to be conducted minimally, at the beginning of each shift, and during any emergency, and at
regular intervals. Ten randomly selected dates and times in the program’s logbook were
reviewed for census counts during the annual compliance review period. Documentation
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validated head counts were conducted at the beginning of each shift, after outdoor activities and
during actual and/or simulated drills. There were no transfers on the dates reviewed. In addition,
the program logbooks included documentation of new admissions, releases, daily census
counts, youth movements, and youth temporarily away from the program. Observations made
during the annual compliance review week indicated it is the program’s practice to conduct
hourly youth headcounts. Five staff were interviewed. Four staff indicated counts are called
every hour by master control. One staff stated they count youth after each movement. If a youth
count cannot be reconciled staff indicated, they re-count until the count is correct. One staff
stated they also freeze operation until supervisors then physically count every youth to reconcile
the count. Emergency counts are conducted after drills or a code is called, when a youth
departs from their assigned area, or when staff do not have a visual on a youth.
5.06 Logbook Entries and Shift Report Review Limited 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 requiring a chronological record of routine events,
incidents, activities, and emergency situations in a logbook in accordance with Florida
Administrative Code. A review of the program logbooks confirmed the logbooks were bound
with pre-printed numbered pages; however, the logbook for a portion of September, all of
October, and some of November were severely damaged. Pages were torn out and stapled in,
with half of the pages being out of order. The February logbook was found to be missing large
sections of the chronological narrative with no explanation. Observations and a review of
logbooks during the annual compliance review period found logbook entries were documented
in ink with no erasures or white-out errors. Errors were typically struck through with a single line,
dated, and initialed by the staff correcting the error; however, in two of the months, the sampled
days each contained instances of completely scratched through information with no indication of
what was removed or who removed it. The logbook’s highlights, indicating important information
categorized according to color, was inconsistent as well as the supervisor’s turn-over signature
and shift labels. Reviewed documentation of randomly selected days within the logbooks
reflected each entry included the date and time of the event, the names of the staff and youth
involved, a brief description of the event, and the name and signature of the staff making the
entry. The logbook, as well as activity schedule, showed there was minimal interference of
educational instruction, reflected youth arrived to and departed school on time, and indicated
recreation was conducted as scheduled. The program utilizes the program’s logbook to brief all
incoming staff, who sign the staff acknowledgement signature field in the logbook indicating they
have reviewed its contents. A review of the logbooks demonstrated staff documented the
required events, incidents, and activities. The logbook included documentation of incidents,
population counts, perimeter checks, youth transports, emergency situations, admissions,
releases, special instructions for supervision and monitoring of youth, requests by law
enforcement to access a youth, and calls to the Florida Abuse Hotline and the Department’s
Central Communications Center (CCC).
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5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures for assignment, inventory, tracking, secure storage,
missing or lost, and damaged program keys. Keys are bound on a tamper resistant ring which
includes a brass-colored tag with the number of keys and a key/tracking number. Program keys
are maintained in master control in a wall cabinet with the corresponding key number which can
be locked if necessary. Master control is secured and youth do not have access. The program
has a daily key log to track keys. The log indicates the name of staff and what type of key they
are to be assigned according to their position. The program maintains a master inventory list of
program keys. A random check of five different sets of program keys compared to the inventory
list indicated the keys were accounted for and the master control staff knew which area each
key was assigned. Active keys are assigned to direct-care staff while restricted keys are
designated for medical staff, kitchen staff, case managers, and therapists. An interview with
master control staff as well as observations indicated the program’s practice is when direct care
staff arrive to the program, personal keys are placed inside of the box located outside of master
control. Medical staff, kitchen staff, case managers, and therapists receive their respective
restricted keys from master control after their personal keys are placed in the box. Both the
master control operator and staff receiving a program key initial the key log before and again at
the end of the shift when the keys are returned. A review of the key logs and logbooks during
the annual compliance review period verified this practice. In addition, the program has a list of
staff who are assigned permanent keys. The key is not easily accessible while locked.
Permanent keys are issued, staff sign an acknowledgment form indicating a key identification
number, and the number of keys issued. A review of the signed acknowledgment forms
indicated each staff signed for the use of permanent keys. An informal interview with the master
control operator and the physical plant manager confirmed damaged keys would be reported to
the shift supervisor and maintenance request form is complete, which is then given to the
maintenance manager along with the broken key to be replaced. A random check of three staff
verified the number of keys on the key ring matched inventory and each staff knew their
function. A review of the Department’s Central Communications Center (CCC) reports during
the annual compliance review period indicated there were no incidents related to key control.
Five staff were interviewed about the program’s key control process. Staff each indicated they
and any visitors turn in their keys to the box in the master control area. Staff then sign-out their
keys before going on shift. When they leave their shift, the keys are logged back in. Youth are
not permitted to have the keys and three staff indicated when keys are lost, they are searched
for. One staff stated the program freezes operation while the facility is searched, one staff also
indicated youth are searched as well
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
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intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a policy and procedures to identify materials considered to be
contraband, to prevent contraband from entering the program, and consequences when found
in the possession of youth in the program. The program’s youth handbook and policy include a
list of contraband items, outlined in the Florida Administrative Code, and informs youth of the
consequences if found with contraband. Each youth is provided with a written copy of the youth
handbook upon admission into the program and each are oriented to the program rules
including the list of items considered to be contraband. The list of contraband items 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. In addition, the
program’s policy includes contraband search procedures of the physical plant, searching the
program grounds, youth searches, and searches of incoming and outgoing mail. The program’s
policy specifies the way any unauthorized or contraband item is to be disposed, to include return
to the sender, mailed to the youth’s home, returned to the youth upon release, or, in the case of
illegal contraband, turned over to law enforcement. The facility visitor log contained a
contraband attestation statement, which was observed in the lobby of the facility. The provider
requires all staff to sign an attestation acknowledging their understanding of the contraband
policy, of which all eighteen newly hired staff had signed. The program’s policy and procedures,
provided during orientation training for all new staff, stipulates staff, including supervisors and
administrators, found in possession of contraband will be subject to disciplinary action up to and
including dismissal. The program documents the confiscation and disposal of contraband. All
instances involving confiscation of illegal contraband require the program to turn the item over to
local law enforcement authorities and file a criminal report. A review of the Department’s Central
Communications Center (CCC) reports since the execution of the contract indicated there were
no instances of contraband found at the program which needed to be turned over to law
enforcement. A review of logbooks, incident reports, and search reports confirmed the
frequency and quality of searches and the results. During the program tour, all of the youth
rooms were viewed, and no contraband was observed. The program’s policy requires case
managers to inspect all outgoing and incoming correspondence in the presence of the youth for
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unauthorized items, contraband, or information which may breach the security of the program.
In an interview with the facility administrator (FA), it was indicated searches are documented on
the room search form and the monthly contraband log. If the CCC or law enforcement needs to
be contacted, the FA or assistant facility administrator (AFA) will make the contact, and items
requiring removal from the grounds are disposed of by the AFA or FA. Five staff were
interviewed. Three staff reported room searches were conducted at least once per day. One
staff indicated they are conducted twice daily, and one staff stated twice each shift. All staff
indicated searches are done through all items and belongings in each youth room to make sure
there is no contraband or non-permitted items within the room.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures to ensure searches and full body visual searches,
are conducted according to Florida Administrative Code at the time of admission, after off-
campus activities, and visitation. Youth are searched before all movement, during a new
admission, during re-admission, after returning from visitation, when returning from off-campus
activities and/or appointments, when suspected of having contraband, or when a youth is
determined to be a security risk. The program conducts searches as a method to prevent the
introduction of contraband and unauthorized items into the program. Policy indicates searches
of youth are conducted after off-site transports, after visitation, before moving youth from an
outside area into the building, and prior to moving youth from the building to an outside area.
There were observations of searches made during line movements and before moving from the
building to an outside area during the annual compliance review week. The program did not
have any off-campus trips, admissions nor visitation while on-site; therefore, an observation of a
search was not conducted. Youth search and full body visual search forms were reviewed and
confirmed the program conducts full body visual searches at the time of admission and other
off-site appointments. Searches were documented in the program’s logbook. Observations
made throughout the annual compliance review week validated youth are provided instructions
regarding the search, searches were conducted by staff of the same gender as the youth, were
conducted in a manner as to not degrade the youth and were based on the Protective Action
Response (PAR)/Right Interactions (RI) training manual. Five days of video were observed
which confirmed searches are conducted on all staff and visitors prior to entering the facility,
and youth are searched according to policy. All five interviewed youth indicated they are
searched between every movement. Five staff were interviewed and confirmed youth searches
occur at 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 maintains a policy and procedures requiring the program vehicles be properly
maintained, contain safety and emergency equipment, and be operated in a safe manner. The
program has two vans used to transport youth. The program ensures both vehicles are properly
maintained, and the use and maintenance of each vehicle is documented in a vehicle log. A
review of the weekly inspections showed all were completed, as required. Each vehicle used for
transporting youth passed an annual safety inspection. Both vehicles used to transport youth
are equipped with the appropriate number of seatbelts, a seat belt cutter, a window punch, a fire
extinguisher, and an approved first-aid kit. During the annual compliance review, one of the on-
board fire extinguishers was found to be discharged inside the container, inside the van. It was
replaced the day it was discovered. Doors for the youth passenger area cannot be opened from
the inside. The safety screen is not applicable as the program is non-secure. A random check of
ten personal vehicles and the program’s transportation vehicles was conducted during the
annual compliance review. The staff vehicles and both transportation vehicles were found to be
locked. There were no scheduled transports available for observation during the annual
compliance review.
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 safety and security of youth and the
community during transportation of youth, and to ensure the appropriate staff-to-youth ratio is
maintained while youth are transported off program grounds. The program has an approved
transport list which is updated monthly to ensure staff driver’s licenses are valid. The approved
driver list is in the administrative area by the facility administrator’s (FA) office. Reviewed
documentation verified all approved drivers had a valid driver’s license. The program is not
applicable for providing secure transportation for secure high-risk and secure maximum-risk
youth, or non-secure youth determined to be at greater risk. Youth are not permitted to drive
program or staff vehicles. An observation was conducted of the vehicles, and they were found to
be in working order. An interview with the FA confirmed the program’s transportation process.
While on transport, none of the five interviewed youth reported having ever been handcuffed to
any part of the vehicle nor witnessing anyone place contraband in any of the transport vehicles.
Five staff were interviewed regarding the program’s transportation policy. During transport, staff
indicated youth are secured in the vehicles with a seat belt and shackles. If a youth is on an
outing, then shackles are not utilized. On a transport, staff are equipped with a two-way radio
and cell phone. Each vehicle is equipped with safety equipment to include a fire extinguisher,
first-aid kit, a tire tool kit, and a window punch. Staff are not permitted to use their personal
vehicles to transport youth and searches for contraband are conducted on each vehicle prior to
and after each use. If an emergency happens while on transport, staff indicated they are to call
the facility and be advised from there. Two staff stated they call 9-1-1 immediately and one staff
also stated depending on the emergency they would also notify law enforcement. Three staff
stated during transport there are two staff to one youth. One staff reported they have never
transported youth.
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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 for weekly safety and security audits. The facility
plant manager is responsible for the safety and security audits. The safety and security audits
are completed utilizing a spreadsheet which shows what deficiencies were identified and when
the issue is corrected. The program utilizes a work order system to identify maintenance issues
and track when they are completed. Work orders are completed by the plant manager or outside
contractors are utilized to conduct repairs. This information is updated in the weekly form. The
safety and security audit results are sent to the Department residential safety and security
specialist. The program has an open minor deficiency dated for February 14, 2025, for
miscellaneous minor repairs required throughout the program which is still on-going. A review of
invoices confirmed different vendors have been to the program to conduct plant maintenance.
Verified the weekly safety and security audits have been sent at least every seven days. The
facility administrator reports the program utilizes the weekly safety and security audits for
identifying and tracking safety and security issues.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures for tool inventory and management. The policy
addresses issuance, inventory, and control of equipment and tools. The policy prohibits
machetes, bowie knives, and other log bladed knives. Tools are maintained in the maintenance
office, which is secured and has limited access. The program maintains a daily and monthly tool
checklist. A perpetual in and out log for used tools is maintained in the maintenance office. A
review of ten tools verified the tools are in the correct location on the shadow board and all the
tools were numbered. No tools appeared to be missing and the plant manager advised no tools
had been lost, damaged, or destroyed since the last audit. The plant manager explained the
process for missing tools as follows; movement is stopped, the youth and the area are
searched, and program administration is notified. A review of the sharps box in the kitchen
indicated there was a sign-in and out log and the box was secured with all knives located in the
box.
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 which establishes supervision requirements for when
youth use tools. The policy addresses all youth will have an assessment to determine youth’s
risk to self and others. Assessments were reviewed and found completed in youth files. The
program policy requires a one to five supervision ratio during vocational training and activities
requiring tool use. During disciplinary work projects the ratio is one-to-three. No work activities
or youth work projects were observed during the review. All five youth records reviewed
indicated youth were trained on safe use of tools. Four of five interviewed staff indicated youth
are permitted to use mops and brooms. Two staff stated youth could also use scrub brushes
and one staff indicated youth are not permitted to use tools. Five youth were interviewed. Two
indicated they do not handle tools. One youth reported they use a paint brush, and this is done
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under supervision of the plant manager. The remaining two youth indicated they use mops and
brooms. One of those two youth assists in the kitchen and handles pots and pans.
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 which requires the program to alert outside
contractors of potential dangers and requests they limit the tools to what is required to do the
job. Tools are checked and inventoried upon arrival and upon exit of the program. Contractors
are required to keep track of their tools while on site and immediately notify staff if any tools are
missing. The program maintains a vendor login in book which requires the vendor read the
requirements for tool use, restrictions of tools, and steps to take if tools are missing. Tools are
inventoried on the same sign in sheet and checked off again upon exit. Documentation was
reviewed and located for three work invoices, and it matched the documentation in the vendor
sign in book. The facility policy required the facility administrator would have to approve any
electronic items which would be considered contraband outside of work purposes.
5.16 Fire, Safety, and Evacuation Drills Limited 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 for fire and safety drills. Egress Plans are
documented throughout the living modules and general-purpose areas throughout the program.
Exit signs are clearly visible throughout the program. All eight fire extinguishers were inspected
within the program had a current, annual fire extinguisher tag and were inspected monthly. Five
staff were interviewed about their participation in drills within the past twelve months. Four staff
reported having participated in drills. One staff had not been employed long enough to
participate in any drills. Five youth interviewed were able to articulate what to do in case of a fire
and indicated fire drills occur anywhere from monthly to two times each month. The facility
administrator indicated drills are conducted monthly for each shift. Fire drills and safety drills
were reviewed since the last annual compliance review. A drill was located for each month on
both shifts except for November. The drill documentation only contained the date, time, and the
staff participants. The other required components such as scenario, findings, and
recommendations were missing from all fire and safety 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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 70 (Revised September 2022)
The program maintains a Continuity of Operations Planning (COOP) binder in master control
and in the facility administrator’s office. There are signs on the doors indicating where the
COOP is located. The COOP had a current annual review cover sheet dated April 11, 2024.
Alternative locations approved by the regional director were listed in the COOP plan. The
program maintains one combined Emergency Disaster Preparedness Plan and COOP. Disaster
supplies were maintained in multiple areas throughout the program. Additional emergency food
was maintained on a separate emergency food rack. Supplies such as bedding, clothing, and
linens were kept in different areas throughout the program. The program maintains a binder with
photos and admission cards which contain all the required components for an emergency youth
binder.
5.18 Storage, Inventory, and Disposal of Flammable,
Limited Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures for the storage and inventory of all flammables,
poisonous, and toxic items. The safety and security officer and plant manager maintain
inventories. Items identified as flammable, poisonous, or toxic fluids may only be drawn by an
authorized person. The youth are not allowed to handle these items and do not have access to
where they are being used or stored. Youth are not permitted to clean, handle, or dispose of
other person’s bio-hazardous material, bodily fluids, or human wastes. The program flammable,
poisonous, and toxic chemicals are maintained in fireproof secured cabinets. The program’s
disposal procedures are in accordance with Occupational Safety and Health Administration
(OSHA) standards. During the review, at no time were chemicals found outside their secured
locations unless they were actively being used. Ten chemicals were selected and reviewed for
accuracy on the facility inventory. Five chemicals were not accurate to the inventory and one
was not located on the inventory at all. A review of the Safety Data Sheets (SDS) discovered
three SDS were missing. The facility plant manager corrected this immediately in the SDS
Binders.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures regarding youth handing and supervision for
flammable, poisonous, and toxic materials. The policy prohibits youth access to where the items
are being stored and used. This was observed during the tour and separate observations which
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 70 (Revised September 2022)
confirmed items are stored in areas youth are prohibited from accessing and chemicals were
not observed left out where youth could access them during the annual review period. Five
youth were interviewed. Four youth indicated they do not use any chemicals. Any cleaning
materials are sprayed or used by staff and then youth use the mops to clean it up. One youth
who assists maintenance on work duty is able to paint; however, they reported staff wets the
brush with paint first and then the youth uses the brush to apply the paint.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
This program states they do not participate in water-based activities. Therefore, this indicator is
rated non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures to allow youth to have visitation and communication
with family members while in the program. The visitation schedule is listed on the daily activity
schedule and is also posted in the lobby. The program’s primary visitation day is Saturday and
Sunday is used as a make-up day. Visits are limited to two hours unless approved beyond.
Visitors sign the visitation log and are required to provide identification. All visitors are pre-
approved through case management. All visitors are searched. For mail, each youth has an
approved correspondence list. All incoming and outgoing mail is reviewed for contraband and to
ensure there is no information being provided or sent which would pose a threat to safety and
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 70 (Revised September 2022)
security. The facility has a telephone schedule maintained with the case managers in their
binders. The youth telephone logs indicated the youth are making routine calls. The facility has
language line services available for non-English speakers. The facility’s correspondence log
was reviewed, and it shows youth were able to receive and send mail as often as they wanted
through case management. The correspondence log indicated outgoing mail was searched. All
youth surveyed indicated they are able to send mail and call their parents/guardians.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The facility has a policy and procedures for recreation and leisure activities. The facility has a
credentialed recreation therapist. The recreation therapist maintains a monthly schedule of
activities for the youth. Activities include social and cognitive skill development, teamwork,
mental stimulation, and physical fitness. The daily activity schedule includes recreation and
leisure activities daily. The recreation therapist maintains wellness plans with three wellness
goals developed with each youth. They conduct physical assessments with the youth as well.
Recreational activities were not able to be observed during the annual compliance review. Five
youth were interviewed. All youth indicated they receive one hour of recreation time daily to
include football, running, music, outings, and pull-ups. One youth indicated the program is
planning to install a volleyball net to add volleyball to their routine recreational activities. All five
interviewed staff indicated the youth have recreation time ranging from one hour to an hour and
fifteen minutes. Activities included, football, basketball, dodgeball, corn hole, connect four, pull-
up bar, jump rope, resistance bands, board games, and kick ball.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 70 (Revised September 2022)
Standard 6: Educational Services
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program has a policy and procedures to implement career and technical education
services. The contract stated the program will provide cardiopulmonary resuscitation (CPR) and
first aid certifications within the first thirty days of a youth’s admission, Occupational Safety and
Health Administration (OSHA) 10 certifications within ninety days of a youth’s admission if
applicable, and Florida Ready to Work Soft Skills credentials. The program also provides Safe
Staff certifications for youth who are interested, reach a certain behavioral management system
(BMS) level, and are suitable by the risk assessment screening. The program is not maintaining
accurate accounting of youth who have received CPR and first aid certifications within the
annual compliance review period. The program was able to provide documentation of
seventeen current youth completion of the certifications. Through documentation of four closed
records reviewed during the annual compliance review period it was found the program was
providing services. Reviewed documentation found twenty-three youth completed their OSHA-
10 certifications and seven completed the Safe Staff certification. Currently there are three
youth enrolled in OSHA-10 and six youth enrolled in Safe Staff. The program has not provided
the Florida Ready to Work Soft Skills credentials during the annual compliance review period.
The program was provided laptops to provide the Soft Skills credential however the laptops
were return last month for they were not operational, and the program is waiting on the provider
to send functioning laptops. The instructional lead educator reported there have been ninety-
seven youth enrolled in the Health Life Management course. Career and technical education
services are provided Monday through Thursday between 6 :00 p.m. and 6:46 p.m.
Documentation and credential of all staff or providers providing services were reviewed and
verified they were qualified to provide services. Two youth records and three closed youth
records were reviewed for contact timeframe requirements for completion of career and
technical education services. Three youth were applicable fore OSHA-10 certifications and
reviewed documentation verified each youth completed the certification. The remaining two
were not applicable either due to age or currently enrolled in the course. Four out of the five
youth obtained their CPR and first aid certifications within the time requirements. The remain
youth was a closed record and the certification could not be located. Five youth were
interviewed. Three were studying for their General Education Diploma (GED), one youth had
already received their GED, and the remaining youth was taking courses through Florida Virtual
School (FLVS). The interviewed facility administrator stated school is being provided by FLVS
as scheduled and the contract pre-vocational and vocational services offered at the program are
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 70 (Revised September 2022)
life skills groups, resume writing, driver's license tests, on-line college, safe staff certification,
and CPR and first aid.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide educational access. The center
provides education services through Florida Virtual School (FLVS). A review of the program’s
activity schedule and the daily academic schedule indicated the activity schedule incorporates
the daily school schedule. No discrepancies were found. The lead teacher's interview showed
all the youth receive credit for completing a course. They also reported the school schedule is
adhered to. Five of the interviewed youth reported the schedule is followed. A review of
randomly selected days in the logbook throughout the past year indicated education classes
started and ended on time except one day when they returned twenty-five minutes late;
however, they made up the required time at the end of the day. The logbook also had missing
documentation on two days when the groups started back after lunch. Observations of the
program video for three days showed classes began and ended on time as scheduled, except
when returning from lunch, which showed returning four to ten minutes late. On those days,
classes started and/or ended later to make up for any missed educational instruction.
6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Education services are provided through a contract with Florida Virtual School (FLVS). The 250-
day calendar is distributed over twelve months and includes twenty days for teacher training and
planning. A review of the daily school schedule revealed education provides six fifty-minute
classes from 8:30 a.m. through 2:45 p.m. with a sixty-minute lunch break from 12:05 p.m.
through 1:05 p.m., fulfilling the weekly requirement of twenty-five hours of instructional time. The
interview with the lead teacher indicated all the youth receive credit for completing a course.
They also reported the school schedule is adhered to. Observations of the program video on
three days showed teachers were present during educational times.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures for developing and implementing a vocational
competency development program. A review of the career education program found it is
appropriate for the educational abilities and goals as well as the length of stay and classification
of the youth. The program provides a Type 2 career education development program, which
includes communication, interpersonal, and decision-making skills. The interviewed facility
administrator stated school is being provided by Florida Virtual School (FLVS) as scheduled and
the contracted pre-vocational and vocational services offered at the program are life skills
groups, resume writing, driver's license tests, on-line college, ServSafe certification, and First
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 70 (Revised September 2022)
Aid/cardiopulmonary resuscitation (CPR). The interviewed lead educator stated students are
provided with career and technical education courses which include Digital Information
Technology and Life Skills Management.
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
According to the contract, the contracted educational provider is required to develop an
Education Transition Plan for each youth. Upon entering a residential commitment program, an
education transition plan must be developed for each youth. Three closed case records were
reviewed and none of the records contained an education transition plan. Florida Virtual School
(FLVS) reported they did not train staff on developing transition plans until after December 1,
2024; therefore, there are no available closed records with a new transition plan developed
upon entry to be reviewed. The interview with the instructional leader indicated exceptional
student education (ESE) services are provided for students with disabilities, English language
learner (ELL) services for language learners, and intervention groups provided for those below
grade level in reading and/or math. The instructional leader reported each student now
completes an educational transition upon entry form, which discusses their continuation of
education to ensure their educational/career needs are met upon transition.
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The contracted educational provider has a policy and procedures in place to provide qualified
instructional personnel. In reviewing the educational instructional staff for the program, including
flex teachers who provide virtual education at the program, it indicated all the teachers have an
active certification, according to the Florida Department of Education website. Flex teacher
certifications suggest all are currently certified in their teaching subjects. Three teachers were
teaching in their field, and they were also teaching courses out of their field. The provider
Florida Virtual School (FLVS) notified parents of teachers who were also teaching out of the
field; however, the letter did not indicate which subjects were taught out of the field. One teacher
provides exceptional student education (ESE) services in the program, and FLVS has provided
their certification as an ESE instructor.
6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
The program has a policy and procedures for youth to be referred to Florida Youth College
(FYC) when a youth earns their high school diploma or General Education Diploma (GED). A
review of documentation found only two youth were referred to FYC during the annual
compliance review period by the program staff, not the education provider. Three of five
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Office of Accountability and Program Support Page 69 of 70 (Revised September 2022)
interviewed youth advised overall the program is good and they recommend this program. One
youth indicated the staff try their best to mentor the youth at the program to help them get on the
right path. The interviewed lead educator stated FYC is available to students once they have
graduated. A staff member assesses the youth’s career goals and gets them into programs
which can help them attain their post-secondary goals. Staff begin recommending youth for FYC
when a youth is almost at graduate status to begin the process.
6.08 Florida Youth College (Post-Secondary Contract Provider) Limited Compliance
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Two applicable youth were referred for post-secondary provider services though Florida Youth
College (FYC). No other youth were referred during the annual compliance review period. Both
reviewed records documented the required information regarding the completed orientation.
Neither youth record included a career plan. The provider stated no formal career plans are
being developed, just notes being entered with the youth’s career interest; however, the
provider is in the process of obtaining a career assessment platform for future use. Only one
reviewed closed record documented the required support follow-ups in the required timeframes.
The other closed record did not document any youth contact being made after the youth was
released from the residential program. Of the five interviewed youth, two are participating in or
are preparing to participate in post-secondary education. One youth has received their General
Education Diploma (GED) and is now working with staff to work with Job Connect and to obtain
their Heating, Ventilation, and Conditioning (HVAC) license. The remaining youth is working on
completing the GED and is working with staff to research which schools they would like to apply
to for college. A third youth is working on completing the GED; however, has been working with
staff to enter the military once released.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 70 (Revised September 2022)

source: DJJ

report_type: QI Residential

file_name: Duval Academy-FINAL-FY2425.pdf

program_name_raw: Duval Academy

rule: Indicator 1.08

excerpt: In-Service Training

rule: Indicator 1.13

rule: Indicator 2.04

rule: Indicator 2.05

rating: Failed Compliance

rule: Indicator 2.06

rule: Indicator 2.07

rule: Indicator 2.11

excerpt: Performance Summaries and Transmittals

rule: Indicator 2.12

rule: Indicator 2.13

rule: Indicator 2.15

excerpt: Exit Portfolio

rule: Indicator 3.06

rule: Indicator 3.13

rule: Indicator 5.06

excerpt: Logbook Entries and Shift Report Review

rule: Indicator 5.16

excerpt: Fire, Safety, and Evacuation Drills

rule: Indicator 5.18

rule: Indicator 6.08