state: FL

facility_name: Kissimmee Youth Academy

summary: QI Residential - FY24-25

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Kissimmee Youth Academy BDD/DD
Youth Opportunity Investment, Inc.
(Contract Provider)
2330 New Beginnings Rd
Kissimmee, Florida 34744
Review Date(s): January 28-31, 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:
Nicos Antonakos, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Belinda Alexander, Office of Education, Central Education Coordinator (Standard 6)
Serena Brown, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Jillian Cumbo, Career and Technical Education, Workforce Education Coordinator (Standard 6)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Interviews)
Rondarrell George, Office of Accountability and Program Support, Regional Monitor (Standard
5)
Carol Hickman, TrueCore Behavioral Solutions, Regional Compliance Manager (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Kissimmee Youth Academy MQI Program Code: 1426
Provider Name: Youth Opportunity Investments, LLC Contract Number: 10287
Location: Kissimmee County / Circuit 9 Number of Beds: 32
Review Date(s): January 28-31, 2025 Lead Reviewer Code: 180
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 72 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 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 72 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 72 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Satisfactory
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 72 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 72 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Satisfactory
5.24 Controlled Observation Satisfactory
5.25 Controlled Observation Safety Checks and Release Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 72 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Indicator Ratings
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Satisfactory
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Non-Applicable
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Non-Applicable
6.08 Florida Youth College (Post-Secondary Contract) 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 9 of 72 (Revised September 2022)
Program Overview
The Kissimmee Youth Academy Borderline Developmental Disability (BDD) and Developmental
Disability (DD) program is a thirty-two-bed program, for fourteen- to twenty-one-year-old males,
located in Kissimmee, Florida. The program is operated by Youth Opportunity Investments,
LLC, through a contract with the Department. The program provides BDD or DD Services. In
addition, the program fosters each youth by providing Skillstreaming the Adolescent, Trauma
Focused Cognitive Behavioral Therapy, and Impact of Crime. Additional treatment services
provided include family/individual therapy, Life Skills Training, the Teen Relationship Workbook
curriculum, mental health therapy, and recreational therapy. Program administration is
comprised of one facility administrator, three assistant facility administrators, one director of
case management, one human resource staff, one business manager, one administrative
assistant, one health services administrator, one food services manager, one physical plant
manager, one unit manager, and one director of clinical services/designated mental health
clinician authority (DMHCA). Case management services are provided by six case managers
and one transition services manager. Mental health staff at the program includes one contracted
psychiatrist, one DMHCA, one licensed therapist, one assistant clinical director, one lead
therapist, one recreation therapist, six mental health/substance abuse therapists, and one
contracted behavior analyst counselor. Medical services are offered daily and are provided by
six registered nurses, one licensed practical nurse, and a contracted designated health authority
who is a licensed medical doctor. Educational services are provided by the Florida Virtual
School (FLVS)/Florida Scholars Academy. The layout of the program includes one self-
contained building with two wings separated by a common hallway which houses medical, staff
offices, a staff break room, and the administrative area. The program has 143 operating security
cameras providing coverage and all were operational at the time of the review. At the time of the
annual compliance review, the program had fourteen vacant positions, which included two
therapists, one case manager, one transition case manager, one shift supervisor, and nine
youth care specialists.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 72 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program maintains a written policy and procedures to ensure all newly hired staff and
volunteers receive an initial background screening. The program had fifty-two newly hired staff
since the last annual compliance review. A review of the staff records found all fifty-two staff
received a background screening prior to contact with youth and confidential records.
Documentation reflected a criminal history report was reviewed, and the Department’s Staff
Verification System (SVS) module was updated for each of the fifty-two staff. None of the
reviewed records were applicable for obtaining an exemption prior to working with youth. One of
the reviewed staff had a break in service as indicated in SVS, and documentation supported the
staff had a new background screening completed prior to working with youth. The program
utilizes a pre-employment assessment tool for all direct care staff. Reviewed documentation
reflected each of the applicable newly hired staff received a passing score on the pre-
employment assessment tool prior to hire. Documentation supported each of the fifty-two newly
hired staff had a signed contraband attestation form in their records. There were no volunteers,
contracted staff, and/or interns applicable for an initial background screening since the last
annual compliance review. The Annual Affidavit of Compliance with Level 2 Screening
Standards was submitted to the Department’s Background Screening Unit (BSU) on January
14, 2025, meeting the annual requirement. In addition, the teachers submitted their annual
affidavit on January 18, 2025.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program maintains a written policy and procedures to ensure all staff and volunteers
receive a background rescreening every five years from their initial date of hire. The program’s
administrator tracks each staff’s hire date and volunteer start dates to determine when the five-
year rescreening should be submitted. The program had six staff applicable for a five-year
rescreening since the last annual compliance review. Each staff’s rescreening was completed
and submitted to the Department’s Background Screening Unit prior to their anniversary date.
Each rescreening was completed at least ten business days prior to each staff’s five-year
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 72 (Revised September 2022)
anniversary. There were no volunteers or interns applicable for a five-year rescreening since the
last annual compliance review.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program maintains a written policy and procedures ensuring an environment free of abuse
and neglect and in which youth and staff feel safe and secure. The policy reflects youth and
staff have unhindered access to reporting alleged abuse to the Florida Abuse Hotline. A review
of the Department’s Central Communication Center (CCC) reports since the last annual
compliance review found there were two incidents which were related to physical, psychological,
or emotional abuse. One incident involved three staff for improper supervision, which was
substantiated, and the other incident involved one staff alleged of improper use of force which
was unsubstantiated. The Florida Abuse Hotline and/or the CCC was notified as required for
each reviewed incident. There were no applicable cases for any potential human trafficking
victims, children of sexual exploitation, or labor trafficking reported at the time of the annual
compliance review. The program’s policy outlines the reporting procedures for staff to follow
when a youth would like to make an abuse call. Additionally, the program maintains an
employee handbook which outlines the program’s code of conduct. All staff are required to sign
and acknowledge receipt of the employee handbook and code of conduct which outlines the
grievance policies and their understanding of the program’s code of conduct. A review of seven
staff records found each record contained documentation of acknowledgement, receipt, and
review of the program’s code of conduct. Observations conducted during the annual compliance
review week found postings of the Florida Abuse Hotline and the Department’s CCC throughout
the program. The program’s steps to report abuse include the staff calling the operations
manager and then the master control operator will inform them the youth wants to make an
abuse call. The operations manager will take the youth to administration to make the call and
document the call in the logbook. The program completed the Trauma Responsive and Caring
Environment (TRACE) self-assessment on August 8, 2024. Five youth were interviewed, and
four youth reported feeling safe in the program. One youth stated they did not feel safe when
they first arrived; however, they felt safe after addressing their concerns with a supervisor. All
five interviewed youth reported never being stopped from reporting abuse to the Florida Abuse
Hotline or the CCC. Each of the five youth knew where the telephone numbers were posted.
Four of the five interviewed youth reported staff are respectful when talking with them. One
youth stated the supervisors are respectful; however, some staff will allow youth to be bullied.
Each youth reported never hearing staff use curse words when speaking to youth. All five-youth
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 72 (Revised September 2022)
reported they never exchanged emails, telephone numbers, or social-media contact information
with staff. All five interviewed staff explained the process for allowing staff and youth to call the
Florida Abuse Hotline or the CCC to report suspected abuse. All interviewed staff reported they
never observed another staff telling a youth they could not call the Florida Abuse Hotline. Each
staff reported they never heard another staff use profanity while speaking with youth. The
interviewed facility administrator (FA) stated all staff are urged to become familiar with the
program’s rules and standards. In addition, employees are expected to follow the rules and
standards faithfully in doing their job and conducting the program’s business. Any staff who
deviates from these rules and standards will be subject to corrective action, up to and including
termination of employment. Staff are always expected to maintain ethical and professional
behavior. This includes the expectation staff are to interact with youth in a manner promoting
their emotional and physical safety while incorporating trauma responsive practices. The
program incorporates trauma-responsive practices by completing Safety Plans for all youth with
trauma triggers or reminders and ways to help the youth cope with trauma reactions. Mental
health staff educate parents on traumatic stress and how it can impact typical adolescent
development. The program creates space to accommodate treatment, programming,
educational, and leisure activities for the youth. The FA verified the TRACE was completed on
August 8, 2024, and the next assessment is scheduled for February 5, 2025.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program maintains a written policy and procedures regarding abuse reporting, which
follows the Department’s criteria for reporting abuse. The program’s practice is to initiate an
internal investigation regarding the complaint and remove the staff involved from contact with
youth, when necessary. A review of the Department’s Central Communication Center (CCC)
reports since the last annual compliance review found there were two incidents which were
related to physical, psychological, or emotional abuse. One incident involved three staff for
improper supervision which was substantiated, and each staff received a written reprimand. The
other incident involved one staff alleged of improper use of force which was unsubstantiated.
Reviewed documentation found management took immediate action regarding the staff involved
incidents by initiating an internal investigation in all incidents. An interview with the facility
administrator (FA) reported management is cognizant of youth and staff needs and provide
direction to each on how to access the Florida Abuse Hotline. Management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program maintains a written policy and procedures regarding the response to incidents in
accordance with Florida Administrative Code. The program had twenty reportable incidents
since the last annual compliance review. A review of five incidents found each was reported to
the Department’s Central Communications Center (CCC) within two hours of the incident or staff
becoming aware of the incident. All five incidents were documented in the program’s logbook. A
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 72 (Revised September 2022)
review of the program’s internal incident reports found there were no additional incidents which
should have been reported to the CCC and were not. The program has experienced a slight
increase in the number of reportable incidents to the CCC compared to the last annual
compliance review period; however, the increase was less than five. The interviewed facility
administrator (FA) stated the program posted the Florida Abuse Hotline telephone numbers for
youth under the age of eighteen and the Department’s CCC telephone number for youth
eighteen years of age and older. All allegations of child abuse or suspected child abuse are
immediately reported to the Florida Abuse Hotline. The program notifies the Department's CCC
within two hours of the incident occurring, or within two hours of any program staff becoming
aware of the reportable incident.
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program maintains a written policy and procedures regarding the utilization of physical
intervention techniques in accordance with Florida Administrative Code. The program had three
Right Interactions (RI) incidents since the last annual compliance review. There was
documentation to support a monthly summary of RI Reports was submitted to the Department
each month since the last annual compliance review. The program’s RI Plan was last updated
on November 16, 2023. The program’s RI Plan was approved by the Department’s Office of
Talent, Leadership, and Culture on December 22, 2023. The program has not experienced an
increase of five or more in the number of RI incidents since the last annual compliance review.
The program’s RI rate during the first quarter was 0.0, which was below the statewide
Residential RI rate of 1.71. An interview with the facility administrator (FA) reported any time
staff uses a physical intervention technique, an RI incident report is completed and filed in
accordance with the Florida Administrative Code. Five interviewed staff reported they used RI
and were able to explain the program's RI process and procedures. A review of three youth
involved RI incidents verified the documentation was completed by the end of the staff’s
workday, the report included statements from all staff involved, the RI report was reviewed by a
supervisor and an RI instructor, and each incident report was reviewed by the FA or designee
within seventy-two hours of the incident. The reviewed RI Reports verified mechanical restraints
were not utilized, the youth did not receive injuries which resulted from the RI, and none of the
youth required an RI medical review.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program maintains a written policy and procedures regarding a pre-service training plan for
all new staff. The pre-service training is provided through a combination of instructor-led and
web-based courses. The program considers case managers, operations managers, therapist,
and assistant facility administrators (AFA) as direct care staff and includes them in the staff-to-
youth ratio. A review of instructor credentials verified all were qualified to deliver the provided
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Office of Accountability and Program Support Page 14 of 72 (Revised September 2022)
trainings. The program has an annual pre-service training plan/calendar, which was approved
by all required officials and is updated as changes occur. Seven staff training records were
reviewed for pre-service certification training. Six of seven reviewed training records were
applicable and documented each staff completed the certification process within 180 days of
hire. All six records showed documentation to support each staff exceeded the required 120
hours of pre-service training. Completed trainings included Right Interactions (RI), first-aid,
cardiopulmonary resuscitation (CPR), automated external defibrillator (AED), professionalism
and ethics, suicide prevention, emergency procedures, child abuse reporting, Prison Rape
Elimination Act (PREA), and program operating procedures prior to having any contact with
youth. The program’s contract outlined program specialist training and hours of job specific
training for safety and security specialists such as adolescent development, balanced approach
to restorative justice, the Department’s Central Communications Center (CCC), civil rights,
communication, confidentiality/Health Insurance Portability and Accountability Act (HIPAA),
diversity, Department history, equal employment opportunity, human trafficking, infection
control/bloodborne pathogens, information security awareness, the Department’s Juvenile
Justice Information System, mental health and substance abuse, quality report writing, youth
supervision, standards of conduct, trauma responsive practices, electronic vapor products, the
grievance process, Exposure Control Plan, the behavior management system, and the intended
and safe use of tools. One shift supervisor was rehired less than two years from separation and
completed all annual update requirements training which included active shooter preparedness,
CPR/first-aid/AED, human trafficking intervention, information security awareness, mental health
and substance abuse, PREA, an RI update, professionalism, interpersonal communication,
ethics, suicide awareness and prevention, trauma responsive practices, and sexual harassment.
Two newly hired therapists were trained in the Developmental Disability Treatment Services.
Two newly hired shift supervisors had completed an additional thirty-two hours of training in
coaching, leadership, and personal accountability. All completed trainings were documented in
the Department’s Learning Management System (SkillPro) and were delivered by qualified
trainers.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program maintains a written policy and procedures regarding in-service training for all staff.
Seven staff training records were reviewed for in-service training. All seven training records
documented each staff exceeded the twenty-four hours of annual in-service training
requirements. All seven staff had current certifications in Right Interactions (RI). Each staff had
certification in first-aid, automatic external defibrillator (AED), and cardiopulmonary resuscitation
(CPR). Completed trainings included human trafficking intervention, information security
awareness, mental health and substance abuse, Prison Rape Elimination Act (PREA),
professionalism, interpersonal communication, and ethics, sexual harassment, suicide
awareness and prevention, trauma responsive practices, emergency response and emergency
drills, infection control, blood-borne pathogens, and the Exposure Control Plan. Three clinical
staff training records were reviewed, and each was trained in mental health, Developmental
Disability Treatment Services, and delinquency interventions. Three supervisor training records
were reviewed and each of the three supervisors exceeded the eight hours of
management/supervisory training in the areas of coaching, leadership, and personal
Florida Department of Juvenile Justice Residential Annual Compliance Report
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accountability. The program has a training calendar which is updated as changes occur. All
trainings were delivered by qualified trainers and were documented in the Department’s
Learning Management System (SkillPro). The program maintains a written in-service training
plan which was submitted and approved by all required parties prior to implementation.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program maintains a written policy and procedures regarding the grievance process
confirming each youth’s right to grieve and ensure all youth are treated fairly, respectfully,
without discrimination, and their rights are protected. The program’s grievance procedures
include informal, formal, and appeal phases with a time frame of two days to provide feedback
to the youth and to correct the grieved situation or condition. The youth are provided with the
opportunity to file an alternative informal request by utilizing a Request to Speak form as a first
opportunity to voice an objection and informally resolve a complaint. Grievance and Request to
Speak forms were available to youth as observed during the program tour. Reviewed
documentation found there were no grievance forms submitted by youth since the last annual
compliance review. Five staff were interviewed, and each staff was able to explain the grievance
process. Five youth were interviewed about the grievance process, and four youth stated they
had never submitted a grievance, three youth knew the process, and two youth did not
remember the process for submitting a grievance. One youth stated they submitted six
grievances and did not get a response. A follow-up interview was conducted with the youth and
the facility administrator (FA). The FA stated there was no record of the youth submitting a
grievance for a physical plant concern; however, the staff will assist the youth in writing a
grievance and administration will follow-up. All five interviewed youth reported being able to
request assistance in completing a grievance form. An interview with the FA reported the
program staff are trained on the program's youth grievance process and procedures. The
program adheres to the grievance process, ensures the grievance process is explained to youth
during orientation, and grievance forms are available throughout the program.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff who’s regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program maintains a written policy and procedure for the requirements for facilitator staff
training for the delinquency intervention models and evidence-based practices. The program’s
policy requires staff to be trained on the specific delinquency intervention models, strategy, and
evidence-based practices curriculum. The program’s non-clinical and non-primary delinquency
intervention model offered at the program is Life Skills Training (LST). The LST group is an
identified supplemental services group. The program had four therapists trained to facilitate LST
for the review period. The trained therapists’ education and work experience were considered
by the program when determining staff delivery for the delinquency intervention model. A review
of sign-in sheets and a formal interview with the designated mental health clinician authority
(DMHCA) verified LST groups are held once a week and all youth are participating in group.
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The DMHCA stated services are provided by non-licensed and licensed clinical staff.
Interventions are provided through group, individual, and family therapy sessions. The
program’s activity schedule was reviewed and determined at least sixty percent of youths’
awake hours included structured, planned programming, or activities. The facility administrator
(FA) interview verified all clinical staff are trained to facilitate delinquency intervention groups.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a written policy and procedures to address life and social skills training
for youth. Life and social skills training is provided utilizing the Life Skills Training (LST)
curricula. The LST groups specifically address communication, interpersonal relationships and
interactions, non-violent conflict resolution, anger management, and critical thinking. A review of
the program’s activity schedule confirmed each group is provided to the youth once a week by
the therapists. All staff conducting groups received formal training and on-the-job training by a
certified trainer to deliver the curriculum. A review of video footage and group sign-in sheets
confirmed services were delivered, as required. Five interviewed youth reported they
participated in life and social skills groups at the program. The facility administrator (FA)
interview reported youth on the Borderline Developmental Disability (BDD), or Developmental
Disability (DD) Services side of the program participate in groups five days a week. Youth are in
groups on required days for developing life and social skills. The FA stated groups are based on
the youth needs, and additional individual life skills such as hygiene are taught on a one-to-one
basis with the youth. The interviewed mental health clinician authority (DMHCA) stated youth
are provided and encouraged daily to use and practice learned skills from groups. Additionally,
youth are presented daily with opportunities during group activities to practice the skills they
have learned.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s restorative justice programming includes Impact of Crime (IOC) groups. IOC is
designated as a Standardized Program Evaluation Protocol (SPEP) primary service at the
program. For details related specific to IOC service delivery, please refer to the annual SPEP
report. In addition, youth participate in reparation activities at the program. The program
administrators explained youth regularly participated in community service projects, such as
participating in a local faith-based organization, hygiene for the homeless, cards for the elderly,
making breast cancer ribbons, painting the classroom, and made a painted portable mural
which was donated to an orphanage. In addition, guest speakers from two local mentoring
agencies come and speak with the youth. A review of the program’s restorative justice binder
which included photos of the community service activities verified the youth participated. There
were no community service activities scheduled during the annual compliance review week;
therefore, none could be observed. The interviewed facility administrator (FA) stated the
program provides activities and instructions intended to increase youth awareness, and
empathy for crime victims and survivors. Five interviewed youth stated they participated in IOC
groups.
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1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program maintains a written policy and procedures addressing youth alerts. The program
enters alerts into the Department’s Juvenile Justice Information System (JJIS) for youth
requiring an alert which may not have been entered prior to the youth’s admission. The program
has an alert board in the main conference room, which identifies each youth’s special alerts,
escape risk, and/or gang affiliation. The alert board identifies youth placed on any type of mental
health and/or medical alert. Reviewed documentation indicated the program’s internal alert
report is reviewed daily during shift briefings by the program's supervisory staff. Observations
verified kitchen staff have access to each youth’s diet and allergy alerts in the kitchen. Seven
youth records were reviewed for medical, and mental health alerts. All applicable alerts were
accurately entered into JJIS. All internal and JJIS alerts were downgraded or discontinued by a
medical staff or licensed mental health staff when required. An interview with the facility
administrator (FA) reported the alert board and binders with all the alerts for the youth are
located in the conference room. The registered nurse (RN) reported the nurses complete the
medical alerts daily. Five staff were interviewed, and each reported they are informed of youth
alerts during shift meetings, through a review of the program’s alert board, and through the alert
binder in the conference room.
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
The program maintains a written policy and procedures to ensure the management of all
records are consistent across operations and programs, the company philosophy, goals,
objectives, and the legal and contractual requirements. A review of seven youth healthcare,
mental health and substance abuse, and case management records showed each was marked
“Confidential” and each record documented the youth’s name, Department identification number
(DJJID), the youth’s date of birth, county of youth’s residence, and committing offense. The
case management records contained sections labeled as legal information, demographics and
chronological information, correspondence, case management and treatment team activities,
and miscellaneous. Observations during the annual compliance review week showed all
Individual Healthcare Records, mental health and substance abuse records, and case
management records were secured in a locked room, which was not accessible to youth.
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1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program maintains a written policy and procedures in place to ensure the program has a
community support group or advisory board meeting at least every ninety to 120 days. The
program has a community advisory board which meets quarterly, and reviewed meeting
minutes, sign-in sheets, and agendas documented meetings took place in person and by
telephone on March 6, June 12, September 11, and December 11, 2024. The advisory board
member roster consists of a law enforcement representative, community partners, a community
business member, a school district representative, a member of the judiciary, a victim advocate
agency, and a faith-based community member. The advisory board includes two different
members who were a parent/guardian of a child with previous involvement in the juvenile justice
system. The program-maintained documentation of their email and mailed recruitment efforts. A
review of community advisory board agendas and meeting minutes confirmed the program
provides the board members with information regarding program updates, community updates,
and restorative justice community service activities. In an interview, the facility administrator
(FA) stated the community advisory board invitations are sent out to the board members and
potential board members are solicited quarterly. The board meets in person, virtually, and by
telephone. A telephone call was made during the annual compliance review week to two
different local community partners who serve as board members. A message was left with the
board members; however, there was no return call; therefore, an interview could not be
conducted.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program maintains a written policy and procedures to ensure staff personnel records
contain accurate and updated information. The program’s practice is to conduct evaluations
ninety days after hire and annually, thereafter, for all staff. The administrative staff reported they
provide coaching sessions as needed. The program maintains a detailed position description for
all staff and a written agreement outlining duties for all contracted staff. Seven staff personnel
records were reviewed, of which three contained an annual performance evaluation, and four
contained a ninety-day performance evaluation. Each staff had an evaluation which was based
upon a set of established performance standards which aligned with the duties outlined on the
staff’s position description. All seven reviewed performance evaluations found each staff’s
evaluation was based on the performance standards for their position. The evaluations rated the
staff’s quality of work, modeling of appropriate behavior, a positive reinforcement in a four-to-
one ratio, and each evaluation included ratings on the staff’s job-specific responsibilities. All
seven job descriptions and each staff’s performance standards were clearly identified. Each
reviewed job description included implementation of the program’s behavior management
system (BMS). Five staff were interviewed, and each staff had knowledge of how often they
received an evaluation. Staff reported they receive annual evaluations, ninety-day evaluations
for new staff, and monthly informal coaching sessions. An interview with the facility
administrator (FA) reported staff turnover is less than it was at the beginning of 2024. In order to
reduce turnover, administration provides coaching, conducts annual performance reviews, and
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staff are informed of their performance. The program ensures a system for evaluating staff, at
least annually, based on established performance standards.
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’s contract is an older contract which did not clearly identify any special conditions
within the Memorandum of Negotiation (MON) with the exception of an increased budget. A
review of the program’s contract reflected certain conditions which were specific to the program
to include special visitations, religious offerings, resources for expectant fathers, and gas cards
for families. The program conducts special visitations and family sessions through a virtual
platform for parents/guardians who are unable to visit the program. The program partners with a
faith-based organization to come on-site twice a month to provide church services to the youth.
Additionally, when a youth is an expectant father, the program will assist the youth in having an
opportunity to view their child’s birth through video conferencing. Finally, the program provided
gas cards to parents/guardians who needed assistance with attending family day due to
financial barriers since the last annual compliance review. The interviewed facility administrator
(FA) confirmed the program provides the special conditions outlined in the contract.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program maintains a written policy and procedures which includes data trend analysis
components. The program’s administration and management discussed research efforts to
enhance operations and contribute to the base knowledge of the Department’s practice. The
data trend analysis is composed by the processes include satisfaction surveys which are
incorporated into the monitoring and verification activities as a part of the program’s quality
assurance program. Satisfaction surveys are provided routinely and are completed on at least a
quarterly basis. Surveys include youth surveys, family surveys, and staff surveys at a minimum.
Surveys target admission activities, topic-specific assessments, and discharge satisfaction.
Survey data is reviewed and evaluated monthly in program-level and corporate leadership
meetings. Survey outcomes are collected and communicated as a part of ongoing program
communication and quality improvement activities. Monthly incident trackers are distributed to
the programs which describe trends Quarterly monitoring and verifications are conducted by the
provider’s compliance team which formulates a report and will provide support, technical
assistance, and coaching to promote improvement, professional development, implementation,
and assurances of corrective strategies as appropriate.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program maintains a written policy and procedures regarding initial contact to the
parent/guardian and court notification after each youth’s admission. Seven youth case
management records were reviewed, and each contained documentation in the chronological
notes indicating the parent/guardian was contacted by telephone and informed of each youth’s
arrival and program information. Each of the seven youth case management records contained
written notification to the youth’s parent/guardian, within twenty-four hours of the youth’s
admission to the program. Each of the reviewed case management records contained
documentation verifying the program notified the youth’s committing court and juvenile probation
officer (JPO) on the day of the youth’s admission or within five working days of the youth’s
admission to the program.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program maintains a written policy and procedures regarding youth orientation. Seven
youth case management records were reviewed. All seven youth case management records
indicated the program provided each youth with an orientation within twenty-four hours of
admission. The orientation included all required elements such as services available, the daily
schedule, expectations and responsibilities, the written behavior management system, which
was posted and provided in the resident handbook, access to medical and mental health
services, access to the Florida Abuse Hotline, zero-tolerance policy regarding sexual
misconduct, special accommodations, the right to be free from sexual misconduct, and items
considered to be contraband. The orientation included the performance planning process
involving the development of goals for each youth to achieve, dress code and hygiene practices,
procedures on visitation, mail, use of the telephone, expectations for release from the program,
community access, grievance procedures, emergency procedures, a program tour, living unit
assignment, treatment team, and medical topics. The program had two youth admissions
scheduled during the annual compliance review week. Observations were not conducted as
youth arrived prior to the monitoring quality improvement (MQI) team being on-site. Seven youth
were interviewed, and all youth confirmed receiving an orientation within twenty-four hours of
admission. Each youth indicated the orientation to the program included program rules,
procedures, and schedules. Each youth was able to explain the orientation process.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program maintains a written policy and procedures to address consent for youth who are
eighteen years of age or older. The policy requires the program to obtain written consent of any
eighteen-year-old youth prior to providing or discussing any information related to the youth’s
physical or mental health screenings, assessments, or treatments with the youth’s
parent/guardian. A review of seven youth case management records found two were applicable
for the youth being eighteen years of age or older. Each of the two applicable records contained
the signed written consent for the eighteen-year-old youth obtained on the day the youth turned
eighteen. The program has no additional applicable youth for the review period.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program maintains a written policy and procedures to address the classification process
and reassessment for activities. The program’s classification includes a review of physical
characteristics, age, maturity level, identified special needs including medical and mental health,
developmental, intellectual, and physical disabilities, history of violence, applicable gang
affiliation, criminal behavior, sexual aggression, vulnerability to victimization, and identified or
suspected medical, suicide, escape, or security risk. Safety and security risks are identified to
assist the staff in guiding the decision-making process determining each youth’s living unit
assignments, room assignment, and the staff assigned to the youth. Seven youth case
management records were reviewed. Each of the youth case management records contained a
completed Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) risk
assessment which was entered into the Department’s Juvenile Justice Information System
(JJIS) prior to each youth’s room assignment. Four of the seven reviewed youth records
identified suspected risk factors. Three youth had a medical risk, and two youth had a security
risk. A review of the Department’s JJIS alerts, and the programs internal alerts confirmed four
youth had issues affecting the youth’s classification. The medical and security risk factors
identified during the classification process were immediately entered into the program’s internal
alert system and in JJIS. The program’s policy regarding reclassification states staff may re-
classify youth at intervals throughout the youth’s length of stay. Staff reclassify youth when
warranted based upon changes in the youth's supervision status, new or updated alerts,
behavioral concerns, and relevant information to the treatment team to ensure safety and
security of the youth and program. Examples of reclassification include living unit or room
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assignment change, assignment to work projects or activities involving tools/instruments which
may lead to be used as potential weapons or means of escape, prior to level change, prior to
anticipated off campus activities, and at the request of the facility administrator (FA) or
designee. Reassessments for classification were completed during monthly treatment team
meetings and prior to an increase in privileges and/or participation in work projects. A review of
seven youth reclassifications found each youth had increased privileges or freedom of
movement. All seven youth reclassifications allowed for participation in work projects and/or
other activities involving tools; however, on one youth’s reclassification dated November 20,
2024, the tool use question was left blank. None of the reviewed youth were applicable for
participation in off-site activities. The FA was interviewed and indicated all youth participated in
an admission classification meeting at intake. All factors such as mental health, physical health,
age, prior victimization, gang involvement, behavior demonstrated at intake, and size is
discussed to determine the appropriate room assignment. The Admission Classification form is
maintained in the case management record.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program maintains a written policy and procedures regarding gang identification and
notification of law enforcement. Seven youth case management records were reviewed and two
were applicable for gang identification and notification to law enforcement. The program had no
additional applicable youth for the review period. Each of the two applicable youth case
management records documented the program notified local law enforcement and law
enforcement in the youth’s home county. The documentation reviewed for each applicable case
management record indicated the program notified the education provider, and the youth’s
juvenile probation officer (JPO) regarding the youth’s gang involvement. A gang alert was
entered into the program’s internal alert system and the Department’s Juvenile Justice
Information System (JJIS) for each youth.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program maintains a written policy and procedures regarding gang prevention and
intervention strategies. The program’s policy and procedures address providing program youth
an opportunity to develop plans to disaffiliate with criminal street gangs. Seven youth case
management records were reviewed, and two were applicable for gang affiliation/identification.
The program had no additional applicable youth for the review period. Each of the applicable
case management records validated the youth were participating in gang prevention and
intervention activities. Each of the youth’s performance plans included relevant goals and
objectives relating to gang intervention strategies. A review of the sign-in sheets for the annual
compliance review period indicated each of the applicable youth were participating in monthly
gang groups as designated. Additionally, the program provides Impact of Crime (IOC) groups to
bring gang prevention and awareness to each youth in the program. The interviewed facility
administrator (FA) indicated the youth participate in monthly gang and intervention and
prevention services. The gang curriculum provided to the youth include 50+ Stories of Fractured
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Lives and ARISE. Youth are usually given an assignment to complete and submit to the
program gang liaison. Additionally, all youth participate in IOC groups.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program maintains a written policy and procedures to address the completion of the
Residential Assessment for Youth (RAY) and reassessments. The policy requires the
completion of an initial RAY within thirty days of admission to the program, the completion of a
reassessment at least ninety days after completion of the initial RAY, and at least every ninety
days after each subsequent reassessment. Seven youth case management records were
reviewed, and all seven records were applicable for RAYs and six records were applicable for
reassessments. One youth was not applicable as the youth had not reached the ninety-day time
frame from their initial RAY. Each of the seven applicable records documented the initial RAY
was completed within thirty days of admission. Each of the six applicable records had a RAY
Reassessment completed. Five of the six youth RAY Reassessments were completed at least
every ninety-days after the completion of the initial RAY assessment, one RAY Reassessment
was completed three days late. One youth was applicable for an updated RAY Reassessment,
which was deemed necessary by the treatment team, to effectively manage the youth’s case.
The program maintained all reassessment documentation in the youth’s official case
management record for all six applicable youth.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program maintains a written policy and procedures to address the completion of a Youth
Needs Assessment Summary (YNAS) within thirty days of admission. Seven youth case
management records were reviewed, and each record contained a YNAS which was completed
within thirty days of the youth’s admission to the program. Each YNAS was documented in the
Department’s Juvenile Justice Information System (JJIS).
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
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youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program maintains a written policy and procedures to address the development of the
performance plan, goals, and plan transmittal. The treatment teams are required to develop an
Individualized Performance Plan (IPP) within thirty days of the youth’s admission to the
program. Seven youth case management records were reviewed. Each of the applicable
records contained an initial IPP completed by the program within thirty days of the youth’s
admission. Each initial IPP was developed after the initial Residential Assessment for Youth
(RAY) and Youth Needs Assessment Summary (YNAS). Each performance plan was developed
by the treatment team and all relevant members participated during the development, including
the treatment team leader, parents/guardians, the youth, administrative representative, living
unit representative, treatment staff, educational staff and any relevant parties who have
significant responsibility in goal completion. One youth required participation by the Department
of Children and Families (DCF) counselor; however, there was no documented attempt to
contact the DCF caseworker in the youth’s case management record. All seven youth case
management records had a signature sheet attached to the original IPP. A review of seven case
management records found the goals in six records were individualized and based on prioritized
needs, reflecting the risk and protective factors identified during the initial assessment. All six
reviewed youth records included each youth’s top three criminogenic needs identified in the
RAY. One youth record did not have individualized goals based upon the youth’s identified risk
or protective factors nor did it address the top three criminogenic needs. All seven performance
plans contained target dates for completion of goals, youth responsibility to accomplish goals,
and the program’s responsibilities to assist the youth to achieve the goals. Each of the
performance plans were signed by the youth, treatment team leader, and all parties who had
significant responsibilities in goal completion. Five of seven youth’s initial IPPs did not reference
the specific delinquency interventions based on the RAY results. Six of seven youth initial
performance plans did not reference the court-ordered sanctions which were reasonably able to
be completed in the program. Three of the performance plans did not include transition goals for
the youth to complete prior to release from the program. Seven youth case management
records were reviewed and four included documentation a transmittal letter and a copy of the
plan was sent to the committing court, and the juvenile probation officer (JPO). Three of the
applicable youth case management records did not document a transmittal letter showing a
copy of the performance plan was sent to the committing court, JPO, and parent/guardian within
ten working days of the plan being completed. Three of the performance plans were mailed to
each parent/guardian with request to sign and return; however, there were no signed
parent/guardian signature pages returned. Reviewed documentation for the applicable youth in
the care of DCF indicated the performance plan was sent to the DCF caseworker. On October
11, 2024, the program conducted an internal audit which identified deficiencies in treatment
team review documentation, performance plans which lacked the top three criminogenic goals
and failed to document the necessary program interventions, Performance Summaries which
were incomplete, and the case management tracker indicated documents were not submitted
within the required timeframes. Corrective actions were instituted with a completion date in
February 2025. In addition, all case management staff received training on January 30 through
31, 2025 which included the Department’s Juvenile Justice Information system (JJIS), RAY, and
Impact of Crime (IOC). A review of two case management records completed in January 2025
included all the required elements for the IPPs. Five youth were interviewed, and each youth
reported they participated in the development of their performance plan.
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Office of Accountability and Program Support Page 25 of 72 (Revised September 2022)
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program maintains a written policy and procedures ensuring revisions to a youth’s
performance plan. A review of seven youth case management records revealed each youth was
applicable for Individualized Performance Plan (IPP) revisions. All seven IPPs were revised due
to youth demonstrating progress toward completing a goal. One youth’s IPP was revised due to
newly acquired information which was revealed. None of the IPPs were applicable for revisions
based on the Residential Assessment for Youth (RAY) Reassessment results, for youth
demonstrating lack of progress toward completing a goal or facilitating transition activities during
the last sixty days of the youth’s stay. All seven-youth had additional plans which should have
been incorporated into the youth’s IPP. A review of seven youth IPPs found two had education
and mental health plans incorporated in the IPP; however, five youth IPPs did not have
education and mental health plans incorporated in the IPP. One youth was in the custody of the
Department of Children and Families (DCF); however, a plan was not submitted to the program
from DCF. On October 11, 2024, the program conducted an internal audit which identified
deficiencies in treatment team review documentation, performance plans which lacked the top
three criminogenic goals, the necessary program interventions, Performance Summaries which
were incomplete, and a case management tracker which indicated documents were not
submitted within the required timeframes. Corrective actions were instituted with a completion
date in February 2025. In addition, all case management staff received training on January 30
through 31, 2025 which included the Department’s Juvenile Justice Information System (JJIS),
RAY, and Impact of Crime (IOC). A review of two case management records completed in
January 2025 included all the required elements for the IPPs.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety-day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program maintains a written policy and procedures to address the requirements for
completion of Performance Summaries every ninety days. Performance Summaries are due
within ninety days of the signing of the youth’s performance plan, or earlier, if requested by the
committing court. The policy requires the treatment team to prepare a Performance Summary
prior to the youth’s release, discharge, or transfer from the program. The Performance
Summary provides information to the youth, parent/guardian, juvenile probation officer (JPO),
and other parties related to the status of each performance goal and describes the youth’s
overall adjustment to, and performance in the program. Seven youth case management records
were reviewed and six were applicable for the completion of at least one Performance Summary
and transmittal. One youth was in the program less than ninety days and a Performance
Summary was not due. Six of the reviewed Performance Summaries were completed within
ninety days of the performance plan, with the exception of one summary being completed four
days late. One youth’s Performance Summary was missing for the month of October 2024.
Each of the six applicable reviewed summaries contained all the elements required including the
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Office of Accountability and Program Support Page 26 of 72 (Revised September 2022)
youth’s status on each goal, treatment progress, academic status, behavior, level of
motivation/readiness to change, interaction with peers, interaction with staff, adjustment to the
program, and positive/negative events. All six of the applicable indicated youth were given the
opportunity to read and add comments to their Performance Summaries. All six youth’s
Performance Summaries indicated a copy of the summary was provided to the youth, and the
original summary was in the youths’ case management record. Five of the six reviewed
Performance Summaries included the youth comments and signatures, one youth’s signature
was missing on the Performance Summary dated November 16, 2024. Each of the reviewed
summaries were signed by the treatment team leader, additional treatment team staff, the
facility administrator (FA) or designee, and the youth. Each of the applicable reviewed
summaries were filed in the youth’s case management record. A review of six applicable youth
case management records verified four included a cover letter stating the Performance
Summary was sent to the committing court, youth’s juvenile probation officer (JPO), and
parent/guardian within ten working days. One youth record included documentation the
Performance Summary was sent to the Department of Children and Families (DCF) case
manager within ten working days. Two of the six reviewed case management records did not
include documentation the Performance Summary was sent to the committing court, JPO, and
parent/guardian within ten working days of completion. Three closed youth case management
records were reviewed for release summaries. All three youth were in the program for more
than forty-five days. Two of the reviewed records contained a copy of the original summary sent
at least forty-five days prior to the youth’s anticipated release date, along with the Pre-Release
Notification (PRN) to the JPO. Each summary contained the justification for release. One youth
record did not contain the original summary along with the justification for release. Two of the
three youth reviewed were applicable for a direct discharge from the program and a discharge
summary was sent to applicable stakeholders. Two of the three closed records included
documentation a release summary and the PRN were sent at least forty-five days prior to
release from the program. One closed youth record did not include documentation a release
summary and the PRN were sent at least forty-five days prior to release from the program. Two
of the three closed records included a signed copy of the PRN in the youth record, one youth
record did not have the signed PRN. Two of the three youth reviewed were eighteen years old
and did not require a notification to the parent/guardian, and the one applicable youth record
included documentation the parent/guardian was notified of the youth’s planned release. All
three reviewed closed records included documentation of an exit RAY which was completed
once the PRN was approved. None of the three closed records were applicable for the Sexually
Violent Predator Program (SVPP) and victim notifications were not required. On October 11,
2024, the program conducted an internal audit which identified deficiencies in treatment team
review documentation, performance plans which lacked the top three criminogenic goals and
failed to document the necessary program interventions, Performance Summaries which were
incomplete, and a case management tracker which indicated documents were not submitted
within the required timeframes. Corrective actions were instituted with a completion date in
February 2025. In addition, all case management staff received training on January 30 through
31, 2025 which included the Department’s Juvenile Justice Information System (JJIS), RAY,
and Impact of Crime (IOC).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 27 of 72 (Revised September 2022)
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program maintains a written policy and procedures regarding parental involvement in case
management services. Documentation supported the program makes efforts to include the
parent/guardian in the assessment process, development of the youth’s performance plan,
progress reviews, formal treatment team meetings, and transition planning. If the
parent/guardian is unable to attend the meetings in person, they are afforded the opportunity to
participate by telephone or conference call or are able to provide verbal or written input prior to
the meeting. At the time of the annual compliance review two treatment team meetings were
observed and the parent/guardian were called and participated by telephone. A review of the
youth’s progress notes revealed the program reaches out to the parent/guardian to facilitate
involvement by telephone, by email, and/or a letter will be sent to the residence.
Parents/guardians are encouraged to participate in treatment team meetings, transition
meetings, exit meetings, and participate in family day activities. The interviewed facility
administrator (FA) stated the case management process is explained to the parent/guardian at
intake. They are provided a parent/guardian/youth handbook by mail with the parent/guardian
notification letter. Monthly treatment team letters are mailed with the treatment team review, and
the parent/guardian is provided with the date/time of the next treatment team. During informal
and formal treatment team reviews, an attempt is made to reach the parent/guardian by
telephone. When the program is able, the parent/guardian is invited to a quarterly family day.
Five interviewed youth stated their parent/guardian participate during treatment team meetings.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program maintains a written policy and procedures to address the provision of intervention
and treatment teams to ensure representatives from the program’s administration and
residential living unit, education, and others responsible for overseeing the provision of
intervention and treatment services are included in the treatment team meetings. The treatment
teams are required to meet every thirty days to formally review each youth’s performance, to
include Residential Assessment for Youth (RAY) Reassessment results, progress on
Individualized Performance Plan goals, and positive and negative behavior, including behavior
which resulted in physical interventions, when applicable. The policy requires the case manager
to conduct informal reviews of each youth’s performance bi-weekly. The case manager meets
with the youth during informal reviews and incorporates input from treatment team members, as
needed. The policy identifies the case manager to be the treatment team leader. The program’s
treatment team members consist of the case manager/treatment team leader, youth, and
representatives from program administration, education, the youth’s living unit, mental health
treatment, education, and medical. The youth’s parent/guardian or the Department of Children
and Families (DCF) case worker, the transition case manager, and the juvenile probation officer
(JPO) are included as part of the treatment team, when applicable. Seven youth case
management records were reviewed. Each of the records documented formal treatment team
reviews were held at least every thirty days. Treatment team documentation included the
youth’s name, date of review, comments from treatment team members, progress in the
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program, progress of goals, behaviors, skills, treatment progress, and RAY Reassessment
results. All seven case management records had documentation showing informal reviews were
conducted bi-weekly. Documentation of informal reviews included the youth’s name, date of
review, comments from treatment team members, progress in the program, progress of goals,
behaviors, skills, RAY Reassessment results, and treatment progress. Each of the reviewed
records documented the notification to the required participants of the treatment team meetings
and who attended. If the parent/guardian and/or JPO did not participate in the treatment team
meeting, there was documentation to show attempts to contact the parent/guardian and JPO. All
forms contained signatures from required team members. During the annual compliance review
week, a treatment team meeting was observed, and observations confirmed all required
participants were present at the meeting. Five interviewed youth reported the staff review each
youth’s performance on the performance plan, goals, behavior, and treatment progress. Each
youth indicated they felt they can demonstrate the skills learned in the program and were able to
articulate their involvement during treatment team meetings.
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 maintains a written policy and procedures addressing transition planning,
conferences, and Community Re-Entry Team (CRT) meetings. Three closed youth case
management records were reviewed and a transition conference for each youth was held at
least sixty days prior to the targeted release date. All required and applicable treatment team
members including the youth, treatment team leader, and the facility administrator (FA) or
designee attended the transition conference in each of the reviewed youth case management
records. Each reviewed record documented the youth’s juvenile probation officer (JPO),
parent/guardian, education staff, and any other pertinent parties were invited to attend the
transition conference and all required parties participated either in person or by telephone. One
youth record included documentation a human trafficking specific service provider attended the
CRT meeting. Each transition conference included a review of transition activities on the youth’s
performance plan, any revisions in the performance plan, identified target completion dates, and
identified persons responsible for completion of transition activities. One youth record identified
additional transition activities. The treatment team leader obtained attendees’ dated signatures,
representing their acknowledgement of the transition goals and accountability for completion. A
copy of the plan sent with a request for return with signature to anyone not in attendance who
had a responsibility for completion of transition goals for all three reviewed closed records. All
three closed records indicated the plan was transmitted electronically to the JPO. A review of
three closed records verified a CRT meeting was conducted prior to the youth’s release. The
youth and case manager participated in the CRT meeting. Documentation verified all the
stakeholders were invited to participate in the CRT meeting.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 29 of 72 (Revised September 2022)
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program maintains a written policy and procedures addressing the assembly of an exit
portfolio to assist each youth once they are released back into the community. Three closed
youth case management records were reviewed and the exit portfolio for each youth was
initiated and discussed during the transition conference. Reviewed documentation revealed the
applicable exit portfolios included a copy of the transition plan, calendar with all dates, times,
and locations of upcoming community appointments, Social Security card, birth certificate, State
of Florida identification card, educational or vocational certificates, educational record, school
transcripts, résumé, and sample employment applications. One of the youth’s closed case
management records did not contain a state identification card. Reviewed documentation for
each record validated the youth’s exit portfolio was verified during the exit conference and the
exit portfolio was given to the youth upon release. Two closed case management records
indicated the exit portfolio was provided to the youth’s juvenile probation officer (JPO). One
closed case management record did not indicate the program provided the exit portfolio to the
JPO. The program attempted to provide a copy of the exit portfolio to the JPO; however, the
JPO refused to sign the release documentation to receive the portfolio. Each youth record was
applicable and contained documentation evidencing the youth was provided with completed
forms and clear instruction as to how to obtain the information. Additionally, during the transition
conference a plan was put into place as to who would be responsible for working with the youth
to obtain the items.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program maintains a written policy and procedures regarding an exit conference for each
youth to review the status of goals developed at the transition conference and to finalize the
release plan. Three closed youth case management records were reviewed and the exit
conference for each youth was conducted after the program notified the juvenile probation
officer (JPO) of the release and at least fourteen days prior to the youth’s release. Each exit
conference included a summary of pending transition goals, date of the conference, and
signatures of all applicable participants. A review of the Department’s Juvenile Justice
Information System (JJIS) revealed the date of admission and date of termination documented
in the case management record for each youth correlated with JJIS. Reviewed documentation
for each record validated the status of transition activities established at the transition
conference were reviewed and updated during the exit conference. For each reviewed record,
all required and applicable members participated in the exit conference. Each exit conference
was held separately from the transition and Community Re-Entry Team (CRT) meetings.
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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 a formal process in place to promote constructive input by youth. The program
has the grievance process, “Request to Speak” forms, and the student council/youth advisory
council. The forms are maintained in the youth’s living units, along with the form drop box. The
youth can submit the form when seeking a discussion with a staff or when requesting any
needed item. Observations during the annual compliance review week confirmed the forms
were located in the youth’s living units. The program’s “Town Hall” meetings and youth advisory
council meetings are held bi-weekly according to policy. These are facilitated by the assistant
facility administrator (AFA) and operations manager. The meetings include a discussion of
program issues and/or youth are given an opportunity to speak about any issues. Agendas and
sign-in sheets were observed of these meetings and validated the program’s practice. The
director of case management confirmed youth complete surveys on a quarterly basis. Surveys
capture information concerning staffing, programmatic issues, and food at the program. Results
are passed to program administration for review. Reviewed documentation during the annual
compliance review week validated the program’s practice. Five youth were interviewed, each
youth confirmed they are able to provide youth input at the program and each youth was able to
explain how they provide their input. The interviewed facility administrator (FA) stated the
student council meets twice each month to discuss concerns and give input on the incentive,
canteen, and recreation calendar. Youth are requested to provide input on how the program is
doing by completing youth surveys. The youth are invited to inform administration of any issues
with the program staff by requesting to speak to the FA. “Town Hall” meetings are held on the
living units once each month to solicit input from the youth regarding the program. Youth
incentives can include having lunch or dinner with the FA for A/B honor roll, living unit of the
month, pizza party or movie night, and award ceremonies.
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Office of Accountability and Program Support Page 31 of 72 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program maintains a written policy and procedures requiring a designated mental health
clinician authority (DMHCA). The program has a director of clinical services who serves as the
program’s DMHCA. The DMHCA is full-time an on-site forty hours weekly as required by the
program’s contract to ensure appropriate coordination and implementation of mental health and
substance abuse services are taking place in the program. As a part of the assigned
responsibilities, the DMHCA ensures consistent and appropriate services in addition to being
on-call twenty-four hours a day seven days weekly for emergency consultation. The DMHCA is
a licensed marriage and family therapist. The reviewed licensed confirmed it was free and clear
in the State of Florida with an expiration date of March 31, 2025. The program’s back-up
DMHCA is the regional clinical manager who has a free and clear license in the state of Florida
with an expiration date of March 31, 2025. The interviewed DMHCA stated their role in the
coordination and implementation of mental health and substance abuse includes identifying
youth needs and the therapist who best fits the youth mental health and substance abuse needs
during admission.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program’s
licensed designated mental health clinician authority (DMHCA) serves as the program’s
supervisor for on-site clinical staff. The program’s staff listing, and contractual requirements
confirmed there is a licensed assistant clinical director staff beyond the DMHCA. The assistant
clinical director is a licensed mental health counselor with a free and clear license in the State of
Florida, which expires March 31, 2025. Additionally, the regional clinical manager is a licensed
mental health counselor. The regional clinical manager has a clear and active license which
expires on March 31, 2025. The regional clinical manager provides support and supervisory
services to the DMHCA and on-site clinical staff. The program is licensed under Chapter 397 by
the Department of Children and Families to provide substance abuse services to adolescents.
The Chapter 397 license expires April 1, 2025. The program’s clinical staffing based on the
contract requires one licensed DMHCA, one recreation therapist, one licensed therapist, and
eight non-licensed mental health clinicians.
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Office of Accountability and Program Support Page 32 of 72 (Revised September 2022)
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and procedures regarding non-licensed clinical staff.
The designated mental health clinician authority (DMHCA) confirmed their responsibility for
ensuring non licensed clinical staff are working under their supervision and performing services
they are qualified to, based on education, training, and experience. The program’s practice is to
complete group and/or individual clinical supervision for the non-licensed clinicians and the
recreation therapist. A review of twelve months of clinical supervision logs since the last annual
compliance review was conducted. The clinical supervision was documented on the program’s
form and included all elements on the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. Documentation
verified each non-licensed clinical staff received clinical supervision for each week they provided
services. The program is licensed under Chapter 397 through the Department of Children and
Families to provide substance abuse services to adolescents. A review of the license reflected it
was displayed in the lobby with the program’s physical address listed. The reviewed license
expires on April 1, 2025. The program had two clinical staff vacancies during the annual
compliance review week for non-licensed therapists which have been vacant since November
15, and December 6, 2024. The program had six non-licensed mental health clinicians providing
therapeutic services since the last annual compliance review. A review of six non-licensed
staff’s education documentation reflected each held a master’s-level degree from an accredited
university or college in the field of counseling, social work, psychology, or a related human
services field. Each non-licensed staff providing clinical services was employed by a service
provider which was licensed under Chapter 397. Each of the six non-licensed clinical staff
received training in the administration of the Assessment of Suicide Risk.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program maintains a written policy and procedures which establishes the system for
gathering important treatment and emergent needs information prior to each youth’s entry into
the general population. The program’s policy requires the staff to administer a mental health and
substance abuse screening, including a suicide risk screening, upon a youth’s admission to the
program. A review of seven mental health and substance abuse records confirmed the program
completed a Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) on the
day of admission. The program documented the review of information including the commitment
packet, reports and records for existing documentation of mental health or substance abuse
problems and/or history of human trafficking information. Each of the seven reviewed MAYSI-2s
were completed in full in the Departments Juvenile Justice Information System (JJIS) and
included the date of completion and the name of staff who completed the screening. Screenings
were completed by trained staff. Four of the seven reviewed MAYSI-2s indicated further
assessment was required, and documentation showed a referral was completed for each of the
four youth. The program’s practice is to complete a referral for each youth regardless of their
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Office of Accountability and Program Support Page 33 of 72 (Revised September 2022)
screening results. None of the reviewed youth records were applicable for emergency
procedures or the youth being in crisis. No reviewed youth records were applicable for suicidal
ideation. The reviewed screening policy and procedure indicated the facility administrator (FA) is
responsible for the implementation of a standardized admission and intake mental health and
substance abuse screening process. The policy addresses the review of available information,
administration of the MAYSI-2, staff training in administration of the MAYSI-2, and a process for
youth in crisis requiring immediate attention. The interviewed FA reported the program has a
contracted board-certified behavior analyst who provides additional services for youth as they
are referred.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a written policy and procedures to establish an evaluation process to
guide the development of each youth’s individualized treatment plan. The program ensures the
mental health and substance abuse needs of the youth are identified through a comprehensive
mental health and substance abuse evaluation process. Each youth receives an in-depth
evaluation within the first thirty days of residential placement. All evaluations are to be
completed by a licensed mental health professional or mental health clinical staff working under
the direct supervision of the licensed mental health professional. Six of the seven reviewed
records indicated a new combined mental health and substance abuse evaluation was
completed. One youth evaluation was still pending due to the youth’s recent admission into the
program. Each of the six applicable evaluations were completed within thirty days of admission
and each youth consented to substance abuse services prior to the evaluation. Each reviewed
evaluation was completed by a non-licensed staff and signed by a licensed staff within ten days.
Each evaluation included the date of referral/admission, date of the evaluation, identifying
information, the reason for the evaluation, relevant background information, behavioral
observations, a Mental Status Examination, procedures administered, discussion of findings,
diagnostic impressions, patterns of alcohol and/or drug abuse, impact of use on major life areas,
risk factors for continued use, and recommendations. None of the seven reviewed records
required an updated evaluation. An interview with the program’s licensed designated mental
health clinician authority (DMHCA) stated the process for obtaining the comprehensive mental
health and/or substance abuse evaluation is for the youth to receive a Massachusetts Youth
Screening Instrument, Second Version (MAYSI-2) screening based on the bio-comprehensive
evaluation, which will be completed within thirty days of the youth’s arrival.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a written policy and procedures outlining the program’s mental health
and substance abuse treatment services. A review of seven youth records indicated each
contained an initial mental health and substance abuse treatment plan within seven days of
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Office of Accountability and Program Support Page 34 of 72 (Revised September 2022)
admission. Each initial treatment plan was documented on the program’s form which included
all elements of the Department’s Initial Mental Health and Substance Abuse Treatment Plan
form. One youth was applicable for psychotropic medications and the plan included the
medication details. Each of the seven initial plans were completed and signed by the licensed
designated mental health clinician authority (DMHCA). Each plan was signed by the youth,
parent/guardian, treatment team leader and program management. Six of the seven records
were applicable for an individualized treatment plan to be completed within thirty days and
treatment plan reviews to be completed at thirty-day intervals. One of the reviewed
individualized treatment plans was for a youth prescribed psychotropic medications and the plan
included the medication monitoring schedule. One plan was not applicable due to the youth
being in the program less than thirty days. The six applicable reviewed records documented
forty-eight treatment plan reviews, and each review was completed at least every thirty days as
required. Individualized treatment plans and reviews documented signatures of the youth,
parent/guardian, juvenile probation officer (JPO), treatment team leader, program management,
living unit staff, and education staff. Each plan was signed by the licensed DMHCA on the day
of completion. Each applicable youth’s treatment plan documented prescribed services, goals,
and objectives which were individualized for each youth. Each plan included individual
counseling, group counseling, family counseling, and applicable psychotherapy. A review of
video compared to sign-in sheets for groups indicated they were occurring as scheduled and as
documented.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
The program maintains a written policy and procedures addressing treatment and discharge
planning. A review of seven youth records indicated each youth was assigned to a treatment
team upon arrival to the program. Reviewed treatment team documentation and Treatment
Team Assignment forms for each reviewed record confirmed the treatment team members were
comprised of the youth, program administration, living unit, education, medical staff, mental
health and substance abuse staff. Each youth with substance abuse treatment goals received
treatment by a qualified professional. The program is licensed under Chapter 397 to provide
substance abuse services to adolescents. Each youth record contained a substance abuse
consent and the Department’s Authority for Evaluation and Treatment. Reviewed progress
notes were documented on the program’s form and contained all elements of the Department’s
Counseling/Therapy Progress Notes form. Reviewed progress notes verified treatment included
individual psychotherapy and psychosocial skills. Each record review verified services were
provided as stipulated in the youth’s treatment plan. A review of three closed youth records was
completed for discharge plans. Each of the three reviewed discharge summaries were
documented on the Department’s Mental Health and Substance Abuse Treatment Discharge
Summary form. None of the reviewed closed records were applicable for youth being released
while on suicide alert/precautions. Each of the three reviewed summaries documented the
future services needed. Reviewed documentation supported the plans were discussed during
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Office of Accountability and Program Support Page 35 of 72 (Revised September 2022)
the exit conference with the youth, parent/guardian, and assigned juvenile probation officer
(JPO). Each record documented the youth and parent/guardian signed the plan and the plan
was sent to the assigned JPO.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program maintains a policy and procedures to establish a delivery protocol for Borderline
Intellectual Functioning and Borderline Developmental Disability (BDD) or Developmental
Disability Services (DD). Required clinical treatment groups include Trauma-Focused Cognitive
Behavioral Therapy and Life Skills Training (LST). Five interviewed youth stated they participate
in family and individual counseling at the program. Five interviewed staff indicated direct care
staff does not facilitate any mental health or substance abuse groups. An interview with the
designated mental health clinician authority (DMHCA) indicated the program provides
individualize treatment through group, individual, and family therapy services to address mental
health and substance abuse concerns of the youth. The interviewed facility administrator
confirmed the required clinical groups at the program. Documentation confirmed the DMHCA
was on-site for forty-hours each week and licensed staff was on site at least five days each
week. The required counselor to youth ratio is not to exceed one counselor to twelve youth for
the BIF/BDD youth and one counselor to ten youth for DD youth. A review of caseload
assignments indicated they were within the contract required ratio for each counselor. A board-
certified behavior analyst provided on-site services as required. The program was providing
individual therapy twice every two weeks for BIF/BDD youth and four times every two weeks for
DD youth, family therapy at least twice monthly, applicable psychiatric services every two
weeks, and mental health/substance abuse groups five times each week as required. This was
verified by the programs group schedule.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program maintains a written policy and procedures for the provision of psychiatric services
within the program. The program’s contracted psychiatrist is responsible for psychiatric
evaluations, consultation, medication management, and medical supportive counseling. A
review of the psychiatrist’s license indicated they held a medical doctor license which was free
and clear in the State of Florida with an expiration date of January 31, 2026. The psychiatrist is
available for emergency consultation twenty-four hours a day, seven days a week. The
psychiatrist provided psychiatric services and served briefly as a representative of treatment
team. Psychiatric recommendations for youth are incorporated into evaluations and planning at
the program. The program did not utilize a back-up psychiatrist during the annual compliance
review period. The program does not use a psychiatric advanced practice registered nurse. A
review of the psychiatric sign-in logs verified the psychiatrist was on-site bi-weekly since the last
annual compliance review. Reviewed documentation indicated the psychiatrist actively
participates in, manages, and supervises psychotropic medication services in the program. The
program has an independent contract with a licensed psychiatrist who provides services as
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needed. The program does not utilize tele-psychiatry services. The psychiatrist reported they
complete Initial Diagnostic Psychiatric Interviews with youth, monthly medication management,
participate in quarterly interdisciplinary meetings, and conduct evaluations for youth with
referrals on an as needed basis. The interviewed psychiatrist reported they are on-site weekly
and on call twenty-four hours daily as needed. The psychiatrist reported they have no concerns
with services provided at the program. The interviewed designated mental health clinician
authority (DMHCA) reported they meet with the psychiatrist to discuss youth receiving
psychiatric services monthly when they are on-site. A review of seven records indicated one
was applicable for psychiatric services and one youth was subsequently placed on psychotropic
medication. The program did not have any other youth applicable for psychotropic medication
during the annual compliance review period. The youth applicable for being admitted on
medications was referred for a psychiatric interview and received a diagnostic interview within
fourteen days of admission. Both applicable youth received an Initial Diagnostic Psychiatric
Interviews which included history, a Mental Status Examination, a Diagnostic and Statistical
Manual, Fifth Edition (DSM-5) diagnosis, treatment recommendations, prescribed medications,
explanation for the need of medications, target symptoms, initial treatment goals, potential side
effects, and frequency of medication management. Each youth was referred for a psychiatric
interview upon admission, as it is the program’s practice to refer all youth. Each interview was
documented on the Department’s Clinical Psychotropic Progress Note (CPPN) form and
included page three when medication was prescribed and/or continued. Two youth including the
youth subsequently placed on psychotropic medication were applicable for eleven psychiatric
medication reviews to be completed at least every thirty days. All were completed as required.
One of the reviewed records was applicable for a psychiatric evaluation resulting in the
prescription of psychotropic medication. Each instance where page three of the CPPN was used
the psychiatrist documented the identifying data, diagnosis, target symptoms of each
medication, effects of the medication, medication dosage, dosage range, frequency, route of
administration, side effects, adherence to the medication regime, and whether there was
telephone contact with the youth’s parent/guardian. Each was signed and dated by the
psychiatrist. Two youth records documented monitoring for Tardive Dyskinesia monthly as
indicated on the CPPN. None of the reviewed records were applicable for the use of tele-
psychiatry.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program maintains a policy and procedures regarding the implementation of a Suicide
Prevention Plan. The plan shall provide guidelines for the identification, management, and
assessment of potentially suicidal youth. The program maintains a Suicide Prevention Plan
which was last signed and reviewed by the facility administrator (FA) on October 2, 2024. A
review of the plan reflected it included identification and assessment, staff training, suicide
precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, and a review process. The review process for suicide attempts and
mortality review included circumstances surrounding the event, 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.
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3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
The program maintains a written Suicide Prevention Plan which serves as the program’s suicide
prevention procedures. The Suicide Prevention Plan addresses the program’s suicide
prevention services, suicide precautions and observation logs, as well as suicide prevention
training. A review of seven youth records indicated each was applicable for an Assessment of
Suicide Risk (ASR) to be completed upon admission as part of the program’s standardized
practice. The program reported they only had one youth who was identified as being actively
suicidal and requiring interventions since the last annual compliance review. A review of the
seven ASRs completed as part of the admission process indicated each was completed in full
and each youth was transitioned to standard supervision after a conference was documented
with the licensed designated mental health clinician authority (DMHCA) and the facility
administrator (FA). All seven were completed by a licensed staff. One youth requiring suicide
interventions was referred for an ASR after the admission screenings. The ASR was completed
within twenty-four hours by a non-licensed staff and signed by the licensed DMHCA the next
day. Each ASR documented a conference between the assessor, DMHCA, and the FA
regarding the decision to continue the youth on precautionary observation. A Follow-Up ASR
was needed and completed for the youth prior to the removal of the youth from precautionary
observation. The Follow-Up ASR was documented on the Department’s Follow-Up ASR form.
The youth was maintained on suicide precautions and constant supervision until the Follow-Up
ASR indicated suicide precautions could be discontinued. When the youth’s Follow-Up ASR
indicated suicide precautions could be discontinued, the youth was stepped down to close
supervision prior to transition to normal routine and standard supervision. Close supervision was
maintained until it was determined no longer necessary by the DMHCA. Reviewed
documentation indicated a conference was held by the FA and licensed DMHCA to reduce the
youth’s level of supervision. Discontinuation of close supervision was documented in
accordance with the program’s Suicide Prevention Plan, as well as the date and time the youth
was stepped down. The Department’s Juvenile Justice Information System’s suicide alerts were
initiated for the youth placed on suicide precautions, and accurately closed following the
recommendations of the Follow-Up ASRs. There was evidence in the program’s logbook
indicating administration or supervisory staff provided instructions related to the suicide risk
assessment findings and suicide precaution decisions. There were no video observations to
verify precautionary observations during the annual compliance review due to the program only
storing thirty days of video footage.
3.12 Secure Observation (Critical) Non-applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
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3.13 Suicide Precautions-Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a written policy and procedures requiring staff to always maintain at
least constant supervision of the youth on precautionary observation and document their
observations of the youth on the Suicide Precautions-Observation Log in intervals which do not
exceed thirty minutes. A review of seven youth records indicated none were applicable for being
placed on precautionary observation. The program had one youth applicable for placement on
suicide precautions since the last annual compliance review. The Suicide Precautions-
Observation Log was maintained for the duration the youth was under suicide precautions. The
appropriate level of supervision and observations of the youth’s behavior was documented in
real time and not exceeding thirty-minute intervals. For the reviewed record warning signs were
observed, and notification to the facility administrator and mental health clinical staff was
documented on the Suicide Precautions-Observation Log. The Suicide Precautions-
Observation Log was reviewed and signed by the shift supervisor and mental health clinical
staff. The Suicide Precautions-Observation Log documented safe housing requirements.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a written Suicide Prevention Plan ensuring details of the suicide
prevention training requirements. Nine reviewed pre-service and nine in-service training records
confirmed staff’s completion of suicide prevention training. The program has two suicide
response kits located in both sub controls on the shadow board. The suicide response kits are
co-located with the first-aid kits. The program is required to complete one mock suicide drill for
each shift at least quarterly. A review of suicide drills for the past twelve months reflected the
program conducted the necessary drills on each shift, as required. Reviewed drills included the
use of lifesaving measures to include the use of cardiopulmonary resuscitation (CPR), first-aid
kits, suicide kits, and an automated external defibrillator (AED). Reviewed documentation
confirmed all drills were simulated. Reviewed documentation confirmed all direct care staff
participated in at least one drill which involved the use of CPR annually. The trainings include
mock suicide drills held no less than quarterly on each shift, for all staff who come in contact
with youth including kitchen and maintenance staff. Video review indicated drills were simulated
and all mock mental health drills were in response to a suicide attempt and/or incident of serious
self-injury. The program youth were not used in drill simulations related to mental health or
substance abuse care. The program provides semi-annual trainings on emergency response
procedures which include “mock” training in emergency response to a suicide attempt or
incident of serious self-inflicted injury. Staff who were not present during a quarterly drill have
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 interviewed facility administrator
reported the program completes quarterly mental health and suicide drills. Nine interviewed staff
reported medical emergency and suicide drills are conducted monthly on their shift. Two
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interviewed staff reported drills are conducted monthly or more and one staff reported they were
not sure how often medical emergency and suicide drills are conducted on their shift.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a policy and procedures to outline operation procedures for crisis
intervention. The program’s Crisis Intervention Plan addresses mental health crisis intervention
services and Crisis Assessments. A review of the plan indicated it included notification and alert
system, referrals, communication, supervision, documentation, and review. The plan states it
shall be the responsibility of all staff to ensure crisis plans are implemented immediately to
afford youth with a maximum amount of safety and security.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program’s Crisis Intervention Plan addresses mental health crisis intervention services and
Crisis Assessments. A review of seven youth records indicated none were applicable for a
Crisis Assessment. The program had no youth applicable for a Crisis Assessment since the last
annual compliance review.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written policy and procedures outlining the mental health and
substance abuse procedures for youth who are believed to be in imminent danger to
themselves or others because of mental illness or substance abuse impairment. The
Emergency Response Plan for Mental Health and Substance Abuse Emergencies requires
youth to receive the highest quality of care, safety, and management. A review of the plan
validated it included immediate staff response, notifications, communication, supervision,
authorization to transport for emergency mental health and substance abuse services, transport
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for emergency Baker Act, transport for emergency Marchman Act, documentation, training, and
review.
3.18 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program maintains a written policy and procedures ensuring youth who are believed to be
an imminent danger to themselves or others because of mental illness or substance abuse
impairment receive emergency mental health or substance abuse services. The program had
one Baker Act during the annual compliance review period. The reviewed record indicated the
staff immediately referred the youth for an assessment and placed the youth on precautionary
observation once warning signs presented. The program’s clinical staff assessed the youth
within two hours and referred the youth for an evaluation at a Baker Act facility. The youth was
transported by law enforcement and returned to the program on precautionary observation until
assessed by mental health staff. The youth was maintained on precautionary observation until
an Assessment of Suicide Risk (ASR) and a Mental Status Examination was completed. The
ASR was completed by a licensed staff.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a written policy and procedures for an ongoing safety planning process
for each admitted youth. Safety planning is designed to identify stimuli which have both positive
and negative effects on the youth. Within fourteen days of admission, the intervention and
treatment team shall meet with each youth to develop the Safety Plan. The Safety Plan shall be
updated in an ongoing collaboration with the youth to identify specific behaviors or triggers
which may decrease the youth’s sense of safety and increase the likelihood the youth may
experience a traumatic stress related response. The Safety Plan shall include input from the
parent(s)/guardian(s) as well as information gathered from the youth’s history and evaluations, if
applicable. The plan shall be updated every thirty days or following any significant behavioral or
mental health event identified by the treatment team. A review of seven youth records indicated
each had a Safety Plan created within fourteen days of admission and reviewed every thirty
days. Each plan documented warning signs, youth baseline behavior, crisis recognition, jointly
developed coping strategies, preferred intervention strategies, and a debriefing process. Each
plan was jointly prepared with the youth, parent/guardian, and mental health staff. Each plan
incorporated information from previous assessments and interviews. None of the plans required
an update due to a significant behavioral or mental health event. Six of the seven reviewed
records contained forty-eight Safety Plan reviews. One reviewed record did not require a review
due to the youth being in the program less than thirty days. The plans are accessible to staff
and located in the sub controls of the east and west phases. Five interviewed youth reported
they contributed to the development of their Safety Plans. The interviewed facility administrator
reported Safety Plans are reviewed and updated monthly at treatment team meetings.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program maintains a written policy and procedures which outlines the designated health
authority (DHA) responsibility for the medical care of all youth at the program. The program’s
policy requires an osteopathic physician (DO) or licensed physician (MD) to have an
unrestricted license and meet all requirements. The program’s DHA is a DO with an
unrestricted, clear and active license to practice in Florida expiring on March 3, 2026. The
physician is specialty trained in family practice with no disciplinary cases or public complaints on
record. The program does not utilize an advanced practice registered nurse (APRN) for clinical
duties. A review of the sign-in/out logs confirmed the DHA on-site visits met the requirements for
at least two hours once a week during the annual compliance review period. In the absence of
the DHA the back-up DHA who holds a clear and active license expiring on January 3, 2026, will
provide clinical services. An interview with the nurse stated the back-up DHA was not utilized
during the annual compliance review period. Provided documentation confirmed during the
annual compliance review period telemedicine/telehealth was utilized on October 10, December
25, 2024, and January 1, 2025, for the youth who agreed to participate in the telehealth
sessions. Records confirm there were no instances of telehealth used to perform a
Comprehensive Physical Assessment (CPA). An interview conducted with the program’s DHA
confirmed weekly on-site visits are conducted, and the DHA is available on-call for twenty-four
hours a day seven days a week. The DHA indicated the medical services provided on-site are
only made by the DHA. During the site visit youth are periodically evaluated, the CPAs are
completed, sick call follow-ups, and policy and procedure development is conducted as needed.
The DHA stated other tasks include a review of the weekly binder provided by the health
services administrator (HSA) of youth off-site visits. Communication between the DHA and the
different medical shifts is maintained with shift reports and posted medical alerts for staff. In
addition to the weekly meetings with the program’s HSA, the DHA participates in quarterly
interdisciplinary risk reduction, quality improvement, and infection control meetings.
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 maintains a written policy and procedures on having licensed medical staff. The
program is required to have a licensed nurse on-site to provide healthcare services to the youth.
The program has five full-time registered nurses (RN) and one part-time licensed practical nurse
(LPN) on-site. The LPN works under the direction of a license healthcare professional while
providing services to the youth. A review of the nurses’ licensure credentials on the Florida
Department of Health Medical Quality Assurance website confirmed all six nurses had clear and
active licenses. All the nursing staff had current cardiopulmonary resuscitation (CPR)
certifications. A review of the medical staff schedule documentation supported the nursing staff
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was in compliance with providing services for the required on-site contracted hours. The RN
clinical manager is on-site Monday through Friday from 9:00 am to 5:00 pm.
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 maintains a written policy for facility operating procedures (FOP) for all health-
related protocols at the program. The program requires an annual review to be conducted on
the FOPs. A review of the FOPs confirmed January 1, 2025, was when the designated health
authority (DHA) and the nursing staff dated the cover pages of all respective treatment FOPs.
The facility administrator (FA) signed and dated the FOPs on January 2, 2025. In addition, on
January 25, 2025, the psychiatrist signed and dated the FOPs for all health-related procedures
and protocols. All policy changes made within the year were signed and dated by the nursing
staff. Provided documentation confirmed the newly employed health care personnel received
the comprehensive clinical orientation including the policies and procedures provided by the
clinical manager. A review of documentation confirmed the approved annual treatment protocols
were written and authorized by the DHA on January 1, 2025.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program maintains a written policy and procedures for authorizing treatment for the youth.
The program’s policy requires each youth in custody to have a valid Authority for Evaluation and
Treatment (AET). A review of seven youth records confirmed six youth’s Individual Healthcare
Records (IHCR) had an original signed and dated AET by the parent/guardian and a
Department representative. One youth was in the care of the Department of Children and
Families and a court order was present in the youth’s IHCR. One out of the seven reviewed
youth was eighteen years old and had a signed AET form completed prior to the youth’s
eighteenth birthday by a parent/guardian. An interview with the nurse confirmed an AET is not
used for youth eighteen years or older. The nurse stated the policy for obtaining a new or
current AET for youth is medical staff will call the parent/guardian to notify them the
acknowledgment for consent for the AET is being mailed for a signature.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program maintains a written policy and procedures for parental notification and consent.
The program’s policy requires the parent/guardian to be notified regarding medical changes. A
review of seven youth records confirmed six youth have documentation of parental notification
for over-the-counter (OTC) medications beyond those indicated on the Authority for Evaluation
and Treatment (AET). Two of the seven youth records indicated a new medication was ordered
and was documented in the progress notes. One of the seven reviewed youth was taking
psychotropic medication upon admission to the program. The reviewed documents confirmed
the written notifications were sent utilizing the Department’s Parental Notification of Health-
Related Care forms including the Acknowledgement of Receipt of the Clinical Psychotropic
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Progress Note (CPPN). The nurse witnesses a telephone call attempt to the parent/guardian
about the youth’s psychotropic medication changes. Parent/guardian verbal consent to
notifications of psychotropic medications was documented on page three of the CPPN. The
youth receiving psychotropic medications was not in the care of the Department of Children and
Families (DCF). Reviewed Documentation indicated the court authorized all treatment and
procedures with a court order. A review of the seven youth records confirmed all youth
vaccinations were verified within thirty days of admission. None of the youth were applicable for
having refused consent for immunizations or to have the Department’s Parental Notification of
Health-Related Care Vaccination/Immunization forms signed prior to the admission date. A
review of the nurse’s interview indicated a verbal and written consent is needed for all
medications including obtaining new or discontinued psychotropic medications, activity
restrictions or procedures. Examples of procedures include, and are not limited to dental, X-
rays, and ultrasounds. Parent/guardians are notified by telephone at the time the doctor’s order
is received. Written consent notification is mailed to the parent/guardian within twenty-four
hours. Parents/guardians can sign an exemption form which is kept in the youth’s Individual
Healthcare Record (IHCR). In the instance of an emergency, the facility administrator (FA),
designated health authority (DHA), the Department's Central Communications Center (CCC),
and parent/guardian are all notified and updated on all incidents. The nurse explained the
process for obtaining youth immunizations and vaccination records. The records are verified at
the time of the youth’s admission. According to the nurse if records need to be obtained, they
will go on the Florida Shots website. If a youth is still in need of a vaccination, the youth can
obtain the vaccination at the program if it is available at the pharmacy or by going to the local
health department.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program maintains a written policy and procedures for youth admission screening. The
program’s policy requires each youth in custody to have a healthcare admission screening. A
review of seven youth records indicated all youth had a completed Facility Entry Physical Health
Screening (FEPHS) form completed on the date of admission. Five screenings were completed
by the licensed practical nurses (LPNs) and two FEPHS were completed by the registered
nurse (RN). Two of the youth had a change in physical custody greater than twenty-four hours
and each had a new screening completed. A review of the nurse interview confirmed youth are
seen by medical staff immediately upon arrival to the program. The youth admission screening
is completed by the RN. The admission screening is documented on FEHPS.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program maintains a written policy and procedures for educating the youth on the
healthcare delivery services. The program’s policy requires each youth to be orientated about
the general process of the health care delivery services the youth will receive at the program. A
review of seven youth records confirmed all the youth received a general care admission
orientation. The orientation included sick call practices, access to medical care, medication
process including side effects monitoring, “emergencies”, the right to refuse care and how it is
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documented, the non-disciplinary role of the health care providers, and standard universal
precautions. The program utilizes an education/orientation binder for youth who refused to sign
the orientation sheet. The program provides health education during youth admission. The
health education information includes at the minimum of seatbelt usage, alcohol and drug
related problems, sexually transmitted disease/infections, smoking education, basic personal
hygiene, immunization, infection control, prevention of sexual and other physical violence,
nutrition, physical fitness, and parenting skills.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program maintains a written policy and procedures for notifying the designated health
authority (DHA) of newly admitted youth. The program’s policy requires the DHA/designee to be
notified when newly admitted youth require emergency care. A review of seven youth records
confirmed only three youth were applicable for having known or suspected chronic conditions
with a referral to the physician. None of the youth records indicated the youth was in-need of
emergency care upon admission. All seven medical records contained documentation on the
youth’s Chronological Progress note/Individual Healthcare Record (IHCR) indicating the DHA
was notified within twelve hours of admission. One youth was applicable for taking psychotropic
medication upon admission and documentation confirm the psychiatrist was notified. The
nursing staff interview confirmed the registered nurse (RN) notifies the DHA at the time of youth
admission and the nurse will document the admission progress note for each youth in the IHCR.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program maintains a written policy and procedures for authorizing treatment for the youth.
The program requires the health-related form to be used for each youth which is in the
program’s physical custody. A review of seven medical records indicated each Health-Related
History (HRH) was updated/completed prior to the Comprehensive Physical Assessment (CPA).
A physician reviewed and signed the HRH forms. According to the nursing staff interview the
admitting registered nurse (RN) is responsible for completing the HRH at the time of the
admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program maintains a written policy and procedures for admitted youth receiving a
Comprehensive Physical Assessment (CPA). The program’s policy requires all youth admitted
to have a standardized CPA upon arrival. A review of seven medical records confirmed each
youth’s physical assessment was completed on the required form. Documented on the CPA
included the time of admission and Medical Grade. The Medical Grade of five was documented
for one youth. A Medical Grade of two was documented for five youth. One youth received a
Medical Grade of one. All Medical Grades were all noted on each youths’ CPA. The Medical
Grade was documented by the designated health authority (DHA). A review of the CPA
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confirmed each section was answered the with “O” or “X”; however, all seven-youth refused part
of the exam. Documentation included a signed refusal form and confirmation of self-
examinations for all youth. The youth’s Problem List was updated for all the medical records
reviewed. Documentation confirmed there were no missing/incomplete elements on the CPA. All
seven-youth had at least one documented Tuberculosis Skin Test (TST) completed. Results for
the TST and infectious and communicable diseases were documented on required forms. A
review of the nurse’s interview indicated the DHA completes a new CPA within seven days of
the youth’s admission and then yearly. A Tuberculosis test is administered to youth yearly along
with a chest X-ray if determined necessary.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program maintains a written policy and procedures for treating sexually transmitted
infections. The program’s policy requires youth to be evaluated and treated if needed for
sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). A review of
seven youth medical records indicated all seven youth were clinically screened and evaluated
for STIs. The seven youth were all referred to the licensed physician (MD). The referral was
documented on the required STI screening tool and a test was ordered. The testing results were
documented on the Infectious and Communicable Diseases (ICD) form and filed in the lab
section of the Individual Healthcare Records (IHCR). None of the youth required a STIs
rescreening. A review of the same seven youth records indicated all the youth were offered
counseling and testing for treatment/referral for HIV. Documentation review confirmed six of the
seven of the youth refused HIV testing. One youth gave written consent for HIV testing, which
was conducted by an outside provider. A sealed envelope marked “Confidential” was present in
the youth’s medical record. Reviewed documentation confirmed the MD reviewed youth results
and pre/post counseling was documented on the IHCR and progress note. All youth
confidentiality is protected by not including the HIV status and any other STI diagnosis on the
program’s internal alert system. An additional review of the program’s policy on HIV testing
confirmed the results are only disclosed to the youth, legal authorized representative, health
care providers during the diagnosis, consultation, or treatment, the Florida Department of
Health, program medical committees conducting monitoring, medical personnel who have been
subjected to significant exposure, and health care program personnel or agents for the
healthcare provider who have a need to know in the course of patient care activities or
administration operations. Five interviewed youth all agreed they can have HIV testing done
while at the program. The nurse’s interview indicated youth are screened for chlamydia and
gonorrhea at admission, if requested and consented. If screening indicates further evaluation
the DHA orders the additional confidential STI screening. Evaluations, testing documents, and
referrals are documented on the ICD form. The nurse stated the results are kept in a closed
envelope marked confidential which is placed in the youth’s IHCR. HIV pre-counseling, testing,
and post-counseling is conducted by a local provider and documented in the HIV logbook.
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4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program maintains a written policy and procedures for submitting a sick call. The program’s
policy requires all youth have access to submitting a sick call request and treatment in an
appropriate timely manner. A review of seven medical records indicated none of the youth had a
sick call complaint three or more times within a two-week period. Five of the seven youth
requested sick calls, and the requests were completed by the youth on the Sick Call Request
form. The nurse completed the sick call for all five youth. Two youth sick calls were completed
by the licensed practical nurses (LPNs) and documentation of sick call was reviewed by the
registered nurse (RN). None of the reviewed youth needed restricted housing of any kind. The
Sick Call Request forms were all filed in the youth’s Individual Healthcare Record (IHCR). The
sick call was documented as a progress note and on the Sick Call Index. A review of the
program’s Sick Call Referral Log indicated all the youth’s sick calls were documented with the
correct dates listed on the Sick Call Index. A review of the posted daily schedule confirmed sick
calls are conducted daily at 8:30 a.m. and 2:30 p.m. on the weekdays and one on the weekend
at 8:30 a.m. When a licensed nurse is not on-site the shift supervisor reviews all sick call
requests. While conducting the program tour, Sick Call Request forms were observed on each
living unit, as well as east and west wing hallways. An exam table and equipment used to
perform sick call was observed during the program tour in the medical office. The sick call
process was observed during the annual compliance review. Youth were escorted to the
medical office by the shift supervisor. The RN obtained the youth’s consent to observe sick call.
The youth was introduced to the RN and was seen in a private area with no other youth present
to hear or see the examination. The staff present was at the open door to the medical examining
area. Five youth were interviewed, and four youth stated they are seen by medical within one
day of submitting a sick call request. One youth responded they are seen immediately after
filling out a sick call request. The nurse interview detailed the program’s sick call process. Sick
calls are held twice a day Monday through Friday and once on the weekend. A youth placing a
health complaint will be seen within one to two hours of submitting a sick call. The nurse
indicated the sick calls are conducted in the medical exam room and conducted by the RNs.
Youth with repeated similar sick call complaints will be referred to the designated health
authority (DHA). The request is documented in the DHA weekly logbook along with the DHA
approved treatment protocols. While on-site, the DHA does not conduct sick call. Youth
approved for restricted housing will be assessed by the supervisor on duty throughout the day.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program maintains a written policy and procedures for emergency care. The program’s
policy requires the program to provide episodic care and first-aid to youth as an intervention to
medical, mental health, substance abuse or dental emergency care. A review of seven youth
medical records indicated six of the seven youth required on-site first-aid or episodic care.
Documentation review confirmed the on-site care was provided by the licensed health care staff
and was documented containing subject, objective assessment, and plan (SOAP) elements for
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all six youth. None of the youth were provided care from a non-healthcare staff. All six youth
received a follow-up evaluation. The program’s episodic and emergency care procedures were
reviewed in the medical office. The program has a total of five first-aid kits. One kit is located in
the kitchen, one is located in west sub-control, and one is located in east sub-control. The
remaining two first-aid kits are in master control. The program has two additional first-aid kits
used for transports. The first-aid kits are checked monthly by the clinical manager and
documented on the First-Aid Monitoring Log. Observations of three first-aid kits and
documentation confirmed the first-aid kits had all the required contents. The program has one
automated external defibrillator (AED), and the procedures book is located in the staff
breakroom. Documentation verified the AED battery and pads were up to date and checked by
the medical staff on the first of each month. The AED pads and batteries will expire on
December 30, 2026. During the program tour, the nursing staff conducted a self-test on the AED
and verified it was operational. Observations verified the green light on the AED battery
indicator was working. Emergency numbers including the Poison Information Control Center
were observed posted in the medical office inaccessible to youth. A review of seven records
confirmed staff completed the training requirements regarding episodic, first-aid, and emergency
care. Additional training records confirmed the direct care staff are trained on the administration
of the epinephrine auto-injector. Documentation review of the emergency medical drills
confirmed during the past twelve months the program conducted emergency drills once a month
on each of the three shifts. Emergency drills contained elements utilizing lifesaving measures
including the use of cardiopulmonary resuscitation (CPR), AED, first-aid, contacting 9-1-1
emergency response, epinephrine pen and the use of the knife for life. A review of
documentation confirmed the direct care staff participated in at least one announced or
unannounced drill containing the use of CPR and “man-down” drill within the last year. Video
observations confirmed the simulated drills contained an episodic care event which calls for
immediate first-aid and the administration of CPR techniques. No episodic care was observed
during the annual compliance review. The program’s policy about overdose prevention training
outlines the training for recognizing and treating symptoms for overdose. The program has a
total of eighteen NARCAN® nasal sprays on-site. One was located in the medical cart and the
additional seventeen boxes were in a locked cabinet. The locked cabinet is only accessible by
the medical staff and the facility administrator (FA). Provided documentation confirmed staff are
trained quarterly on when and how to use NARCAN®. The program inventories NARCAN®
when it comes in from the pharmacy, and it is added to the over-the-counter (OTC) medications
count. Medical staff will document the amount in the inventory binder. An inventory count is
conducted weekly. Five staff were interviewed regarding calling 9-1-1 for medical emergencies.
Four of the five staff interviewed stated they are allowed to call. One interviewed staff stated a
medical code is called and medical staff will respond since there is no telephone on the living
units. All five interviewed youth agreed they can be seen by the doctor or dentist if needed. An
interview with the program’s nurse verified the location of the first-aid kits and AED. According
to the nurse the program has a total of seven first-aid kits. Two kits are available for transports
and the other kits are located inside of the program. The program’s one AED is located in the
staff breakroom. The program’s nurse describes the process of documenting on-site episodic
care as a progress note and on the episodic log. The nurse added, the youth who are sent off-
site for emergency care are documented on the transport log and in the DHA weekly logbook.
To ensure the direct care staff can respond effectively, the medical drills are conducted by the
registered nurses (RNs) monthly with all three shifts.
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4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program maintains a written policy and procedures for youth receiving off-site health care.
The program’s policy requires the program to coordinate and create referrals for off-site care for
medical services. A review of seven youth records confirmed none of the youth were applicable
for received off-site care. An additional three youth records were requested. All three-youth had
a Summary of Off-Site Care Consultation Report form filed in the Individual Healthcare Record
(IHCR). All youth had the off-site emergency care visit documented on the Episodic Care Log. A
notification to the parent/guardian about the off-site emergency care visit was documented. Two
of the three youth were applicable for having discharge documentation filed in the IHCR. A
review of the documents confirmed the designated health authority (DHA) reviewed and signed
all off-site care findings. Only one of the three youth required an additional referral for follow-up
testing and appointments, which was completed. A review of the program’s nurse interview
indicated youth sent off-site are tracked on the transport log and DHA weekly logbook. The
medical staff notify the DHA as soon as possible when the youth is transported for off-site care
and when the youth return. In the event a youth needs a follow-up appointment the medical staff
will keep track of the appointments on a calendar and DHA logbook.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program maintains a written policy and procedures for identifying youth with chronic
conditions. The program’s policy requires each youth with an identified chronic condition to have
a treatment plan. A review of seven youth medical records indicated three youth were applicable
on the Facility Entry Physical Health Screening (FEPHS) form for having chronic conditions. A
review of documentation confirmed none of the youth had any communicable diseases or were
undergoing treatment for physical health conditions. Three of the seven youth were prescribed
medication on an ongoing basis. Additional documentation reviewed in the three medical
records confirmed, youth were classified with having a Medical Grade of two through four.
Reviewed Documentation confirmed all three youth were on the chronic illness list and received
periodic evaluations at least every ninety-days. None of the seven youth were currently taking
anti-tuberculosis medications. A review of the periodic evaluations confirmed the evaluations
were conducted prior to renewing a prescription medication for the same three youth. None of
the youth were applicable for having an off-site evaluation needing a designated health authority
(DHA) follow-up or had a lapse in care or missed an evaluation. The Department’s Problem List
was updated for all three-youth receiving medication. An interview with the facility administrator
(FA) noted the medical staff are present in the morning meeting to update the direct care staff
with any important medical concerns pertaining to the youth. In addition, staff would be updated
by the medical department from daily emails with the youth alerts. In the conference room the
youth medical-alert board is updated as needed along with the medical-alert binder. The DHA
stated in an interview all periodic evaluations for chronic conditions are tracked every ninety-
days or less as needed. The program’s nurse interview indicated the internal alerts are how the
program monitors youth with chronic conditions.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program maintains a written policy and procedures for medication management. The
program’s policy requires the program to maintain the youth’s medication routine upon
admission. A review of seven youth Facility Entry Physical Health Screening (FEPHS) forms
and progress notes confirm only two youth were applicable for taking medication when admitted
into the program. The current prescriptions and medications for each youth were verified prior to
admission and documented on the chronologic progress note in the youth’s Individual
Healthcare Record (IHCR). Reviewed documentation confirmed the designated health authority
(DHA) and psychiatrist were notified upon the youths’ arrival to the program about the
medication prescribed. The youth had current, valid orders for medications prescribed. All
changes to the medication were placed on the Practitioner Order form by the DHA. None of the
youth were applicable for being in restricted housing. A review of seven youth medical records
confirm four youth were applicable for having over-the-counter (OTC) medications administered
which were not listed on the AET. All seven youth had a Medication Administration Record
(MAR) which clearly stated the medication start and stop times, youth name, Department of
Juvenile Justice identification number, date of birth, allergies, precautions, and Medical Grade.
The MARs contained a picture of the youth and initials of staff and youth on each medication
entry. Two of the four youth had trained non-healthcare staff assist in delivery of medication only
when a licensed staff was not available. A review of MAR documentation confirmed no
medication errors or undocumented explanations were present. All seven youth MARs had
nursing staff documenting side effects, at a minimum, weekly. One of the seven youth refused
medical treatment and it was documented clearly on the MAR and the Refusal of Treatment
form. A review of medical documentation reveal none of the youth required parenteral
medication. Two of the seven youth records indicated the DHA was notified upon admission for
the youth admitted on psychotropic medication. The psychiatrist conducted an Initial Diagnostic
Psychiatric Interview within fourteen days of admission. Both youth were monitored and had a
medication review every thirty days as required. A review of the psychotropic medication
policies confirmed there was not a standing order, any emergency treatment orders, or pro re
nata (PRN) orders for psychotropic medication. During the annual compliance review an
observation was made of medication administration. The youth was escorted to the medical
office by the shift supervisor. In the medical office there was no other youth present as the
nursing staff was administering the medication. The registered nurse (RN) identified themselves
and explained the reason the youth was taking the medication. Prior to the youth receiving the
medication the RN verified the youth’s name, allergies, alert status, right medication, dosage,
time, and route. The RN prepared the OTC medication and administered the youth the
medication. The youth was advised to open their mouth for the staff to confirm the youth
swallowed the medication. The nurse and youth both initialed the MAR. The youth then
departed the medical office with the supervisor. Five interviewed youth were asked about the
process of how they receive their medication. Two of the five youth responded the RN gives the
youth their medication. The nurse brings the medical cart to the living unit and asks the youth
their name prior to dispensing medication. The remaining three youth stated they are not
prescribed medication for the nurse to dispense. An interview with the program’s nurse detailed
the nursing protocol for non-healthcare staff verifying medication. The nurse stated only RNs
admit the youth and the Prescription Verification form is completed. The non-healthcare staff are
trained by the health services administrator (HSA) to dispense medication in an occurrence
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where the RNs are not available. The daily medication pass time starts at 7:00 a.m., mid-day
medication pass is at 1:00 p.m., and the evening medication pass begins at 6:00 p.m.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program maintains a written policy and procedures on tracking inventory of all medication
and medical equipment. The program’s policy requires all medical equipment to be classified
and perpetually inventoried. While in the medical office, observations verified the nursing staff
unlock the lock box in the medical cart to count the controlled medications. The medication cart
was observed to be clean and organized with stock items separated from youth medication.
There was no medication being stored in the medical refrigerator during the annual compliance
review week. During the week of the annual compliance review, three OTC medications were
reviewed, and the inventories were accurate. Three sharps were reviewed, and inventories were
accurate. Three narcotic or controlled medications were reviewed and found the inventories
were accurate. All sharps counted matched the final count listed on the inventory and the actual
counts. There were no controlled medication, OTC, or sharps observed being dispensed.
Perpetual and weekly inventories of the sharps and stock OTC medication were conducted. The
medication, sharps and OTC medications were all stored in a designated locked area clearly
labeled. A review of seven supervisory-level, non-healthcare staff training records confirmed the
registered nurse (RN) conducted the training for delivery and oversight of medication self-
administration. The program is currently utilizing a local pharmacy to dispose of the expired and
discontinued medications and collect used sharps and bio-waste items. Items are returned for
non-usage will allow the program to receive a credit with the pharmacy. In the instance of a
discrepancy with the inventory, the nurse who found the discrepancies reports the inventory
discrepancies to the medical clinical manager. The clinical manager will notify the medical
supervisor and then notify the facility administrator (FA) or designee. An internal investigation
will begin, and the Department's Central Communications Center (CCC) will be called for all
medical incidents. An interview with the program’s nurse explained the medical disposal
process. The process will include two medical staff. The two RNs or the pharmacist will sign the
medication disposal form. Medication will be returned to the pharmacy. The nurse stated
controlled substances such as narcotics are delivered by the pharmacy and stored behind a
double lock cabinet. Two nurses are required to count the controlled medication shift-to-shift.
The program maintains a copy of the pharmacy license of the contracted pharmacy. The
pharmacy conducts monthly on-site checks of all the medications on-site.
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 to OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program maintains a written policy and procedures for infection and exposure control. The
program’s policy requires infection control procedures for prevention, containment and
treatment. The program has an infection control procedure and guidelines signed by the
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designated health authority (DHA) on January 1, 2025. The facility administrator (FA) signed
and reviewed the policy on January 2, 2025. The nursing staff reviewed the policy on January 3,
2025. The procedures included common, infectious diseases of childhood, self-limiting, episodic
contagious illnesses, viral or bacterial infection diseases, tuberculosis, hepatitis A, B, and C,
human immunodeficiency virus (HIV), Methicillin-Resistant Staphylococcus Aureus (MRSA),
bio-terrorist agents, chemical exposures, and outbreaks of lice and epidemics. A review of
documentation provided confirmed staff had access to the protective equipment and hepatitis B
immunizations. A review of the occupational exposure book confirmed there were no incidents
requiring the local health department or Department's Central Communications Center (CCC) to
be notified for an infectious disease during the compliance review period. The Exposure Control
Plan written in accordance with Occupational Safety and Health Administration (OSHA)
standards was signed on January 2, 2025. The program will dispose needles in the sharp’s
container. The program maintains separate records for youth and staff who experienced an
occupational exposure. An interview with the FA confirmed the Exposure Control Plan is located
in the medical office and is reviewed yearly with direct care staff. The interviewed nurse
explained the training process for program staff being trained on infection control and exposure
control. The training is provided by the health services administrator (HSA) or director of nursing
(DON) and is provided yearly for the staff. The training is provided to the youth at the time of
admission. A copy of the Exposure Control Plan is located in the medical office accessible to all
staff. The nurse reported Orange County provides health department services.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a written policy and procedures ensuring the location of all youth, at all
times through active supervision and the implementation, monitoring, and use of an accounting
system of scheduled, unscheduled, and emergency counts. 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, and
consistently applying the behavior management system. The program has a daily youth activity
schedule which was posted on all living units and throughout the program. The shift schedule
ensures a staff to youth ratio of one staff to six youth for the Borderline Developmental Disability
(BDD) or Developmental Disability (DD) program during day and evening hours, and one staff to
ten youth during sleep hours which meets contractually required ratios. Observations during the
annual compliance review week verified staff were actively and positively engaging with youth
during classroom activities, school breaks, head counts, mental health groups, movement, and
outdoor recreation activities. The observations ensured staff-to-youth ratios were maintained, as
required. Interviews with three staff on the living units confirmed each staff immediately knew
the number of youth they were supervising. The program’s system for accounting of youth
requires the physical counting of youth at various times throughout the day. Staff shall conduct
and document 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 it is practical after order has been restored. All staff shall monitor the
movement of youth into and out of the program. Daily census information at a minimum shall
include the total daily census count, new admissions, releases or direct discharges, transfers,
and youth temporarily away from the program.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program maintains a written policy and procedures addressing the implementation and
training of the behavior management system (BMS), which has not changed since the last
annual compliance review. The BMS is posted and outlined within the youth handbook allowing
easy access for youth and includes rules governing conduct and positive and negative
consequences for behavior including while in the classroom. Through observations, the BMS
was seen posted throughout the program. The BMS shall complement the performance and
treatment planning process, including the coordination of individualized behavior plans, as
applicable. The facility administrator (FA) will ensure all staff having direct contact with youth are
trained on the BMS. Youth have access to a youth handbook which clearly outlines the BMS,
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program rules, and the progressive disciplinary system for the youth. Observations of staff and
youth interactions confirmed staff were adhering to the BMS by utilizing a ratio of four-to-one
positive to negative consequences when redirecting the youth, as indicated in the program’s
policy. All staff members having direct contact with youth are trained in the implementation of
the BMS, to include the common components which serve as the basis for the BMS, in pre-
service training. Ongoing training is provided as needed and appropriate during shift supervisor
and general staff meetings. A review of seven youth case management records indicated each
youth participated in orientation upon arrival to the program and received a copy of the youth
handbook. Seven staff pre-service training records were reviewed, and all staff were trained in
the program’s BMS system. Five youth were interviewed, and each stated negative
consequences include early bedtime, level freeze, more days added, and confinement. One
youth stated youth can be placed in controlled observation for fighting. Each interviewed youth
stated they receive canteen, “Gotchas”, activities, and different types of incentives as rewards
for good behavior. Five interviewed youth stated staff are consistent in what behaviors they give
rewards and consequences to. Each youth was able to explain the difference between each
level and how you move from level to level. Each of the interviewed youth stated no youth are
ever allowed to punish other youth. Five staff were interviewed, and each was able to provide
the implementation of the BMS and describe how it is used with ratio included. Each staff
described “Gotchas”, canteen, and different kinds of privileges as rewards for good behavior.
Canteen is given out every two weeks, while “Phat Friday’s” is every week. Five of the
interviewed staff each stated basic rights cannot be taken away from youth as a consequence.
Each interviewed staff stated youth are informed of their consequences through problem
behavior reports and they are able to explain their behavior. An interview with the facility
administrator (FA) indicated the program’s BMS uses the iChoose system, which is focused on
modeling, coaching, and incentivizing pro-social healthy behaviors which consists of a point
system used at the program. The youth earn points based on behaviors and points are added
by day to total up to 200. These points are used to purchase canteen. The youth can either earn
or fail to earn their points to "Make Their Day". As the youth earn their points, it progresses the
youth to level up in the program. The FA stated consequences are monitored through treatment
teams and reviewed in the morning meeting. Additionally, the FA stated staff’s implementation
of the BMS to ensure consistency is monitored through a point system, which is reviewed each
shift and calculated by the shift manager. The behavior reports (BRs) received are checked to
see if any other actions are needed. The number of youth who make their day are reviewed in
the morning meeting.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, and practice confirm the program does not use room
restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
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The program maintains a written policy and procedures outlining the requirement to conduct and
document ten-minute checks during sleep hours or at other times, such as during an illness or
room restriction. The program has a total of 143 video cameras capable of recording thirty-days
of video footage. During the annual compliance review week, all cameras were operational.
Prior to conducting checks, staff are positioned where they are able to see any movement within
the living unit. Staff are required to conduct room checks every ten-minutes and document the
time of the check on the Ten-Minute Check Log when youth are sleeping. A review of six
separate video footage samples of ten-minute checks from each program living unit and log
sheets reflected there were no discrepancies. Documentation confirmed staff who complete the
checks initial or sign the check sheet. Five interviewed staff stated room checks were conducted
every ten minutes when a youth was placed in their room for sleeping or non-punishment
reasons.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program maintains a written policy and procedures to ensure the continuity of custody and
care of youth and protection of the public in the event of an emergency prevents occupancy of
the program’s primary building and structure. The program shall maintain an administrative hard
copy record, which is easily accessible and mobile in the event of an emergency situation
resulting in the program relocating quickly or in the event needed information cannot be
accessed electronically. Additionally, the program shall establish and maintain critical identifying
information and a current photograph of each admitted youth which is easily accessible to verify
a youth’s identity, as needed during their stay in the program. The program’s policy indicates
counts are conducted during riots, escapes, power outages, or during any other disruptions
which may occur. Head counts are conducted before and after each movement, and during
emergencies and drills. A review of the logbook confirmed the program documented counts
during shifts, emergencies, and before and after each movement. The logbooks included youth
who were temporarily away from the program, transferred, admitted, and released. Additionally,
observations confirmed the program staff conducted a physical head count during school and
before and after each movement. Five interviewed staff stated counts are conducted before and
after each movement, during drills, emergencies, and when a program count is conducted.
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5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a written policy and procedures to ensure the maintenance of a
chronological record of events, incidents, and activities in a central logbook. The logbook
documents head counts, shift changes, and group movement. At a minimum, each logbook
entry shall be legible and include the date and time of the event, the names of staff and youth
involved, a brief description of the event, the name and signature of the person making the entry
and the date and time of entry. No logbook entries shall be obliterated or removed. All errors
shall be struck through with a single line and initialed by the staff correcting the error. All direct
care staff and supervisors shall be briefed when coming on duty. A review of the logbooks and
observations verified since the last annual compliance review, all errors were struck through and
initialed by staff and no loose or missing pages were found. Logbook entries included shift
briefing, youth movement, head counts, emergency drills and situations, program checks, and
law enforcement data. Internal incidents reported to the Florida Abuse Hotline and/or the
Department’s Central Communications Center (CCC) were documented. Reviewed logbooks
showed recreation was conducted. All entries included the dates and times of events, with the
names of the staff and youth involved.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program maintains a written policy and procedures to ensure program safety and security,
safety of staff, youth and the public by implementing and maintaining a system of program key
control. All staff shall be provided with guidelines and training on the key control policy and
required procedures on the physical control and use of program keys, while ensuring the
provision of community protection through safe and secure programming for youth. The
assistant facility administrator (AFA) is assigned as the key control manager who is responsible
for the security and accountability of keys and key control systems as well as damaged keys. An
informal interview with master control staff indicated the program’s practice is when direct care
staff arrive to the program, personal keys are collected by master control and placed on a board
in master control. Additionally, observations confirmed the program has a key log sheet for staff
assigned permanent keys which they are required to sign indicating the number of keys issued
and the key identification number. Permanent keys are kept to a minimum and must be
authorized in writing by the facility administrator (FA). An informal interview of three staff
confirmed each staff knew the number of keys and each key’s function. Restricted keys are
located in master control and only accessible to authorized staff who are assigned to specific
job functions requiring restricted key use. Designated staff for restricted key use are case
managers, supervisors, nurses, teachers, human resources, therapists, maintenance, and the
assistant facility administrator (AFA). Damaged keys are to be reported to the shift supervisor
and returned to the AFA. The AFA will then discard the keys and update inventories. The AFA
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conducts quarterly inspections of emergency keys and annual audits to make sure keys are
functioning, verified, located, and inventoried. Since the last annual compliance review, there
were no incidents reported to the Department’s Central Communications Center (CCC) or
Program Monitoring and Management (PMM) deficiencies related to key control concerns.
Master control staff reported the process for restricted key use is to check the log and key
cabinet area at the beginning and end of each shift to make sure all keys are accounted for.
Observations verified there was a review of key inventories, and all keys were accounted for.
The key lock box was out of reach and unable to be accessed from outside of master control.
Five interviewed staff knew the process of obtaining keys and replacing damaged ones.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a policy and procedures addressing safety and security and to control
the introduction of materials considered contraband into the program. Search practices shall be
initiated to assist in prevention, detection, and removal of all items considered contraband or
unauthorized within the program. All staff shall be trained to properly identify contraband items
and the steps required for removal of contraband. Search practices and observations shall be
conducted throughout the program and shall include searches of youth, staff, visitors, property,
program grounds, and the program’s physical plant. A review of the youth handbook verified
prohibited items include sharps, escape paraphernalia, tobacco products, lighters or matches,
unauthorized currency or coin, non-program issued keys, any unauthorized article of food or
clothing, jewelry, candy, gum, drinks, flashlights, gang related items, pornography, aerosol cans,
ropes, wire, or other items not indicated as approved within the handbook. Additionally, illegal
contraband included, non-program issued electronic equipment or cellular devices,
smartwatches, electronic or vaporless cigarettes, any intoxicating beverage or any beverage
which causes or may cause an intoxicating effect, any controlled substance, marijuana, hemp,
industrial hemp, or any prescription or nonprescription drug which has a hypnotic, stimulating, or
depressing effect, and any firearm or weapon of any kind, or any explosive substance. The
youth handbook states consequences for youth found with contraband, which is outlined in the
behavior management system. A review of the visitor’s sign-in log verified it included an
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attestation statement. There was a total of fifty-two new staff hired during the annual compliance
review period. A review of seven staff records found each included a signed contraband
attestation form. The program documents the confiscation and disposal of contraband.
Reviewed documentation included the procedures for searching incoming and outgoing mail.
The policy reports all illegal contraband will be surrendered to law enforcement, and unlawful
activity will be reported to law enforcement. Observations confirmed the program documented
the confiscations of contraband and disposition which was maintained in the youth’s case
record. A review of the Department’s Central Communications Center (CCC) reports since the
last annual compliance review indicated there was one instance of contraband found at the
program which was turned over to law enforcement. The interviewed facility administrator (FA)
stated any contraband which is illegal is turned over to the Sheriff’s department to dispose of
while any contraband which is not illegal is secured in the FA's office and dated and
photographed until the investigation is complete, then disposed of offsite. Five interviewed staff
all explained the process of youth room searches and confirmed they are done randomly. The
staff, FA, and supervisor will all conduct room checks.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a written policy and procedures to ensure searches, and full body visual
searches, are conducted, as prescribed, or otherwise permitted based upon the Right
Interactions (RI) training manual. Prior to conducting any search, staff shall prepare the youth by
explaining the purpose of the search and what to expect while assuring the youth’s safety. Staff
shall avoid use of unnecessary force and shall treat the youth with dignity and respect to
minimize the youth’s stress and embarrassment. During the annual compliance review week
there were no scheduled transports, no visitations, and no youth returning from off-campus
activities; therefore, searches could not be observed. There were two new admissions during
the annual compliance review week; however, the youth arrived at the program before the team
was on-site. In person observations and a video footage review of fifteen staff at various days
and shifts indicated searches were conducted as required. Logbook documentation and video
review verified youth were being thoroughly searched before and after each movement.
Additionally, observations confirmed searches were conducted by staff of the same gender as
the youth and conducted in a manner as not to degrade the youth and were based on the Right
Interactions (RI) training manuals. Five staff were interviewed, and all were able to explain how
and when youth are searched. Five interviewed youth all stated visual and full body searches
occur after each movement, after outdoor activities, when returning from off campus, after
visitation, and school.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a written policy and procedures to ensure all program vehicles used in
the transportation of youth are properly maintained and documentation of use and vehicle
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services are maintained. Transporting staff shall have a cellular phone for use in the case of an
emergency during the transport. Mechanical restraints shall be used in the secure transportation
of youth and all mechanical restraint equipment will be double locked. Youth shall never be
restrained to stationary objects. Each vehicle being used for transportation of youth shall pass
an annual safety inspection. Reviewed documentation confirmed each vehicle received an
annual safety inspection and was maintained. During the annual compliance review week, the
program had two vehicles; however, was using one vehicle to transport youth according to the
assistant facility administrator. A documented annual safety inspection was available for both
vehicles. Each vehicle was equipped with safety screening which separates the vehicle’s front
seat from the back-seat area and accommodates the high-risk youth, seat belts, a seat belt
cutter, a window punch, a fire extinguisher, and an approved first aid kit. Rear and youth
passenger vehicle doors cannot be opened from the inside. Ten vehicles were checked in the
program’s parking lot and all vehicles were confirmed to be locked. Five youth were interviewed.
Four interviewed youth stated they wear hand restraints, a seat belt, and leg shackles during
transports and have never been handcuffed to the vehicle. One interviewed youth stated they
have never been on a transport.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a written policy and procedures to ensure an appropriate minimum staff-
to-youth ratio is maintained while youth are transported off program grounds ensuring the safety
and security of youth, staff, and the public. All transporting staff shall have a valid Florida
Driver’s License and an acceptable driving record. Any staff whose driving record is deemed
unacceptable shall not be permitted to operate a program vehicle for the purposes of
transporting youth. All staff must inform their immediate supervisor of driving violations.
Reviewed documentation verified all active drivers had a valid driver’s license. Human
resources staff shall obtain monthly driving record information from the Department of Motor
Highway Safety and Motor Vehicles (DMHSMV) for all staff. Youth are not permitted to drive
program or staff vehicles. The program uses a minimum staffing ratio of one staff for every five
youth; however, at least two staff shall accompany youth on all transports with one staff present
of the same gender as the youth. Five interviewed staff all stated youth are secured during
transports by a seat belt, shackles, and handcuffs. Each staff stated they are provided with a
cellphone and radio during transports as communication devices and a first-aid kit, window
punch, fire extinguisher, and glass punch as safety equipment. Additionally, each of the
interviewed staff verified transport vehicles are search for contraband before use and they are
not allowed to use their personal vehicles to transport youth. All five interviewed staff were
knowledgeable and able to explain the emergency response process during vehicle transport
and knew what the ratios for transport were. Five interviewed youth stated they have never seen
anyone place contraband in a transport vehicle. During the annual compliance review week,
there was not a transport scheduled; therefore, an observation could not be conducted. The
interviewed facility administrator (FA) confirmed both vehicles used for transport have a safety
screen.
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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 maintains a written policy and procedures requiring a safe and secure physical
plant, grounds, and perimeter to be maintained and for weekly safety and security audits to be
conducted. The facility administrator (FA), and program leadership is responsible for conducting
weekly safety and security audits and submitting the findings to the Department. Reviewed
documentation confirmed weekly safety and security audits were conducted and any identified
deficiencies were documented on the reports including the status and due date of any needed
corrective action. A review of the program’s Preventative Maintenance Checklist forms since the
last annual compliance review indicated inspections were completed, as required, and
documented deficiencies and repair updates. The interviewed FA reported the program
completes a key performance indicator (KPI) report based on the reported information from
each morning meeting. This information is totaled each month and compared to the previous
month. A meeting with the management team is conducted to plan how to reduce deficiencies.
Internal reviews are completed by corporate staff to verify deficiencies are being reduced.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a written policy and procedures for tool inventory and management to
ensure youth do not use tools or equipment as weapons or for security breaches. The
program’s policy requires all program equipment and tools to be properly controlled and secured
to minimize the risk of tools and equipment being used as weapons, means of escape from the
program, or other security breaches. A review of the program’s inventory list and the tool
storage shed verified tools are securely stored when not in use, easily marked for identification,
and inventoried prior to and following work activities. All sharp edged and pointed tools are
inventoried daily when in use, including kitchen tools. There is a monthly inventory of tools
which do not have sharp edges or points. Prohibited tools at the program include machetes,
bowie knives, and other long bladed knives. If a tool is broken or inoperable, the maintenance
manager is responsible for replacing the broken tool. A review of the inventory used to
document issuance and return of tools found no discrepancies. In the event a tool is missing
staff shall notify the facility administrator (FA), the tool control officer, assistant facility
administrator and/or maintenance supervisor immediately. A tag is hung on the shadow board
until a replacement tool is in place. If a Class A tool is missing, during a work project or activities
involving youth, the FA or designee is immediately notified and the staff member supervising the
inventory writes an incident report, documents in the program's logbook, and notifies the
Department's Central Communications Center (CCC) within the required timeframe. A review of
the Department’s CCC reports verified there were no instances of missing/lost tools since the
last annual compliance review.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries to staff and youth. The reviewed policy and
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procedures included supervision requirements, issuing tools to youth and staff, and activities
involving tools. The ratio is one staff for every five youth during vocational training and tool use.
A review of the program’s procedures and documentation verified staff are required to complete
a sign-out and sign-in log when Class B tools are taken and are returned to the designated
storage room. Reviewed documentation confirmed youth were trained on the intended and safe
use of Class B tools. Reviewed documentation confirmed seven youth were trained on the
intended and safe use of Class B tools. Seven youth case management records were reviewed,
and risk assessments were completed prior to youth using tools. Youth are prohibited from
using Class A tools. Five staff were interviewed, and each stated youth can use brooms, mops,
and scrub brushes. Five youth were interviewed, and each stated they use mops and brooms.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a written policy and procedures establishing guidelines for outside
contractors who come on-site to complete repairs. When a private contractor or vendor enters
the program, they sign the Outside Contractor On-Site Work Project Log which lists
unauthorized items. An informal interview with the assistant facility administrator (AFA) indicated
when contractors are on-site, contractors receive written instruction detailing responsibilities
regarding tool management and contraband and shall confine their work to the authorized area
using safety and security precautions. A review of work project logs since the last annual
compliance review verified the contractors signed the log confirming notification of what items
are considered unauthorized. A review of three project invoices showed the vendors signed
contractor agreements and an inventory of tools was completed and documented. A review of
outside contractor logs confirmed the program reviewed the inventory or equipment when the
vendor arrived and left. An informal interview with the AFA reported the program’s practice is to
assign a staff in the event the maintenance manager is not available to the contractor to ensure
the work is being completed and all tools are secured. The program's policy states the facility
administrator (FA) is responsible for providing approval and permissions for personal cellular
telephone and/or equipment/electronic devices capable of taking pictures and audio or video
recordings, including smartwatches.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program maintains a written policy and procedures to ensure fire safety and evacuation
drills are conducted, and youth and staff are prepared for immediate implementation or
mobilization in the event of an emergency or disaster. The Continuity of Operations Plan
(COOP) requires the program to conduct unannounced fire drills quarterly for each shift.
Reviewed documentation confirmed fire drills were conducted for all shifts as required. The
program conducted monthly emergency drills on each shift ensuring disturbances, escapes,
bomb threats, chemical spills, medical situations, and severe weather were covered on a
rotating basis. Each reviewed drill included the type of drill, date and time, participants, a brief
scenario description, deficiencies identified during the drill, and applicable corrective actions.
The program’s fire evacuation routes were posted throughout the program. All twenty-two of the
program’s fire extinguishers were inspected annually. Five staff were interviewed, and each
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reported they participated in fire drills, medical drills, suicide, weather, and escape drills. All five
interviewed youth stated they participated in fire drills and have been instructed on what to do in
the event of a fire. An interview conducted with the facility administrator (FA) confirmed the
program conducts monthly fire and COOP drills on all shifts.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a policy and procedures to provided safety of the youth, staff and public
including in the event of an emergency or disaster. An observation of a Department approved
Disaster and Continuity of Operations Plan (COOP) verified it was available for all staff. An
informal interview with the assistant facility administrator (AFA) verified the COOP is available to
all staff, and is located in the conference room, master control, and the main office. The plan
was reviewed, updated, and approved by the Department on May 15, 2024. The COOP
addresses alternative relocation sites approved by the Department’s regional director/designee.
The program’s Emergency Disaster Preparedness Plan and COOP are coordinated as one
combined plan. The COOP provides basic care and custody of youth in the event of an
emergency or disaster, addresses phases of a disaster plan, and emergency management
including preparedness, response, and recovery. The COOP addresses emergencies including
fire prevention, bomb threats, evacuations, chemical spills, severe weather, and terrorist
attacks. The equipment and supplies required for continuous operation and services during
emergencies or disasters are in the administration office, medical office, and kitchen. An
informal interview with the AFA reported the emergency supplies include batteries, flashlights,
radios, canned food, and gloves. The program maintains identifying information on each youth
in the program, and if the program must evacuate the youth record accompanies the youth to
the temporary location. Reviewed documentation confirmed the program maintains critical
identifying information in hard copy binders including case management, and medical. The
program’s hard copy records are easily accessible and mobile in the event of an emergency
resulting in the program relocating quickly or in the event needed information cannot be
accessed electronically for all youth in the program. The facility administrator (FA) reported fire
drills, COOP drills, suicide drills, and medical drills are completed on all shifts monthly and
quarterly. A review of seven youth case management records confirmed each contained the
youth’s name, a photograph, Department identification number, admission date, date of birth,
gender and race, overall health status, address, and parent/guardian contact information which
included name, address, telephone number of the person with whom the youth resides and their
relationship to the youth, and person(s) to notify in case of an emergency. In addition, the
records contained the youth’s assigned juvenile probation officer (JPO), committing judge, state
attorney, and public defender.
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5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains a written policy and procedures to ensure strict control of flammable,
toxic, poisonous, and caustic materials. All toxic chemicals are located in an outside secured
storage area where youth do not have access. A review of the flammable, poisonous, and toxic
items and inventories verified the items were securely stored and inventories were accurate.
The program maintains a list of program staff with positions/titles who are authorized to handle
the materials which included the facility administrator (FA), maintenance manager, supervisors,
case managers, and counselors. The program policy requires only the maintenance or other
trained staff who have the safety equipment for diluting, handling, and disposing of hazardous
waste and/or solid waste, to be responsible for disposing of hazardous items and toxic
materials. Reviewed documents confirmed the program’s disposal procedures of chemicals
were created in accordance with Occupational Safety and Health Administration (OSHA)
standards. All hazardous chemicals which are no longer used or are outdated are disposed of
by returning them back to the vendor or sending the chemical to the hazardous waste center in
accordance with the Safety Data Sheets (SDS). The program maintains a SDS Log to track the
disposal of such items. A review of the Disposal Logs indicated the program did not have any
chemicals disposed of since the last annual compliance review. In an informal interview, the
assistant facility administrator (AFA) stated the program only purchases what is used and has
not disposed of any items. If there are any chemicals in need of disposal, the maintenance staff
fill out the Disposal Log and drop off the chemicals at the bio-hazardous waste station. All liquid
waste from work details is disposed by pouring the liquid in plumbing drains. Kitchen liquid
waste, except for grease, is disposed in the kitchen drain. Grease is placed in a separate
container for disposal. The program uses a local disposal company to dispose of the grease in
the grease trap every quarter. The program has a procedure in place in the event of a chemical
spill. If a chemical spill occurs, the shift supervisor and maintenance staff are notified, the staff
shut down the air handlers and ventilation systems and close all windows and doors. A SDS
binder is located inside the storage area with a picture of each material corresponding to the
SDS. The program maintains chemicals used daily in a locked storage area inside the program
and outside. The program has a Chemical Daily Usage Log to track all toxic materials when in
use by authorized staff. Observations of the storage area indicated it is clearly marked
hazardous chemicals, securely locked, and has a posted list of authorized staff.
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-
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annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a written policy and procedures prohibiting youth from handling any
flammable, poisonous, and/or toxic items or materials. Program youth are strictly prohibited from
using, handling, or cleaning with dangerous or hazardous chemicals, respond to chemical spills
or clean, handle, or dispose of any biohazardous material, bodily fluids, or human waste. Youth
are strictly prohibited from the maintenance area where toxic items and chemicals are stored.
Five youth were interviewed, and each reported they do not handle or use any chemical
cleaning products.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a written policy and procedures to ensure youth are allowed to receive
visitation and communication with approved family members. The program has a posted
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visitation schedule and rules at the front of the program. The program’s policy provides each
youth opportunities to promote communication and engagement which fosters family
reunification and community connections. The program assists youth and families in maintaining
connections in a visitation environment which provides monitoring, control of movement, and
security practices to ensure visitor, youth, staff, and program safety. The program maintains a
list of approved visitors; however, attorneys, representatives of the court, juvenile probation
officers, other agency representatives, and clergy are authorized to visit at any time. Searches
of visitors will be conducted upon entry and all youth shall be searched following visitation
sessions. A review of the logbooks and visitation sign-in sheets verified the program allows
visitation for approved family members. Visitation is held two days a week on Saturdays and
Sundays from 1:00 p.m. to 4:00 p.m. A review of the telephone chronological notes verified
youth have consistent telephone communication with family members. An informal interview
with the regional director of compliance reported all outgoing and incoming mail is searched by
the case manager. The program’s visitation policy indicated consideration for requests of
alternative visitation arrangements with parents/guardians, if needed. Youth can write letters or
call by telephone at least once a week to approved family members. None of the reviewed youth
had a history of human trafficking. For youth whom English is not their primary language the
program uses interpreter services and a language assistance program. Five youth were
interviewed, and each stated they can call their parent/guardian or send a letter.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program offers a diverse range of recreational and leisure activities for each youth. The
program has a daily activity schedule, which reflects each youth receives at least one hour of
recreation each day for leisure activities, including large indoor and outdoor muscle activity.
Logbooks were reviewed for the annual compliance review period, and recreation was
documented each day for at least one hour, as required. Observations during the annual
compliance review week confirmed the youth were actively engaging in outdoor activities. The
program's contract required a recreation therapist. A review of the staff credentials confirmed
they met contractual qualifications. A review of seven youth Individualized Performance Plans
(IPP) confirmed each youth record contained a wellness plan goal. Five youth were interviewed,
and each youth reported the program allows youth the opportunity to play basketball, and
football. In addition, one youth reported they play video and card games. Five staff were
interviewed, and each reported the youth received one hour of indoor and outdoor activities
such as playing board games, playing sports, basketball, football, and working out. There is new
fencing being installed around the program; therefore, the big recreation area is not available.
New fencing has been completed around the small recreation area with basketball hoops
secured into the concrete. Youth were observed playing basketball in the small recreation area.
5.23 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program maintains a policy and procedures to ensure youth searches and room inspections
are conducted prior to placing a youth in a controlled observation room. Youth shall never be left
alone in a controlled observation room until an inspection of the room is conducted, it is deemed
safe and secure and in compliance with the following room specifications. Reviewed
documentation for eight youth placed in controlled observation was completed and verified each
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Office of Accountability and Program Support Page 65 of 72 (Revised September 2022)
youth and room was searched prior to placing the youth there. Each room was a minimum of
thirty-five unencumbered square feet and had a solid core metal door with a shatter resistant
observation window which allows for sight and sound observation. Additionally, each room was
equipped with windows which are shatter resistant and had no electrical outlets or switches.
Observations confirmed the program utilizes a controlled observation checklist which
documents youth and room searches. Youth are provided a security rated, fire retardant plastic
mattress suitable for use on the floor or a suicide resistant bed.
5.24 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy and procedures address controlled observation, which may be used as an
immediate short-term crisis management strategy when a youth’s aggressive, violent, or
potentially dangerous behavior substantially threatens the physical safety of others,
compromises program security, and when non-physical interventions would not be effective.
Youth demonstrating acute psychological distress shall not be placed in controlled observation.
The facility administrator (FA) shall ensure all use of controlled observation is implemented only
as authorized and in accordance with policy. All program staff shall be sufficiently trained in both
use and documentation of controlled observation. Since the last annual compliance review
period, there were a total of thirty-eight controlled observations. A review of documentation for
eight youth placed on controlled observation verified no youth were suspected of suicide or a
mental health crisis. Each controlled observation was verified by a supervisor or higher-level
staff. Seven of the reviewed youth showed active aggression towards others and were
physically out-of-control with less restrictive methods being ineffective, while one youth never
physically made it to controlled observation due to quickly becoming calm and realizing their
actions. Six of the reviewed controlled observation documentations showed youth were in
controlled observation less than four hours. Two of the youth were in controlled observation
longer than two hours with the program director approving and granting an extension. Each
youth was advised for the reason of placement and had a health status checklist completed. If
complaints or injuries were observed, a healthcare staff was notified for assessment and
treatment of all youth.
5.25 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s written policy and procedures address controlled observation safety checks and
release procedures. The policy states safety checks of youth will be completed every fifteen
minutes to ensure the youth’s safety and observations of the youth’s behavior shall be
documented, including the time, code, explanation of behavior, and staff initials on the
Controlled Observation Safety Checks form. Continuous sight and sound supervision of youth
will be maintained as a provision of continuous, uninterrupted visual and sound monitoring of
the youth when demonstrating physical behaviors, posing a high risk of self-injury, and
documentation of all safety checks will be documented on the Controlled Observation Safety
Checks form. Medical staff will be notified of any illness or reported injury. Youth shall not be
denied meals or dietary needs when in controlled observation. Once a youth is determined
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 72 (Revised September 2022)
ready for re-integration from controlled observation into the general population, the facility
administrator (FA) or designated supervisory staff must give written approval prior to the youth’s
release from controlled observation. A review of eight controlled observation safety checks and
release procedures verified staff making placement completed the first page of the controlled
observation report and submitted the form to a supervisor. Staff conducted and documented
safety checks at least every fifteen minutes and observed the youth’s behavior. The FA or
designated supervisory staff, approved each of the youth’s release from controlled observation,
which was based on whether the youth was no longer an imminent threat to self or others. Each
of the eight youth required an internal alert upon placement and release from controlled
observation. The controlled observation report, Health Status Checklist, and controlled
observation safety check forms were maintained in an administrative file for each youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 72 (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 career and technical education (CTE) services being provided as contracted include Florida
Ready to Work Soft Skills, Occupational Safety and Health Administration 10 (OSHA-10), and
first-aid/ cardiopulmonary resuscitation (CPR). The program’s contracted CTE services do not
include industry certifications from the Master Credentials List (MCL). The program is contracted
to provide OSHA-10, which is a base level certification which can lead to industry certifications
identified on the MCL from American Welding Society (AWS) and National Center for
Construction Education and Research (NCCER). The transition services manager (TSM)
provides career and technical education services with first-aid/CPR and facilitates Florida Ready
to Work Soft Skills and OSHA-10. The TSM is certified in first-aid/CPR. Certification is not
required to facilitate Florida Ready to Work Soft Skills and OSHA-10 as those are certified by
each organization upon youth passing the web-based modules and assessments. Thirty-seven
youth are enrolled in coursework towards earning an industry certification. Five youth records
were reviewed, and each youth had completed OSHA-10 and first-aid/CPR, and they were on
track to complete the required Florida Ready to Work Soft Skills within the contracted time
frame. One of the five reviewed youth arrived at the beginning of this month and will be on track
to complete these requirements within the determined time frame. Five interviewed youth stated
there are no interruptions during the school day. Five youth were asked how well you think this
program is preparing you for GED, high school, vocational school, employment, and/or college.
Two youth responded very well, two youth responded well, and one youth responded not well.
The interviewed facility administrator (FA) stated youth are given an Independent Living Skills
Assessment following intake to identify deficiencies. The youth work with the TSM to address
their needs. The youth are provided with a Florida State Identification (ID), learn to write a
resume/cover letter, and practice filling out job applications. Graduates have the option of
attending Florida Youth College for college courses or CTE certifications. The masonry program
is offered which includes OSHA-10 and 30 construction certifications. The FA stated the
program provides Florida Ready To Work, Project Anchor, CTE certification, and masonry
vocational services.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 72 (Revised September 2022)
The program maintains a written policy and procedures to provide for educational access. The
program integrates education into the daily schedule. A sample of three videos and three
logbook reviews showed youth are being sent to class on time; however, two of the three days
reviewed in the logbook had no notation of when school ended or movement showing school
ended. In addition, randomly selected logbook entries over the past year were reviewed and
youth were moved accordingly with little deviation. Five interviewed youth stated there are no
interruptions during the school day. Five youth were asked how well you think this program is
preparing you for GED, high school, vocational school, employment, and/or college Two youth
responded very well, two youth responded well, and one youth responded not well.
6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle.
The contracted education provider ensures the integrity of the required minimum instruction time
distributed over a twelve-month period. The district approved calendar and daily school
schedule were reviewed, which incorporated the required 250 days of instruction, with twenty
days used for teacher planning, and a minimum of twenty-five hours of instruction weekly. The
daily school schedule was approved by the board on April 29, 2024. Youth are enrolled in
academic courses through Florida Scholars Academy and receive credit, as appropriate, when
courses are completed. A sample of three videos and three logbook reviews showed youth are
being sent to class on time; however, two of the three days reviewed in the logbook had no
notation of when school ended or movement showing school ended. In addition, randomly
selected logbook entries over the past year were reviewed and youth were moved accordingly
with little deviation. In a review of the lead educator’s interview, the instructional leader reported
the educational schedule is adhered to.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle.
The education contract provider is responsible for developing a career education program
appropriate for the educational abilities and goals of youth in the program and appropriate for
the length of stay and classification of youth in the program. The career education program does
include Type 1 through Life Management Skills and Personal Finance and Money Management
courses. The career education program does include Type 2 through career and technical
education (CTE) course offerings which provide exploration and knowledge of occupations
within those specific careers. The career education program does include Type 3 through CTE
course offerings which provide content and competencies for those specific careers. A career
strengths and interest questionnaire is completed by youth upon entry. Each CTE course
offered by the education provider includes soft skills for those specific careers. The education
contracted provider is responsible for providing Career and Professional Education (CAPE)
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 72 (Revised September 2022)
courses leading to pre-apprentice certifications and industry certification. Youth at the program
are enrolled in Digital Information Technology and Foundations of Programming which are
courses which lead to the CAPE Industry Certification Comp TIA A+. The interviewed facility
administrator (FA) stated the youth are given an Independent Living Skills Assessment following
intake to identify deficiencies. Youth then work with the transition service manager (TSM) to
address their needs. The youth are provided with a Florida State Identification (ID), learn how to
write a resume/cover letter, and practice filling out job applications. Graduates have the option
of attending Florida Scholars Academy for college courses or obtaining CTE certifications. n.
The lead educator interview was completed by the instructional leader. The interviewed
instructional leader stated youth complete a career strengths and interest questionnaire upon
entry and are placed into Digital Information Technology and Life Management CTE courses.
Progress reports are sent to case management, by email within twenty-four hours of treatment
team meetings. Teachers add behavior notes to the academic progress reports.
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle.
The contracted educational provider maintains a policy and procedures requiring an Education
Transition Plan to be developed upon each youth’s admission. Three closed case records were
reviewed, and none contained an Education Transition Plan. Many youth entered the program
before July 1, 2024, when the new education provider Florida Virtual School (FLVS), began their
contract, so they would not have had an Education Transition Plan developed by the provider.
In the lead educator interview, it was reported any student which was admitted to the program
prior to July 10, 2024, may have had Entry Transition Plans with the district; however, those
were not given to the new education provider at the time of transfer. Any student which was
admitted between July 10, 2024, and December 1, 2024, may have had a paper Entry
Transition Plan filled out; however, it was from an old form. Starting December 2, 2024, all
paraprofessionals were trained how to complete the new Entry Transition Plan and those will be
uploaded into the Department’s Juvenile Justice Information System, (JJIS) by the school
counselors/transition specialists.
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle.
The contracted educational provider has procedures in place to provide for qualified
instructional personnel. A review of six certifications of current teachers and two teachers which
left, as well as fifteen flex teachers, found twenty-two had a valid Florida educator’s certificate.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 72 (Revised September 2022)
One teacher’s credentials were not active on the Department of Education (DOE) website. Five
reviewed teaching credentials found personnel were not teaching in their field and there was no
approval obtained by the school board for out-of-field teaching. A review of the three youth
school schedules found two teachers were listed on two of the schedules. These teachers did
have an active teaching certification on the DOE website; however, their teacher’s information
was not provided. After reviewing three youth records for out-of- field parent/guardian
notification letters, it was noted no notifications were sent out prior to October 14, 2024, and
none of the letters accurately reflected the classes, or teaching assignments outside of their
field of expertise.
6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle.
The education contracted provider is responsible for referring all youth who receive their high
school diploma or equivalent to Florida Youth College (FYC) so they can work with a career
navigator on postsecondary courses and/or enrollment in a state or technical college. A review
of three youth closed records revealed youth were still working towards earning their high
school diploma at the time of their release; therefore, they did not meet the eligibility criteria for
a referral to FYC. An additional applicable youth record was reviewed for a youth who did meet
the eligibility criteria and was referred to FYC. The Florida Scholars Academy instructor was
informally interviewed regarding postsecondary pathways and support offered to youth. The
instructor identified Florida Youth College and technical colleges as postsecondary pathways
and stated support is provided through individual teacher assistance and peer-to-peer.
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Each referral received by Florida Youth College (FYC) from the education contracted provider is
assigned a career navigator. The career navigator then connects with youth through the
residential contracted provider to schedule an orientation session. During orientation, the youth
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 71 of 72 (Revised September 2022)
and career navigator develop a career pathway plan to include postsecondary courses and/or
enrollment in a state or technical college. The career navigator continues to assist youth on their
career pathway plan and have incremental follow-up sessions scheduled through the residential
contracted provider. A review of three youth closed records revealed youth were still working
towards earning their high school diploma at the time of their release; therefore, they did not
meet the eligibility criteria for a referral to FYC. An additional applicable youth record was
reviewed for a youth who did meet the eligibility criteria and was referred to FYC. There was
documentation to support the date of orientation and the occurrence of a thirty-day and sixty-
day follow-up. The youth’s ninety-day and 180-day follow-up were not applicable because
follow-up would occur in the future. The FYC youth record indicated the career interests of
youth. A copy of admission to a postsecondary program was not included as the youth was
working towards an Occupational Safety and Health Administration 30 (OSHA-30) credential
and was undetermined at this time of the annual compliance review if the youth’s career
pathway will include enrollment in a postsecondary program.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 72 of 72 (Revised September 2022)

source: DJJ

program_name_raw: Kissimmee Youth Academy - BDD/DD