summary: QI Residential - FY24-25

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
JoAnn Bridges Academy
Rite of Passage
(Contract Provider )
950 S.W. Greenville Hills Road
Greenville, Florida 32331
Review Date(s): March 25 -28, 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:
Andre Watson, Office of Accountability and Program Support, Lead Reviewer (Standard 1 & 6)
Patrick Brock, Office of Education, Northeast Central Education Coordinator (Standard 6)
Sydney Campagna, Juvenile Unit for Specialized Treatment and Twin Oaks Vocational
Academy, Clinical Coordinator (Standard 3)
Renette Crosby, Office of Accountability and Program Support, Regional Monitor (Interviews)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (interviews)
Kayshala Patterson, Office of Accountability and Program Support, Regional Monitor (Standard
2)
Rebecca Smith, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: JoAnne Bridges Academy MQI Program Code: 1444
Provider Name: Rite of Passage Contract Number: 10361
Location: Madison County / Circuit 3 Number of Beds: 28
Review Date(s): March 25-28, 2025 Lead Reviewer Code: 228
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, (5) Safety and Security, and (6) Educational
Services, which are included in the Residential Standards.
Overall Rating Summary
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 63 (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 Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Non-Applicable
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 63 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 63 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* 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 * Non-Applicable
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 63 (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 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 7 of 63 (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 Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 63 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
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) 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 9 of 63 (Revised September 2022)
Program Overview
The JoAnn Bridges Academy is a twenty-eight-bed program, for twelve to eighteen-year-old
females, located in Greenville, Florida. The program is operated by Rite of Passage, Inc,
through a contract with the Department. The program provides the following services: mental
health overlay services (MHOS) and substance abuse education. In addition, the program
fosters each youth by providing Aggression Replacement Training (ART), Seeking Safety,
Impact of Crime (IOC), Living in Balance, Dialectical Behavior Therapy (DBT), Character Traits,
and Trauma Recovery, and Empowerment for Adolescent Girls and Young Woman (G-TREM).
Additional treatment services provided include family, individual, and recreational therapy.
Program administration is comprised of a program director (PD), one administrative assistant,
one clinical director, one recreation therapist, one transition coordinator, and a building
manager. Case management services are provided by three therapeutic managers. Mental
health staff at the program include one clinical director, one psychiatrist, and three therapeutic
managers. Medical services are offered daily and are provided by a medical doctor who is the
designated health authority (DHA) and two registered nurses (RN). The DHA is required to be
on-site weekly for two hours. The clinical manager is required to be on-site for forty hours and
RNs are required to be on-site for sixteen hours a week. Educational services are provided by
the program. The layout of the program includes one large building with two youth dorms, a
gymnasium, cafeteria, and two classrooms. There are also two portables on site, and an
outdoor field for recreation. The program has forty-three operating security cameras providing
coverage and all were operational at the time of the annual compliance review. At the time of
the annual compliance review, the program had four youth coach counselors and one
therapeutic manager positions vacant.
.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 63 (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 policy and procedures addressing initial background screenings of
employees, volunteers, mentors, and interns. The Annual Affidavit of Compliance with Level 2
Screening Standards was completed and sent to the Department’s Background Screening Unit
(BSU) on January 19, 2024. Seven staff were applicable for initial background screenings. Each
of the seven staff had a background screening completed prior to contact with youth and
confidential records. Each staff reviewed had a criminal history report reviewed. Each applicable
reviewed staff completed a pre-employment assessment tool and had a passing score on the
pre-employment assessment tool. Each staff was added to the staff Clearinghouse employment
roster. Each staff had a signed contraband attestation form.
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 policy and procedures addressing five-year background re-screenings
for all staff. One staff was applicable for five-year background re-screening. The applicable five-
year re-screening was completed every five years as required. The re-screening was submitted
to the Department’s Background Screening Unit/Clearinghouse at least ten business days prior
to the five-year anniversary or retained prints expiration date.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 63 (Revised September 2022)
▪ 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 policy and procedures addressing the reporting and investigating of
suspected or alleged child abuse. Five staff personnel records were reviewed, and all records
included documentation the staff reviewed and signed a code of conduct. The Florida Abuse
Hotline and the Department’s Central Communications Center (CCC) numbers are posted
throughout the program, which were observed during the program tour. The program’s steps to
report abuse consists of any staff member with the knowledge or reasonable cause to suspect a
child is being abused or neglected shall report information to the Florida Abuse Hotline, or the
CCC. Staff shall immediately notify the program director (PD) and on duty supervisor as soon as
the call to the Florida Abuse Hotline has been placed. The staff will complete an internal incident
report and forward the Information to the respective supervisor once the call has been made to
the FloridaAbuse Hotline or CCC.. The program director or designee shall complete notifications
to the CCC and Florida director. Youth are provided unhindered access to report alleged abuse.
At no time shall a youth be prevented from self-reporting or making a call to the Florida Abuse
Hotline or the CCC. The shift supervisor shall be immediately notified of a youth’s request to
contact the Florida Abuse Hotline or CCC. The supervisor shall immediately attempt to notify the
PD of the placement of an abuse call. Staff will assist youth in placing an abuse call by dialing
the telephone number, recording the date and time of the call, obtaining the operator’s name
and number as well document this information on an internal incident report. The staff will
maintain sight and sound supervision of the youth but will remain in an area which allows the
youth to report freely. The program had a total of two incidents related to physical,
psychological, or emotional abuse since the last annual compliance review. One of the incidents
was closed as an unsubstantiated incident and the other remains open. The program completed
a Trauma Responsive and Caring Environment (TRACE) self-assessment on April 19, 2024.
Five youth were interviewed and each of five youth reported they feel safe at the program, have
never been stopped from reporting abuse to the CCC or the Florida Abuse Hotline, and have
the number or access to the Florida Abuse Hotline or CCC. Each of the five youth reported staff
being respectful when talking to youth, have never heard a staff use curse words when
speaking to youth, and have never exchanged any personal contact information such as emails,
telephone numbers, or social media information with staff.
Five staff were interviewed and each of the five staff were able to articulate the process for
allowing youth and staff to call the Florida Abuse Hotline or CCC. Each of the five staff reported
never having observed a staff telling a youth they could not call the Florida Abuse Hotline or
ever having heard a staff using profanity while speaking with a youth. The PD was interviewed
and reported the shift supervisor or administrative staff place the call to the CCC and follow the
CCC procedures for the program. Youth have access to the Florida Abuse Hotline and the shift
supervisor will follow the incident reporting procedure following the Florida Abuse Hotline/CCC
call. The PD further stated training is conducted with the youth and staff.The PD also stated, the
Florida Abuse Hotline and CCC numbers are posted throughout the facility, and all calls are
logged into the CCC and the Florida Abuse Hotline call log. Reports are completed and turned
into administration and filed. CCC calls are discussed weekly in the management meeting and
monthly in the staff meetings. The PD reported the program’s TRACE assessment was
completed April 2024.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 63 (Revised September 2022)
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 policy and procedures addressing staff misconduct and consequences
of misconduct. The program had two incidents where there were allegations of physical,
psychological, or emotional abuse in the program during the annual compliance review period.
In each of the incidents, there was evidence management took immediate action to address
allegations of physical, psychological, and emotional abuse. Documentation was reviewed to
identify applicable corrective actions by management. The program director (PD) was
interviewed regarding management response to allegations and reported two staff members
received disciplinary action due to allegations of abuse towards a youth. The PD further stated
management’s response to allegations of abuse is zero tolerance.
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 policy and procedures addressing incident reporting. The program had
a total of five reports to the Department’s Central Communications Center (CCC) during the
annual compliance review period. Each of the incidents were reviewed. All five incidents were
reported within two hours. Each of the incidents was documented in the program logbook. No
other additional incidents were discovered which should have been reported to the CCC during
the annual compliance review.
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 policy and procedures addressing Protective Action Response
(PAR)/Right Interations (RI) reporting. The program had two PAR/RI incidents during the annual
compliance review period. The documentation reviewed for the each incident revealed the
reports were completed by the end of the staff’s workday and included statements from all staff
involved. No mechanical restraints were used during the incidents. Each RI resulted in an injury
to the youth. The Department’s Central Communications Center (CCC) and the Florida Abuse
Hotline was contacted following the incident within the two hours of becoming aware of the
incident as required. Each involved youth received a medical review post-RI review and a
follow-up doctor’s appointment was made for the youth. The RI Report was reviewed by a
supervisor and administrator within seventy-two hours of the incident. A copy of the RI report
was placed in the program’s centralized file. Monthly summaries were maintained by the
program and submitted to the Department. The RI plan was updated December 12, 2023. The
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 63 (Revised September 2022)
RI plan was approved by the Department on January 17, 2024. The program’s PAR rate during
the annual compliance review period was 0.00, which is below the statewide Residential PAR
rate of 1.71. The interviewed program director reported all incidents are monitored daily, weekly,
and monthly. Five staff were interviewed regarding PAR. Each of the five staff reported they use
RI. Each of the five staff were able to articulate the process.
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 policy and procedures addressing pre-service training and certification
which states all direct care staff shall receive orientation training and the required pre-service
training. The recreation therapist, kitchen staff, therapeutic manager, and maintenance staff
occasionally may supervise youth, and are counted in the staff-to-youth ratio. All instructors
were qualified to deliver training. The program submitted a pre-service training plan prior to its
implementation. The training plan was approved the programs’ s director, the assistant
secretary for residential services and the director of the Department’s Office of Talent
Leadership, and Culture (TLC). Five staff training records were reviewed. Each staff completed
the initial 120 required training hours in the required timeframe. All staff completed the required
training prior to youth contact.Each staff completed the additional trainings such as active
shooter preparedness, adolescent development and behavior, balanced approach to restorative
justice, the Department’s Central Communications Center (CCC), civil rights, communication,
Confidentiality, and Health Insurance Portability and Accountability Act (HIPPA), Department of
Juvenile Justice Legacy, equal employment opportunity, gang awareness, human trafficking
intervention, infection control/bloodborne pathogens, information security awareness, mental
health and substance abuse, Motivational Interviewing (MI), quality report writing, safety,
security, and supervision of youth, sexual harassment, effective and respectful treatment of
youth, trauma responsive practices. Each staff also completed the following contract required
training ingender specific training, administration of medication, and behavior management.
Each staff completed the following trainings as required by Florida Administrative Rule including
grievance process, infection control, exposure control plan, behavior management system, and
the intended, and safe use of tools. Each staff completed the additional training of mental health
overlay services, prenatal and neonatal staff education, and monitoring, observation, and
emergency care of pregnant females, and their infants.
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 policy and procedures addressing in-service training requirements.
Five staff training records were reviewed for in-service training. Each staff completed the
required twenty-four hours of in-service training. Each staff completed in-service trainings in
active shooter preparedness, cardiopulmonary resuscitation (CPR)/First-Aid/automated external
defibrillator (AED), Human Trafficking, information security awareness, mental health and
substance abuse, Prison Rape Elimination Act (PREA), Protective Action Response
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 63 (Revised September 2022)
(PAR)/Right Interactions (RI), professionalism, interpersonal communication, and ethics, sexual
harassment, suicide awareness and prevention, and trauma responsive practices. Each of the
staff are currently certified in PAR/RI. Two supervisors were selected to review for additional
annual supervisory training. Each supervisory staff completed a minimum of eight additional
hours of supervisory training. Each staff completed trainings required by Florida Administrative
Rule in emergency response and emergency drills, infection control, bloodborne pathogens, and
exposure control plan, prenatal and neonatal staff education, and monitoring, observation, and
emergency care of pregnant females, and their infants. Each staff completed the mental health
overlay services training. All instructors were qualified to deliver training. The program’s in-
service training calendar was submitted prior to its implementation. The training plan was
approved by the program director, the assistant secretary for the Department’s Office of
Residential Services and the director of the Department’s Office of Talent Leadership, and
Culture (TLC).
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 policy and procedures addressing the grievance process which
includes the training requirements for staff. The program’s grievance process includes the
informal phase, formal phase, and appeal phase. The program’s informal process states all
youth are informed of their rights regarding the grievance process during the initial orientation
process. Program staff will encourage informal resolution of complaints with staff members
involved;however, all youth have access to a formal grievance and appeal process. Assigned
grievances will be reviewed by the assigned staff member within two days of the assignment. If
not resolved at this level, a supervisor will investigate and respond within two days. Each youth
will be met with individually to review the grievance and outcome. Youth will sign and date the
documentation signifying satisfaction with the process. The program reported having no
grievances for the annual compliance review period. Five youth were interviewed regarding the
program’s grievance process. Each of the five youth were able to articulate the process for filing
a grievance. Each youth reported forms are placed throughout the facility, there are three
phases, and there are timeframes for each phase. Each youth reported being able to ask for
assistance in completing a grievance form. Five staff were interviewed regarding the program’s
grievance process. Each of the five staff were able to articulate the grievance process. Each of
the five staff reported grievance forms are placed throughout the program. Four of the five staff
reported supervisors review grievances. One of five staff reported the program director reviews
grievances. The program director was interviewed regarding the program’s grievance process
director was able describe the phases of the grievance process. The program director reported
the program did not have any grievances during the annual compliance review period.
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
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Office of Accountability and Program Support Page 15 of 63 (Revised September 2022)
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program provides services which focus on developing life and social skill competencies in
youth, activities or instruction intended to increase youth's awareness of, and empathy for crime
victims, opportunities to participate in community projects, and recreation and leisure activities.
Life and social skills intervention services are provided which addresses at a minimum
identification and avoidance of high-risk situations which could endanger self or others,
communication, interpersonal relationships and interactions, non-violent conflict resolution,
anger management, and critical thinking including problem solving and decision making.
The program’s only life skills groups are considered primary services. The program director was
interviewed and reported the program addresses the needs of a targeted gender group
individually. Five youth were interviewed regarding having practiced any new skills learned
ingroup and have they practiced outside of group. Each of the five youth were able to articulate
how new skills learned was practiced. Examples provided consisted of controlling anger,
walking away, deep breathing, and counting backwards. The designated mental health clinical
authority (DMHCA) was interviewed regarding information for all group/activities provided during
the past annual compliance review period. The DMHCA provided a listing of groups being held
at the program and what staff facilitate those groups.
1.12 Restorative Justice Awareness for Youth Non-Applicable
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is the only restorative justice activity the program is providing. 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.
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 policy and procedures addressing internal alerts which included
information on how alerts are identified, documented, updated, and communicated to staff. The
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program’s policy states when risk factors or special needs are identified during or following the
classification process, staff shall immediately update the internal program alert information and
shall enter this information in the Department’s Juvenile Justice Information System (JJIS). Only
appropriate staff may recommend downgrading or discontinuing a youth's internal alert status.
Five youth were reviewed for internal alerts. All alerts were documented on the alert list and in
the Department’s Juvenile Justice Information System (JJIS) on the same date. All alerts
matched JJIS and the internal alert system. The program director was interviewed regarding
internal alert systems and alerts. The program director reported the program’s formalized
procedures regarding review of important medical issues pertaining to the youth include sharing
the information during weekly health and wellness class. The medical department and the
clinical director are responsible for entering and closing out alerts in the Department’s Juvenile
Justice Information System. The nursing staff was interviewed and reported the health services
administrator (HSA) is responsible for updating the medical alert system. Five staff were
interviewed and reported they are informed of the youth alerts to include medical, mental health,
and security through alert binders located in the lobby which each shift must review, shift
reports, logbooks, shift supervisors, and chronological data sheets.
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 policy and procedures addressing youth records. Visual observation
confirmed the program maintains separate youth individual healthcare and management
records. Five healthcare and five case management records were reviewed for compliance.
Each individual management record contained the youth’s name, Department identification
number, date of birth, county of residence, and committing offense. Each individual
management record contained sections for legal information, demographics and chronological
information, correspondence, case management and treatment team activities, and
miscellaneous. Each record was marked “Confidential”, and all were stored in a secured room.
The filing cabinets are marked “Confidential”.
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 policy and procedures addressing community advisory board
meetings. The program’s community advisory board meetings every ninety to 120 days.
Documentation review supports the program director actively solicited involvement community
participants. Documentation further supports the program director recruited victims and parent
of youth who were previously involved in the juvenile justice system. The program did not
reschedule meetings within the quarter as the victim and parent were scheduled for the
originally scheduled meeting. Advisory board meetings are held in person and virtually.
Documentation review confirmed members are notified of meetings and agenda by electronic
mail and standard mail. The program director was interviewed and reported the community
advisory board serves as a link to the program andthe local community. Board members are
diverse and sensitive to the ethnic background of youth in the program. The board meets
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quarterly and is actively involved in the program. The advisory board is active with
recommendations on community projects and events, facility improvement, programs, and
volunteers. The interviewedadvisory board memberreported being actively involved. The board
member reported the board including the youth as being the best there is because of the impact
on the community. The youth work hard as volunteers in the community and they are pleasant
and know how to work with elderly people.
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 policy and procedures addressing staff performance expectations.
Performance evaluations are conducted at ninety-days and annually. Five job descriptions were
reviewed to ensure each staff’s performance standards were clearly identified which included
staff whose job functions includes implementation of the program’s behavior management
system (BMS) . A sample of five performance evaluations were reviewed to ensure the
evaluations were completed as outlined in policy and annually. All performance standards
reviewed on the evaluations matched the job description for each staff. The program director
was interviewed and reported the program turnover as none, and performance evaluations are
completed on a ninety-day and annual basis. Five staff were interviewed. Four of the five staff
reported they receive formal evaluations on a yearly basis. The remaining staff reported
receiving a formal evaluation of performance every six months.
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 maintains a policy and procedure addressing special contract conditions. The
program’s contract and Memorandum of Negotiation (MON) were reviewed for special contract
conditions. The special conditions required were identified as one hundred percent of eligible
youth will complete seventy-five percent of community service, one hundred percent of eligible
youth will participate in off campus pro-social enrichment activities one time a month, mental
health interventions are offered seven days a week, shall offer youth with substance abuse
issues the opportunity to to participate in alcoholics anonymous/narcotics anonymous (AA/NA),
and van loop will be offered for parents in specific geographical areas every other month. The
program director (PD) was interviewed and reported van loop as the contract negotiated item
being offered at the program. A follow up informal interview was conducted with the PD to
confirm the utilization of further special contract conditions. Documentation review confirmed all
eligible youth participated in special contract condition activities as contractually required.
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1.18 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program includes the review and analysis of data in decision-making practices. Data trends
are shared among administration and with staff to proactively make policy, practice and
programming changes designed to foster system and program improvement. The monthly
review of site-operations summary report is posted where easily accessible by staff, educators,
and stakeholders. Data is also reviewed in monthly staff meeting. Communication is forwarded
by email and or letter to community stakeholders on a quarterly basis. The program implements
collected data to improve their process by conducting weekly conference calls with leadership
team. The data system information is shared with staff and is posted in the lobby of the
program. The program continues to monitor information while fostering more management
involvement.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures outlining the process to ensure initial contacts are
made with the youth’s parent/guardian, committing court, and juvenile probation officer (JPO).
Five reviewed case management records had documentation verifying each youth’s
parent/guardian was contacted by telephone within twenty-four hours of each youth’s arrival. All
five reviewed case management records included written notification of each youth’s arrival to
the program to the parent/guardian within forty-eight hours of admission. All five reviewed case
management records reflected program staff notified the committing court and assigned juvenile
probation officer (JPO) of each youth’s arrival on the day of admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to address the youth orientation process. A program
orientation was conducted for all five reviewed youth case management records within twenty-
four hours of admission. Orientation included services available, review of daily schedule,
expectations and responsibilities of each youth, written behavioral management system, access
to medical, and mental health and substance abuse services, access to the Department’s
Central Communications Center (CCC) and Florida Abuse Hotline, zero tolerance regarding
sexual misconduct, what is considered contraband, and illegal items, and consequences for
having these items, performance plan process, hygiene, and dress code, procedures for
visitation, mail, and telephone usage, each youth’s anticipated length of stay, goal completion,
expectations for release, access to community, grievance process, fire drills, and emergency
procedures, facility tour, health education topics, services available, daily schedule, living unit,
and treatment team assignment. Five interviewed youthindicated the orientation process started
within twenty-four hours of arrival. Each youth stated orientation included program rules,
procedures, and schedules. The youth admission orientation process was not observed due to
no admissions occurring during the annual compliance review.
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.
None of the five reviewed case management records was applicable for the youth being
eighteen years of age or older. A request was made to the program for a sample of three youth
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records for youth over the age of eighteen. There were only two youth eighteen years of age or
older in the program during the annual compliance review period. The two youth case
management records were reviewed and confirmed written consent was obtained to provide
physical and mental health information to their parents/guardians.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a policy and procedures which outlines the classification factors, procedures,
and reassessments for activities. A review of five youth records indicated the program utilized a
classification system in accordance with the Florida Administrative Code, which promotes
safety, security, and effective delivery of treatment services. Each reviewed record documented
an initial classification form which included physical characteristics of the youth, age and
maturity level, identified special needs, history of violence, gang affiliation, if applicable, criminal
behavior, sexual aggression, and vulnerability to victimization. Also, the form included the
youth’s perception of vulnerability, the youth’s history of potential, or verified human trafficking,
and risks such as suicide, medical, escape, and security. Each initial classification form
assigned all newly admitted youth to a living unit and indicated the commitment packet and
alerts were reviewed. All five records indicated youth reassessments and reclassifications were
completed before considering an increase in the youth privileges or freedom of movement.
Three applicable youth were reclassified prior to participation in off-campus activities and
participation in work projects or other activities involving tools or instruments. The interviewed
program director explained upon admission, youth factors such as mental health status,
physical health status, cognitive performance, age, and prior victimization are considered in the
classification meeting when assigning youth to a living unit/sleeping room. In addition, this
information is used to determine the best placement for the youth to ensure their safety and
well-being. The data is used throughout the youth’s stay as they may move rooms according to
the Positive Performance System as they level up and earn more incentives.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures which outline gang identification and notification of
law enforcement. The program did not have any youth identified as being involved with gang
activities during the annual compliance review period; however, the program has processes in
place for notification to law enforcement when a youth is identified as being involved with a
gang. The process includes entering gang alerts into the Department’s Juvenile Justice
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Information System (JJIS) upon identification and sharing the information with the education
provider or local school district providing services at the residential program and the youth`s
juvenile probation officer (JPO).
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures to address a youth’s participation in gang prevention
and intervention activities. During this annual compliance review period, there were no youth
applicable for gang identification prevention and intervention. Any youth identified to be a gang
member or have gang affiliations or are at a high risk of gang involvement will participate in
Impact of Crimes groups weekly. In addition, a goal shall be included into their individual
performance plan pertaining to gang membership and/or affiliation containing interventions and
strategies of gang prevention and intervention. The program director interview indicated the
program gang intervention and prevention strategies provide the youth with resources as well as
the opportunity to develop a plan to disaffiliate from the criminal street gang if the youth want to
do so.
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 has a policy and procedures to ensure an initial Residential Assessment for Youth
(RAY) is conducted within thirty days of admission. A review of five youth case management
records found documentation in all records verifying the RAY was completed within thirty days of
admission. All initial assessments were maintained in the Department’s Juvenile Justice
Information System (JJIS). All five of the reviewed records were applicable for ninety-day
reassessments. One out of five records had a reassessment completed every ninety days as
required. The remaining four records did not have reassessments completed every ninety days,
three records were two days late, one was fourteen days late, and one was twenty-one days
late. Three of the five records were applicable for additional reassessments deemed necessary
by the intervention and treatment team. Each reassessment was completed as required. All five
youth case management records maintained all reassessment documentation as required.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
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The program has a policy and procedures to ensure a Youth Needs Assessment Summary
(YNAS) of each youth is conducted within thirty days of admission. A review of five youth case
management records verified each record included a Youth Needs Assessment Summary
(YNAS) completed in the Department’s Juvenile Justice Information System (JJIS) within thirty
days of each youth’s admission. Each record documented the youth’s top three criminogenic
needs.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program has a policy and procedures in which the intervention and treatment team,
including the youth, shall meet and develop the Individual Performance Plan (IPP) based on the
findings of the youth’s initial assessment, within thirty days of admission. Each of the five
reviewed youth case management records included performance plans which were completed
within thirty days of admission in the Department’s Juvenile Justice Information System (JJIS)
and done after completion of the Youth Needs Assessment Summary (YNAS). Documentation in
each of the five youth case management records indicated the intervention and treatment team,
including the youth, were present to provide input to the performance plans. Each of the five
youth interviews reflected each youth participated in the development of their performance plan.
All performance plan goals were measurable and included target completion dates. The
individualized goals included in each performance plan were based upon the prioritized needs
reflecting the risk and protective factors identified ensuring the initial assessment process. Each
goal identified specific delinquency interventions based on the Residential Assessment for Youth
(RAY) results. Performance plan goals also identified responsibilities of staff and youth. The
performance plans included the top three criminogenic needs identified in the YNAS and
transition goals, and targeted court-ordered sanctions which could be reasonably initiated, or
completed while the youth was at the program. All five youth case management records
included performance plan transmittal letters which were sent out to all applicable parties within
the required time frame. Performance plans were signed by the treatment team leader, youth,
and other parties who have responsibilities in goal completion. Original performance plans were
maintained in all five youth case management records. Five interviewed youth reported they
participated in developing their performance plan and knew their goals. Each of the five-youth
confirmed they received a copy of their performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a policy and procedures in which performance reviews will result in revisions
to the youth’s Individualized Performance Plan (IPP) when determined necessary by the
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intervention and treatment team. All five reviewed case management records were applicable
for performance plan revisions. Each youth’s treatment team was involved in determining the
need for performance plan revisions. Revisions were made based on goal progress, new
information revealed, and Residential Assessment for Youth (RAY) Reassessment results. All
five youth were applicable for reassessments to facilitate transition activities and received
reassessments as required. Each applicable youth had additional plans, including academic, or
treatment plans, incorporated into the performance plan. In addition, the program advised none
of the youth were served by the Department of Children and Families and/or the Agency for
Persons with Disabilities.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program has a policy and procedures outlining Performance Summaries and transmittals. A
review of five youth records indicated all five were applicable for Performance Summaries.
Seven youth performance summaries were reviewed for the five reviewed youth. Out of the
seven, four performance summaries were completed late, one was two days late, one was one
day late, one was three days late, and one was eight days late. The remaining three
performance summaries were completed at ninety-day intervals, beginning ninety days from
signing the youth’s performance plan. All performance summaries were completed prior to
release. Each applicable Performance Summary included each youth’s status on each
performance plan goal, overall treatment progress, behavior, academic status, and credits
earned in the program if the youth was a high school student, including performance, and
behavior in school, significant events, interactions with peers and staff, level of motivation, or
readiness to change, overall treatment progress, and all other required elements. All five case
management records indicated the youth were allowed to read and add comments before
signing the Performance Summary. Each youth was provided a copy of the summary, and the
original copy was filed in the youth’s case management record. Moreover, all records contained
the date and the signature of the treatment leader, youth, and program director, or designee.
Each reviewed record documented the program sent a copy of the youth’s Performance
Summary within ten working days to the youth’s committing court, assigned juvenile probation
officer (JPO), parent/guardian, and Department of Children and Families, if applicable. A review
of three closed case management records verified each release summary included the
justification for release, discharge, or transfer. All three release summaries included the
justification for release and Pre-Release Notification (PRN). All three youth were a direct
discharge, and the discharge summary was included. The release summary and PRN were sent
at least forty-five days prior to release. A signed copy was maintained in each youth’s record.
None of the youth were applicable for the court objecting to their release. Once approved, the
program provided written notification to each youth’s parent/guardian. Each closed case
management record contained an Exit Residential Assessment for Youth. None of the youth
were applicable for the Sexually Violent Predator Program. None of the reviewed records were
applicable for victim notification.
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2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures outlining parent/guardian involvement in case
management services. Five reviewed case management records included documentation
confirming program staff attempted to involve parent/guardian in the assessment process,
performance plan development, transition planning and progress review. Parents/guardians
were provided with opportunities to attend or participate in these events through advanced
notice of formal treatment team meetings dates and times. If unable to attend, the
parent/guardian is provided the opportunity to participate by telephone or video conferencing, or
to provide verbal, or written input prior to the meeting. A treatment team meeting was unable to
be observed as none were scheduled during the annual compliance review week. The program
director (PD) interview indicated during the youth's stay; the case management department
sends notifications requesting the parents/guardian’s involvement in all treatment team
meetings related to the youth. Additionally, monthly calls are also made to update
parents/guardians on the youth's progress or lack thereof and any upcoming events or
meetings. Also, the case management team offers van loops so parents/guardians can
participate in visitation and family day. Five interviewed youth stated their parent/guardian are
involved in their case management through participation in 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 has a policy and procedures to ensure all required treatment team members
meets bi-weekly, formally and informally, to review each youth’s performance. Five youth case
management records were reviewed for formal and informal treatment team reviews. In each
record, the case manager and therapist were identified as treatment team leaders. The
treatment team for each youth included the youth, administration representative, case manager,
living unit representative, education, clinical staff, medical staff, juvenile probation officer (JPO),
parent/guardian, and transition service manager (TSM) when applicable. Participants were
present or provided written input. Team members actively participated or provided input for
meetings. The youth’s JPO and parent/guardian participated by telephone. Each reviewed case
management record included formal treatment team reviews completed at least once every
thirty days as required. All five reviewed records were applicable for informal bi-weekly
treatment team meetings and included all required elements. Treatment team reviews included
youth name, review date, attendees, input from team members, how youth are progressing,
youth behavior, any physical interventions, and Residential Assessment for Youth (RAY)
Reassessment results when applicable. All other elements were included in the treatment team
documentation as applicable, and the documentation was maintained in each youth’s record.
The youth’s treatment team members, JPO, and parent/guardian were invited, and encouraged
to participate in youth formal treatment team reviews. A treatment team meeting was unable to
be observed as none were scheduled during the annual compliance review. Five interviewed
youth stated they are allowed to demonstrate their learned skills and discuss their progress in
treatment team meetings. Each youth stated staff talk about their performance to include
progress on performance plan goals, positive and negative behavior, and treatment progress.
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2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has apolicy and procedures which outline transition planning, conferences, and
Community Re-Entry Team (CRT) meetings. Three closed youth records were reviewed. Two
records indicated the transition conference was held at least sixty days prior to the youth’s
targeted release date. The remaining record indicated the transition conference was four days
late. The case manager provide documentation which indicated this was due to a change in the
youth’s original targeted release date, which occurred after the transition conference was held.
The youth, treatment team leader, program director or designee, juvenile probation officer
(JPO), parent/guardian, medical, and education staff were invited, and participated in each
youth’s transition conference. During the transition conference the team conducted a review of
the transition activities on each youth’s performance plan, revised the performance plan as
necessary, identified additional transition activities as needed, identified target completion
dates, and identified persons responsible for completion. A copy of each plan was sent with a
request for return with signature to each applicable party not in attendance at the transition
conference. The treatment team leader obtained participant signatures or electronic
acknowledgement of responsibilities. All three closed case management records included
supporting documentation indicating the program and youth participated in the CRT meeting
prior to release and an invitation sent through email was maintained within the youth records.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures which the residential commitment program will
assemble an exit portfolio for each youth to assist the youth when released back into the
community. A review of three closed youth case management records found each youth’s exit
portfolio was discussed and initiated during the transition conference. One of the three youth
records contained copies of the state identification card, social security card, and birth
certificate. The remaining two records contained the state identification card; documentation
verified the program requested the social security card and birth certificate several times;
however, it was not provided. All three closed case management records included a copy of the
youth’s transition plan, calendar with all dates, times, and all locations of upcoming community
appointments, educational and/or vocational certificates earned in the program, all educational
records, school transcripts, resumes, and completed sample employment application. Each Exit
ortfolio was discussed and initiated for the youth at the transition conference, and then verified
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during the exit conference. The Exit Portfolio was provided to each youth and juvenile probation
officer (JPO). None of the youth were applicable for secure risk requirements and the program
did not have contract specific requirements for the exit portfolio.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures which indicate an exit conference shall be conducted,
in addition to formal or informal meetings, to review the status of goals developed at the
transition conference and finalize release plans. Three closed youth case management records
were reviewed, and each youth record contained an exit conference which was conducted after
the program notified the youth’s juvenile probation officer (JPO) of the youth’s release date. Two
of the three records indicated the exit conference was held at least fourteen days prior to the
youth’s release date. One record documented the exit staff was five days late due to a change
in the youth’s original targeted release date. A review of the documentation indicated the date of
the conference, signatures, and a summary of pending transition goals were included. Each
youth record contained the youth’s date of admission and date of termination documented in the
case record, which correlated with the Department’s Juvenile Justice Information System (JJIS).
The status of transition activities established at the transition conference and plans finalized for
the youth’s release were reviewed. The Exit Conference documents included a review of
transition conference goals, a summary of pending transition goals, provisions for continuation
of education and/or employment, evidence the youth’s case manager, and parent/guardian are
aware of the plan, documents, and post-release discharge plans, and signatures for all required
parties. The youth’s JPO and parent/guardian participated by telephone.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to promote constructive input by youth. The youth
can provide constructive input through the bi-monthly youth council meetings and weekly
questions, concerns, and recognition meetings. Reviewed documentation indicated the bi-
monthly youth council meetings are being held as required. Staff recognized the youth during
these meetings and youth can present questions and concerns relating to the program. The
youth can also fill out grievances and Request to Speak forms and submit them through a drop
box which is checked daily by the director of student services. Five interviewed youth confirmed
youth input is given in the program through bi-monthly youth council and weekly questions,
concerns, and recognition meetings. The interviewed program director explained during
treatment team meetings the youth’s input is obtained and surveys are completed. Also, youth
can submit request to speak forms to provide feedback and participate in weekly questions and
concerns meetings.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program has a designated mental health clinician authority (DMHCA) who holds a valid and
active license as a licensed clinical social worker in the State of Florida. The license expires
March 31, 2027. There were two DMHCA’s during the annual compliance review period. Both
held valid and active licenses which expire on March 31, 2025, and March 31, 2027. The
DMHCA is on-site forty-hours a week to ensure appropriate coordination and implementation of
mental health and substance abuse services are taking place. The program maintains the
DMHCA position description within the program’s policy and procedures, which was reviewed.
The program does have a back-up DMHCA with a valid and active license which expires on
March 31, 2027. The DMCHA was interviewed and reported their role is to assign therapists
their caseloads, ensure services are provided, review documentation, provide guidance,
support, and supervision to the therapists, and monitor clinical services. The DMHCA provides
groups and crisis interventions for clinical services at the program. The DMCHA conducts daily
check-ins with the staff along with weekly clinical supervision.
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 does not employ any other full time licensed clinical staff. The program holds a
Chapter 397 license and was available on-site for review.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) serves as the clinical director,
ensures the non-licensed clinical staff working under their supervision are performing services
they are qualified to provide based on education, training, and experience. Direct supervision
was provided face-to-face, on-site, on a weekly basis by the DMHCA during the annual
compliance review period as evidenced by a review of weekly supervision logs. All direct
supervision logs were recorded on the Department’s Licensed Mental Health Professionals and
Licensed Substance Abuse Professionals Direct Supervision Log form. The program has a
Chapter 397 licensed which expires in 2027. The program is in contract compliance with the
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non-licensed mental health and substance abuse clinical staffing and number of hours they are
on-site. There is one current vacancy for a therapeutic manager (TM) and a previous vacancy
for a DMHCA for approximately two months. The program currently employs two non-licensed
therapeutic managers. One holds a master’s-level degree from an accredited university in an
appropriate field. The other TM holds a bachelor’s degree from an accredited university in a
human services field. This staff completed fifty-two hours of pre-service training prior to working
with the youth. Both TMs are working under a Chapter 397 license and can provide substance
abuse clinical services. Both TMs also completed twenty hours of training to provide
Assessments of Suicide Risk (ASR) as evidenced by a review of training documentation.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Five mental health and substance abuse records were reviewed for admission screening. All
records indicate youth who enter the program receive a clinical mental health and substance
abuse screening on the day of admission. All reviewed mental health and substance abuse
screenings were completed by non-licensed mental health staff and signed by a licensed mental
health professional. All records indicated the mental health and substance abuse screening
utilize valid and reliable screening instruments. All reviewed screenings document mental
health/substance abuse history, recent history or trauma of victimization, current medical status,
behavioral observations, and suicide risk. All records indicated a valid and reliable suicide risk
screening instrument resulted in findings and/or recommendations for further evaluation and
treatment. Two of five records indicated the Assessment of Suicide Risk resulted in notification
to the program director and the designated mental health clinician authority (DMHCA)
immediately. Two of five records included documentation the youth were placed on
precautionary observation (PO) during intake with mental health staff. The two records indicated
the program director and DMHCA followed the program’s policy and procedures for emergency
care. Three of five reviewed records included documentation the youth were placed on standard
supervision during intake with mental health staff. The program maintains a standardized
screening process which includes review of commitment packet information, reports and
records, administration of the MAYSI-2 in the Department’s Juvenile Justice Information System
(JJIS), or Clinical Mental Health Screening by a licensed mental health professional and Clinical
Substance Abuse Screening by a “qualified professional”, and referral of juvenile offenders
identified by screenings as in need of further evaluation, or immediate attention. Records
indicate staff received training in mental health and substance abuse issues and administration
of the MAYSI-2. Records indicate a standardized process for referral of youth identified as in
need of further mental health and/or substance abuse evaluation to an appropriate service
provider/professional or, when immediate attention is needed, to a hospital, or Baker Act, or
Marchman Act receiving facility. The program director was interviewed regarding the screening
process for mental health and substance abuse problems and suicide. The program director
reported the program follows Florida Statute, Administrative Rule, and the Department's
guidelines for mental health and suicide precautions.
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3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
Five youth mental health and substance abuse records were reviewed for mental health and
substance abuse assessments. All five reviewed records indicated the program completed a
combined mental health and substance abuse evaluation. All records indicated the date of
referral is made on the date of admission. All records documented a new evaluation is
completed within thirty calendar days of admission. All records documented youth consent for
substance abuse (SA) services. All records indicated a non-licensed clinical staff completed the
evaluation and is signed by a licensed mental health professional within ten calendar days after
the evaluation was conducted. All five mental health and substance abuse evaluations include
identifying demographics of the youth, reason for the evaluation, relevant background
information, behavioral observations, mental status examinations, results of an administered
interview, discussion of findings, the Diagnostic and Statistical Manual of Mental Disorders
Version Five (DSM-V) diagnosis, patterns of alcohol and other drug abuse, impact of alcohol
and other drug abuse on major life areas, risk factors of continued alcohol and drug abuse, and
recommendations. None of the youth required an updated evaluation.
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.
Five youth mental health and substance abuse records were reviewed for mental health and
substance abuse treatment. All five reviewed records indicated the Initial Treatment Plans were
developed within seven days of initiation of treatment and documents all required elements. All
reviewed Initial Treatment Plans included signatures from the clinical staff, the licensed clinical
supervisor, the youth, treatment team leader, program management, and living unit
representative. All five records included documentation the initial treatment plans were mailed to
the parents/guardians requesting signature. All records indicated the youth’s juvenile probation
officer (JPO), education representative, and other applicable treatment team members were
interviewed for their input. Three of five reviewed Individualized Treatment Plans included
psychiatric services. All five reviewed plans included individualized treatment plan reviews on a
form which contains all of the required elements. Thirty-five of thirty-six treatment team reviews
were completed every thirty days; one review is documented as being three days late. All
records indicated the Individualized Treatment Plan included signatures from the clinical staff,
licensed mental health clinical staff, youth, treatment team leader, program management, living
unit representative, and education representative. All five records included documentation the
initial treatment plans were mailed to the parents/guardians requesting signature. All records
indicate the youth’s JPO, and other applicable treatment team members were interviewed for
their input. Two of five reviewed records indicated the youth receive individual counseling once
a month for sixty minutes. The three remaining records indicated the youth received individual
counseling bi-weekly for thirty minutes. The program manager provided documentation of a
previous deficiency to address the concern. All five records indicated the youth received group
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counseling four times a week for sixty minutes and family counseling once a month for sixty
minutes. All records indicated the youth receive psychiatric services; four records indicate the
youth receive services once bi-weekly, while the remaining record indicated the youth received
services once a month. All records provided documentation indicating the goals and objectives
are individualized for each youth. All mental health groups are primary services and are
reviewed by the Technical Assistance Specialist.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
Five youth mental health and substance abuse records were reviewed for treatment and
discharge planning. Five reviewed records indicated the youth is assigned to a treatment team
upon arrival at the program. All records indicated treatment teams were comprised of the youth,
program administrator, living unit representative, education representative, medical staff, and
mental health staff. Four of five records were applicable for substance abuse treatment and
clinical staff was present. All records showed documentation the program requested signatures
from the parents/guardians. Four of five records indicated the youth needed substance abuse
treatment and consent through a signed Youth Consent for Substance Abuse Treatment form.
All records documented an Authority for Evaluation and Treatment (AET) form. All records
indicated the mental health or substance abuse treatment notes were documented on a form
which contains all of the required elements. All five records contained progress notes
documenting the youth receives individual psychotherapy or counseling and psychosocial skills
training as stipulated on the treatment plan. Five youth records were reviewed for discharge
planning. None of the youth records selected were applicable. Three additional closed records
were selected for review. All three reviewed closed records indicate the discharge plan was
documented on the Department’s Mental Health/Substance Abuse Treatment Discharge
Summary form. All three Discharge Summaries include future services needed. The records
included documentation the Discharge Summary was reviewed with the youth,
parents/guardians, and juvenile probation officers (JPO) during the exit conference and a copy
was provided to the required parties.
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’s required clinical group according to their contract is Aggression Replacement
Training groups. Five youth were interviewed regarding family and individual counseling. All five-
youth reported they are attending family and individual counseling with one participating two
times a month and four participating monthly. Five staff were interviewed regarding mental
health and substance abuse group facilitation. All five staff reported direct care staff, including
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themselves, do not facilitate any mental health or substance abuse groups. The designated
mental health clinician authority (DMHCA) was interviewed regarding mental health and
substance abuse services. The DMHCA reported individual therapy, family therapy, and groups
are provided in the program. The groups provided are Living in Balance, Aggression
Replacement Training, and Character Traits. The program director was interviewed regarding
specialized services at the program. The program director reported the program provides
mental health overlay services (MHOS) for the youth. The DMHCA is on-site for forty hours a
week at least five days a week. There are no other licensed staff on-site. The current counselor
to youth ratio is fourteen youth to one therapeutic manager. The program provides individual
therapy at least once every two weeks and more often as needed. A review of treatment plans
revealed the youth are receiving the individual counseling and prescribed. The youth are also
receiving family therapy as prescribed. The youth were able to see the psychiatrist when
needed for medication management. The licensed mental health counselor, who is the DMHCA,
provides on-site mental health services to include therapeutic services, involvement in treatment
planning, and staff training and consultation. There are a total of four mental health groups
provided each week for all youth.
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 utilizes a psychiatrist with a clear and active license which expires January 31,
2026. The psychiatrist is available twenty-four hours a day, seven day a week. The psychiatrist
provides input to the designated mental health clinician authority (DMCHA) and/or the assigned
therapeutic manager for treatment teams. The recommendations of the psychiatrist were
observed to be incorporated in the individualized mental health and treatment plans. The
psychiatrist sign-in and out logs for the annual compliance review period were provided for
review. These confirmed the psychiatrist was on-site every two weeks as required by contract
with no discrepancies noted. The psychiatrist actively manages and supervises psychotropic
medication services in the program. The psychiatrist was interviewed regarding the services
provided in the program. The psychiatrist reported they evaluated and treat youth as needed
and is available for staff consultation. The psychiatrist reported being on-site every two weeks
and evaluates all new admissions and youth on medications for medication management as
needed. The psychiatrist reported meeting with the DMHCA and nurse every two weeks or as
needed. The formalized procedures for reviewing youth information regarding medical issues
with medical staff is for the psychiatrist to review the youth's record upon admission and then
when any special events occur. The DMHCA was interviewed regarding psychiatric services and
reported they meet with the psychiatrist twice a month to discuss youth who receive psychiatric
services. Five youth records were reviewed for psychiatric services. Three of the five youth
entered the program on psychotropic medications. All five youth were referred for psychiatric
interview, which is the program’s policy. The three youth admitted on psychotropic medications
received a diagnostic interview within fourteen days of admission. All five initial psychiatric
interviews included the youth’s history, a mental status exam, the youth’s diagnosis, and
treatment recommendations. Two of the youth were not placed on psychotropic medications
after their initial psychiatric interviews. The other three initial psychiatric interviews included the
medications prescribed, explanation of the need of psychotropic medications, target symptoms,
initial treatment goals, potential side effects, risks and benefits of taking the medication, and
frequency of medication monitoring. All five initial psychiatric interviews were documented on
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the Department’s Clinical Psychotropic Progress (CPPN) form and was clearly labeled “Initial”.
Three of the five initial psychiatric interviews resulted in the prescription of psychotropic
medications or changes to the youth’s existing medications. The other two youth were placed on
psychotropic medications during their commitment. All five youth received medication reviews
every thirty-days by the psychiatrist. A review of all the CPPNs included documentation of the
psychotropic medications prescribed along with any changes. All reviewed CPPNs also included
the youth’s identifying data, diagnoses, target symptoms, evaluation and description of effect of
prescribed medications, prescribed psychotropic medication name, dosage, and quantity, side
effects, youth’s adherence to the medications, vitals, signature and date of the psychiatrist.
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 has a written plan detailing suicide prevention service. A review of the plan
revealed the following items were included: identification and assessment of youth at risk of
suicide, staff training, suicide precautions, levels of supervision, referral, communication,
documentation, and immediate staff response. The plan also included a review process for
suicide attempts and mortality review which included documentation of the circumstances
surrounding the event, facility procedures relevant to the incident, relevant training received by
involved staff, pertinent medical and mental health services involving the victim, possible
precipitating factors, and recommendations. The Suicide Prevention Plan was reviewed by the
designated mental health clinician authority (DMHCA) and program director on February 12,
2025, and February 11, 2025, respectively.
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.
Five youth mental health and substance abuse records were reviewed for suicide prevention
services. Four of the five youth were applicable for receiving suicide prevention services. Three
of four youth were placed on Precautionary Observation (PO) as a result of staff observation,
and one was placed on PO during admission screening. Four records contained precautionary
observation start dates and Assessment of Suicide Risk (ASR) referral dates. All four records
indicated the ASR was completed on the Department’s ASR form. Three records indicated the
youth were placed on Constant Supervision while the fourth youth was placed on one-to-one
supervision. Three of four records indicated the youth’s parent/guardian and juvenile probation
officer (JPO) was notified of the youth’s potential suicide risk. Four records indicated mental
health staff completed the ASR while providing supportive services, and the assessment was
reviewed by a licensed mental health professional within twenty-four hours. All four
assessments include the staff completing the assessment, their title/credentials, and the results
of the ASR. Four reviewed ASRs showed documentation they were completed within twenty-
four hours of screening/concern. One of the four reviewed ASRs indicated the youth was
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discontinued on suicide precautions and was not transitioned to close supervision until the non-
licensed mental health staff conferred with the designated mental health clinician authority
(DMHCA). All four records included documentation of the date and time the clinician conferred
with program director or designee and licensed mental health professional. Three indicated the
ASRs were conducted immediately due to the youth being in crisis. Four records indicated a
follow-up ASR was completed prior to the removal of youth from precautionary observation. Two
records indicated the follow-up ASR was documented on the Department’s Follow-Up
Assessment off Suicide Risk form. The other two records were documented on the
Department’s ASR form and not the follow-up form. All four records documented the youth’s
Follow-Up ASR indicating suicide precautions could be discontinued and the youth stepped
down to close supervision prior to transitioning to standard supervision. Four records indicated
close supervision was maintained until it was determined no longer necessary by the DMHCA
and there was documentation of a conference held with the program director to reduce the level
of supervision. Four records indicated the discontinuation of close supervision was documented
in accordance with the program’s suicide prevention plan, including an initiating an alert on the
Department’s Juvenile Justice Information System (JJIS). A review of the programlogbooks
indicated the four youth placed on PO were documented and administrative staff provided
instructions related to the suicide risk assessment findings and decisions. While on PO, all four
youth were allowed to participate in select activities with other youth in designated safe
housing/observation areas of the facility.
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’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Five youth mental health and substance abuse records were reviewed for Suicide Precaution
Observation (PO) logs. Four of five records were applicable for review. Four records included all
PO logs were maintained for the duration each youth was placed on PO. The appropriate level
of supervision and observations of the youth’s behavior was documented in real time and not
exceeding thirty-minute intervals. All PO logs were observed to be reviewed and signed by each
shift supervisor and mental health clinical staff. All reviewed PO logs included documentation of
safe housing requirements.
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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.
Ten staff, five pre-service and five in-service, were reviewed for suicide prevention training and
all ten received the appropriate amount of suicide prevention training. The program has seven
suicide response kits located in the medical cart, the director of student services office, medical
office, one for each van, and one in each storage closet. All suicide kits are co-located with first-
aid kits. The program conducts mock suicide drills on each shift quarterly and includes all staff
who come in contact with the youth. A review of mock suicide drill documentation showed the
program conducted more than one drill on each shift for all quarters within the annual
compliance review period. A review of video forsuicide drills was completed with no exceptions.
All mock drills in response to a simulated suicide attempt or incident of serious self-injury. No
youth were used in the mock suicide drills. Documentation showed the program provides semi-
annual training on emergency response procedures which included “mock” training in response
to a suicide attempt or incident of serious self-inflicted injury. Any staff who was unable to
participate in a drill was provided the opportunity to review the drill information and signed a
signature page indicated the review of documentation. The program director was interviewed
regarding suicide prevention planning. The program director reported the program provides
training and mock drills for staff, which include emergency response to suicide attempts or self-
inflicted injury. Five staff were interviewed regarding mock suicide drills. All five staff reported
medical emergency and suicide drills are conducted monthly on their respective shifts.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written crisis intervention plan. The crisis intervention plan was
reviewed and included the following elements: notification and alert system, means of referral,
communication, supervision, documentation, and review.
3.16 Crisis Assessments (Critical) Non-Applicable
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.
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The program has a written crisis intervention plan. The program did not utilize Crisis
Assessment procedures during the annual compliance review period.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a combined emergency mental health/substance abuse services and crisis
intervention plan. A review of the plan showed the following required elements were included:
immediate staff response, notifications, communication, supervision, authorization to transport
for emergency mental health services under Chapter 394 or substance abuse services transport
under Chapter 397, documentation training, and review.
3.18 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Five youth mental health and substance abuse records were reviewed for safety planning. All
five records included documentation a Safety Plan was completed within fourteen days upon
admission. Four of the five reviewed plans included documentation they were jointly prepared
by the youth, parents/guardians, and clinical staff. One reviewed safety plan did not include
documentation the parent/guardian was involved in preparation of the safety plan and did not
include a reason as to why. All five initial safety plans incorporated recommendations from
current clinical assessments or screening instruments and included trauma responsive
practices. Two of the five youth records included documentation the safety plans were reviewed
and updated every thirty days. A total of thirty-nine updated safety plans were reviewed, one
review was completed three days late and six were completed one day late. Three of the youth
safety plans were updated as necessary following significant behavioral or mental health
events. All reviewed safety plans included warning signs, baseline behaviors, crisis recognition,
jointly developed coping skills, intervention strategies, and a debriefing process. Reviewed
documentation showed staff who have contact with the youth are able to review the safety
plans. The safety plans are maintained in the youth mental health and substance abuse
records. Five youth were interviewed regarding their safety plans. all five-youth reported they
contributed to their safety plans. The program director was interviewed and reported the safety
plans for the youth are updated monthly or as needed.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The designated health authority (DHA) is a licensed physician. The DHA holds an unrestricted
license and meets all requirements for independent and unsupervised practice in the State of
Florida. The DHA has a license, which expires January 31, 2026. The DHA has specialty
training in family practice. There was no indication the DHA had any disciplinary cases or public
complaints on record. The program does not employ a physician’s assistant (PA) or advanced
practice registered nurse (APRN). The contract stipulates the DHA must be on-site at least once
a week for a minimum duration of two hours a visit. A review of sign-in/out logs during the
annual compliance review period confirmed the DHA was on-site at least once a week for a
minimum of two hours a week. In the event of a scheduled absence of the DHA, the program
has an established agreement with a licensed physician to ensure continuity of medical care for
the youth. The designated back-up physician holds a valid, unrestricted license, which is set to
expire on March 31, 2026, and satisfies all qualifications for independent, unsupervised practice
in the State of Florida. The back-up physician was not called upon during the annual compliance
review period. The DHA conducted all administrative duties. There was no indication the
program used any type of tele-medicine services during the annual compliance review period.
An interview with the DHA revealed they are on site weekly to perform Comprehensive Physical
Assessments (CPAs), sick calls, and evaluations for ongoing chronic conditions.
Communication with staff while off-site is conducted with text and telephone. All services are
provided by the DHA. The on-site nurse keeps off-site care findings, instructions, and
information readily available for the DHA to review on-site weekly. The healthcare staff and DHA
meet weekly to review the important medical issues pertaining to the youth at the program.
Another DHA is available for coverage when the DHA is on vacation or during scheduled
absences. The DHA does not have concerns with the health care at the program.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a total of two registered nurses (RN) for all on-site coverage. All nurse
licensure credentials were clear and active, according to Florida Department of Health (DOH).
One license is valid through April 2026 and the other is valid through April 2027. All nursing staff
have a current cardiopulmonary resuscitation (CPR) certification, both of which expire February
2027. According to the contract, the required on-site hours for nursing are for the RN clinical
manager to be on-site forty hours a week and additional RNs for sixteen hours a week. On-site
nursing program coverage shall be provided seven days a week for a total of fifty-six hours by
RNs licensed in the State of Florida. A review of the work scheduled confirmed the hours are
met.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The designated health authority (DHA) conducted an annual review of all respective treatment
facility operating procedures (FOP) and signed on January 1, 2025. The program director
subsequently reviewed and signed the treatment FOPs on January 31, 2025. The psychiatrist
and clinical director completed their annual review, signed, and dated the FOPs on February 6,
2025. The dentist finalized their review on February 19, 2025. Both nurses signed and dated the
respective treatment FOPs on January 28, 2025. The FOPs were revised on January 1, 2025.
One newly hired healthcare staff member underwent a comprehensive clinical orientation to the
Department’s health care FOPs, facilitated by a registered nurse. A review of approved
treatment protocols and standing procedures was authorized by the DHA, as required.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
an Authorization for Evaluation and Treatment (AET) form. Each of the five youth had an AET
form stamped with the word “copy” and properly filed within the IHCR, as required. None of the
youth were over the age of eighteen or in the custody of the Department of Children and
Families (DCF). All AET forms contained signatures from the respective parent/guardian, with
no evidence of refusal to sign. Additionally, each AET form was signed by a Department
representative. All AET forms were found to be valid. An interview with nursing staff revealed all
AETs are examined upon admission. If a new one is needed, then case management and the
youth's juvenile probation officer (JPO) are contacted. The AET for eighteen-year-old youth is
conducted on the date the youth turns eighteen.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
the parental notification/consent. An additional youth record was requested for additional
examples of parental notification/consent and was provided for a total of six records reviewed.
Three of six youth were applicable for parental notification of over-the-counter (OTC)
medications beyond those covered by the Authority for Evaluation and Treatment (AET). In each
of the three applicable cases, there was documentation of consent provided by the
parent/guardian. Five of six youth were applicable for parental notification for new medication
ordered. All five applicable youth had written notifications sent to their parent/guardian utilizing
the appropriate Department forms. Four of six youth were applicable for taking psychotropic
medications upon admission, the remaining two youth started psychotropic medications after
admission. For each of the six-youth prescribed psychotropic-type medication, staff witnessed
all telephone call attempts to the parent/guardian, as documented by two nurse signatures in
progress notes. Each of the six youth on psychotropic medication, whether new, discontinued,
or significantly changed, had parental/guardian verbal consent documented on page three of the
Clinical Psychotropic Progress Note (CPPN). None of the six applicable youth reviewed were
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under the care of the Department of Children and Families (DCF). All six youth had
documentation verifying the youth’s vaccinations within thirty days of admission. Three youth
requested the flu shot and verbal consent was obtained by parent/guardian. None of the youth
were required to obtain a religious exemption. An informal interview with on-site nursing
confirmed the program utilizes the Florida Shots website or the Department’s Juvenile Justice
Information System (JJIS) for verification of youth vaccinations. An interview with nursing staff
revealed parental notifications are made for all new orders, with parental consent obtained by
telephone, and notifications also mailed out. These procedures are followed for every new
order. Efforts to notify parents are initiated on the same day the order is received, with additional
attempts made daily until consent is obtained. In cases of youth illness, injury, or life-threatening
situations, 9-1-1 is contacted for urgent care, and staff will escort the youth to the designated
facility as directed by the Department of Health Authority (DHA). All youth undergo an initial
psychiatric evaluation. Those prescribed psychotropic medications are reassessed within two
weeks of admission, while all other youth are assessed within thirty days. Furthermore, all youth
receive a follow-up appointment with a psychiatrist within thirty days of their initial assessment.
Youth on psychotropic medications are seen monthly for ongoing medication management. In
addition to psychiatric evaluations, all youth have access to individual, group, and family
counseling with a mental health therapist. Following any visit or medication change, parental
notifications are sent out, accompanied by a copy of the CPPN.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
the healthcare admission screening and rescreening form. Each of the five IHCR’s contained a
Facility Entry Physical Health Screening (FEPHS) form, which was completed on the date of
admission. All five FEPHS were completed by a registered nurse (RN). None of the FEPHS
were completed by direct care staff. None of the five youth were applicable for a change in
custody lasting greater than twenty-four hours. The nursing staff is the first point of contact for
youth upon arrival at the program and is notified by email prior to intake. Upon arrival, staff
notifies the medical team either by telephone or in person. The registered nurse (RN) conducts
the admission screening. If a youth has been out of the custody of the program for more than
twenty-four hours, a new facility entry screening is conducted upon their return, and medical
staff is promptly notified of their reentry. An interview with nursing staff revealed vaccinations are
not administered on-site. Instead, vaccination records are verified through the documentation
provided with the youth upon intake, as well as by checking the Florida Shots database. The
review of these records occurs on the day of intake. For youth who are exempt from
vaccination, parents must provide an exemption form from the youth’s primary care provider or
health department.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
youth orientation to healthcare/education services. All youth had documentation for the
completion of orientation to healthcare services upon admission to the program. The youth’s
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orientation included all necessary topics and was signed by each youth and healthcare staff,
acknowledging the completion of orientation. Health Education is mandated monthly in the
program’s contract; however, it is consistently conducted every Saturday and Sunday, as
supported by the sign-in sheets for the annual compliance review. These sessions are led by
registered nurses (RNs) and cover all required topics.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
notification to the designated health authority (DHA) and/or designee. Four of the five youth
were found applicable for having a chronic condition. None of the four youth were identified as
in-need of emergency care upon admission. All four applicable youth had documentation of a
referral being sent to the DHA within twelve hours of the youth’s admission. Three of the five
applicable youth were taking psychotropic medication upon admission, while the remaining two
started psychotropic medication after admission. The three applicable youth admitted on
psychotropic medications had documentation of the psychiatrist being notified. An interview with
the nursing staff revealed the DHA is notified on the same day by the nurse for youth admitted
with serious or chronic conditions. These notifications are documented in the progress notes
section of the medical records.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
the Health-Related History (HRH) form. All five reviewed youth IHCRs contained an HRH
completed within seven calendar days of admission. Each of the five HRHs reviewed was
completed prior to completion of the Comprehensive Physical Assessment (CPA); as evidenced
by signature and date. All the HRHs were reviewed by the designated health authority (DHA);
this was indicated by the checkbox on the CPA. An interview with nursing staff revealed the
registered nurse (RN) is responsible for completing the HRH on the same day the youth enter
the program.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of a
Comprehensive Physical Assessment (CPA) form. All the CPAs reviewed were completed on
the Department’s CPA form, as required. All five youth had a current CPA on file at the time of
admission; however, the program’s facility operating procedures indicate a new CPA will be
completed regardless of whether one is in the youth’s IHCR at the time of admission. All five
reviewed CPAs were completed within seven calendar days of the youth’s admission to the
program. Each of the new CPAs was completed by the designated health authority (DHA). All
five reviewed CPAs documented the correct Medical Grade. All five CPAs indicated a
gynecological examination was “refused” and a refusal form was signed by each youth and
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placed in IHCR as required. None of the youth had a gynecological examination completed. All
youth had their signatures documented on CPAs. Each section of the CPA was marked
respectively with an “O” or an “X” accordingly. All five youth had the Department’s problem list
updated, as required. All five youth had at least one verified tuberculosis skin test (TST)
documented in the IHCR. All TST results matched on the CPA and Infectious and
Communicable Disease (ICD) forms. An interview with the nursing staff revealed the DHA
conducts a new CPA for all newly admitted youth, as well as for any youth over twelve months
with a Medical Grade of two or higher. The youth’s medical records are reviewed for
tuberculosis (TB) screenings. If a current TB test is on file, no new test is administered;
however, if the test is over one year old, a new test will be performed. Gynecological exams for
female youth are not routinely conducted.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
sexuality transmitted infections (STI) screening. All five youth were screened and evaluated for
STIs. Three of the five youth were applicable for further evaluation and were referred to the
designated health authority (DHA). All three youth were referred for further testing by the DHA,
and the referral was documented on the STI screening tool. In each of the three cases, testing
was ordered and performed. Each youth had testing, and results documented on the Infectious
and Communicable Diseases (ICD), as required. None of the youth were out of the
Department’s physical custody; therefore, re-screening was not required. All five youth were
offered Human Immunodeficiency Virus (HIV) counseling, testing, and/or evaluation, as
indicated by a signature on “HIV Youth Consent form” with box checked “yes” or “no” for
consent. Three youth consented and received HIV testing. All three youth had HIV results filed
confidentially in a sealed envelope marked “confidential.” Each sealed envelope was signed by
DHA. Each youth received pre/post counseling from a certified HIV instructor from Madison
County Health Department, which was documented in Health Education record. The youth’s
confidentiality was protected by not including the youth’s HIV status and any other STI diagnosis
in the program’s internal alert system. The program had policies and procedures which
addressed HIV testing results and results are only disclosed to youth, and statutorily identified
entities. Interviews with five youth were conducted, and all expressed they could request an
HIV/AIDS test. An interview with the nursing staff revealed youth are screened for sexually
transmitted infections (STIs) using the STI and HIV screening tools. If the screening indicates
the need for further evaluation, the DHA is notified, and an order for additional assessment is
issued to the Madison County Health Department, where an appointment will be scheduled. STI
screenings, evaluations, referrals, and testing are documented on the Infectious and
Communicable Disease form, as well as in the progress, and lab sections of the Individual
Health Care Record (IHCR). If a youth has been out of the program or Department’s physical
custody for more than thirty days and/or presents symptoms, all new screenings will be
conducted. HIV test results are stored in a sealed envelope marked “confidential” within the
youth’s IHCR. For any youth who requests and signs consent for HIV testing, an order is written
and scheduled with the Madison County Health Department. Pre- and post-counseling is
conducted using the form provided by the health department. The Madison County Health
Department is responsible for conducting the pre-counseling, testing, and post-counseling. The
entire process is documented in the education section of the medical records, within the
Infectious and Communicable Disease section.
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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.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
sick call process. Three of five youth records were applicable for the sick call review. None of
the reviewed youth presented with similar sick call complaints three or more times within a two-
week period. Eight sick calls were reviewed; the youth completed an individual Sick Call
Request form each time. In each of the sick calls, the nurse completed the Sick Call Request
form. All eight of the sick calls reviewed were completed by the registered nurse (RN). The sick
calls were each found filed in the IHCR in reverse chronological order. None of youth had been
in restricted housing during the annual compliance review period. The reviewed sick call forms
were documented in accordance with the Florida Administrative Code. Each sick call reviewed
was documented on the Sick Call Index. All the sick calls were documented on the program’s
Sick Call Referral log. The dates listed on the Sick Call Index corresponded to the completed
Sick Call forms located in each IHCR. A review of the daily schedule, along with the posted
schedule and nurses’ interviews, confirmed sick call was conducted as required by contract
requirements. Sick call hours were posted outside the medical clinic and in each wing. Sick call
is available seven days a week, starting at 7:30 a.m. and as needed. Licensed nurses will
conduct sick if available; however, the program has procedures whereby the shift supervisor
reviews all sick call requests as soon as possible and within four hours after the request is
submitted. Sick call forms are available to youth in each wing and nurse’s office. An exam table
and equipment are used to perform sick calls. No sick calls occurred during the on-site annual
compliance review. Five youth were interviewed, and each reported they could see a nurse
within one day of submitting a sick call request. Nursing staff interviews revealed in the case of
emergencies, staff immediately contact medical personnel to assess the youth. For non-
emergent issues, youth are required to submit a sick call. Sick calls are reviewed every morning
after breakfast. Registered Nurses (RNs) routinely handle sick calls, while the Designated
Health Authority (DHA) manages them when on-site and scheduled. Sick calls are documented
in the sick call index, sick call log, sick call form, and progress notes. Sick calls are conducted
each morning starting at 7:30 a.m. and continue until completed. If a youth submits three or
more sick calls within a two-week period, they are added to the list to see the DHA. The
program adheres to approved treatment protocols and does not utilize restricted housing or
confinement.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
an episodic, first aid, and/or emergency care situation. All five youth required on-site episodic
care. Each of the twenty-one medical incidents was conducted by licensed healthcare staff. The
healthcare staff documented each case in subjective, objective, assessment, and plan (SOAP)
format. There were no cases of episodic, first aid, or emergency being provided by non-
healthcare staff. The program’s episodic and emergency care procedures were reviewed with
no issues. There is a total of nine first aid kits, two of which are utilized for transportation. First
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aid kits are in both youth wings, in the medical cart closet in gym, kitchen, large trailer, and small
trailer. Additionally, the program maintains five suicide kits located in both wings, supply closets,
and medical cart closet in gym. On-site healthcare staff confirmed a monthly review of first aid
kits is conducted to ensure contents are maintained and stored in accordance with guidelines to
prevent expiration and are replenished as needed. A review of three first aid kits located in the
medical cart closet in the gym confirmed kits are fully stocked with designated health authority
(DHA) approved contents. Additionally, a review of monthly tracking sheets demonstrated on-
going monitoring of first aid kits occurs as required. The program has one automated external
defibrillator (AED) and is kept in medical cart closet in the gym. The operating procedures for
the AED are located with the AED and in the medical office. On-site medical staff check the AED
to ensure the batteries and pads are operable, as evidenced by their daily log sheets. There is
no indication the AED is monitored by an outside provider. The medical staff conducted a self-
test on AED with no issues, and the AED had a green battery indicator light. The AED batteries
are due to expire January April 30, 2026, and were last changed January 11, 2023. The AED
pads are due to expire on April 30, 2027, and were last changed on February 1, 2025. A list of
emergency numbers was found in the medical office, accessible to all staff and inaccessible to
youth. A sign in sheet confirmed the director of nursing (DON) trains direct care staff on the
administration of the epinephrine auto-injector. A total of five staff training records documented
the completion of episodic, first aid, and emergency care training. A review of the program’s
episodic, first aid, and/or emergency care drill documentation reflected drills were completed on
each of the four shifts. These drills were performed monthly throughout the annual compliance
review period and were thoroughly documented and stored in the medical drill binder. All direct
care staff participated in at least one drill, which included cardiopulmonary resuscitation (CPR)
procedures. A video review of five medical and suicide drills revealed one drill was simulated,
while the other four were discussed with staff. The simulated drill effectively demonstrated an
episodic care event, requiring immediate first aid, CPR administration, and the initiation of
emergency protocols for life-threatening situations. The program maintained accurate
documentation for all emergency drills, which were unannounced and conducted quarterly on
each shift as specified in the contract. No episodic care events occurred during the on-site
annual compliance review. The program maintains Narcan policies and procedures concerning
its use and accessibility. During the annual compliance review, it was confirmed healthcare staff
conduct a weekly inventory of Narcan. Narcan is stored in five suicide kits, one in the
breakaway medical cart closet, and the remaining in a locked medical office cabinet. All staff
receive both initial and annual training on the use of Narcan and are provided with access to it.
An interview was conducted with five staff regarding 9-1-1 procedures. All five staff confirmed
they are authorized to call 9-1-1 in the event of a youth’s medical emergency. Additionally, two
staff indicated they would first notify medical personnel, while the remaining two stated they
would notify their supervisor first. Five youth were also interviewed, and all reported they have
access to a doctor, or dentist when needed. An interview with the nursing staff revealed on-site
episodic care is documented in the episodic log, the episodic form, and the progress notes
within the medical file. For non-health care issues, documentation is completed on the
Department form and submitted to medical. All emergency room paperwork is stored in a folder
for review by the DHA. After-hours paperwork is placed in the medical box for the nurse to
review during their next shift. Follow-up appointments are scheduled as necessary. The program
has an AED located in the medication closet in the gym. AED procedures are outlined both with
the AED and in the first aid log. The AED is checked by registered nurses, with the battery
expiration date set for April 30, 2026, and the pads expiring on April 30, 2027. The last
replacement of the batteries and pads occurred on February 1, 2025. The emergency drill
schedule for the year has been completed, and CPR training is conducted every three months
during each shift. Emergency contact numbers are posted in the medical office and are not
accessible to youth. Emergency drills are conducted by each shift monthly.
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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.
A review of five youth Individual Healthcare Records (IHCRs) was conducted to assess the
completion of off-site care referrals. Three of the youth were applicable for off-site care referrals,
and all three IHCRs indicated the need for some form of off-site care. For each instance of off-
site care provided, a Summary of Off-Site Care Consultation Report form was appropriately filed
in the respective youth’s IHCR. None of the cases required off-site emergency care. Additionally,
parental notification efforts were not required in any of the cases, as they involved human
immunodeficiency virus (HIV) testing. All three cases included discharge documents, and the
designated health authority (DHA) reviewed and signed off on the off-site care findings.
Furthermore, all three youth required follow-up appointments, which were properly arranged and
completed. An interview with nursing staff revealed all emergency room (ER) paperwork is
stored in a designated folder for review by the DHA. After hours, all paperwork is placed in the
medical box for the nurse to review during the next shift. Follow-up appointments are scheduled
as needed. All documentation is brought to the medical office and stored in a folder for the
DHA’s review, while the registered nurse (RN) ensures all orders are followed, notifying the DHA
of any new orders. The paperwork remains in the folder until reviewed by the DHA and is then
filed in the medical records. Nursing staff track follow-up testing, referrals, and appointments
using the referral log, appointment calendar, and chronic log.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
chronic condition periodic evaluations. Four youth were found applicable for having a chronic
condition. All four youth were identified during the Facility Entry Physical Health Screening
(FEPHS) upon admission. None of the youth had been identified as having a communicable
disease. All four youth were taking medication on an on-going basis. One of the four youth were
undergoing treatment for a physical health condition. One of the four youth were classified with
a Medical Grade between two and four. None of the youth were identified as pregnant. All four
applicable youth were placed on the chronic list. The four applicable youth received a periodic
evaluation at least every ninety-days as required. There was no indication of any youth requiring
anti-Tuberculosis medication. Two of the four youth were applicable for renewing prescription
medication. Both youth had periodic evaluations conducted prior to renewing a prescription
medication which expired. None of the youth required an evaluation to be conducted off-site;
therefore, a designated health authority (DHA) follow-up was not required. There were no
indications of lapses in care or missed periodic evaluations. All four youth had the Department’s
Problem List updated in accordance with Florida Administrative Code. An interview with the
program director revealed weekly meetings, along with additional face-to-face meetings as
necessary, are conducted with healthcare staff to address key medical concerns of the youth.
According to an interview with the DHA, periodic evaluations for youth with chronic conditions
are carried out and monitored every ninety days or sooner. The on-site nurse is responsible for
tracking visit schedules to ensure all youth with chronic conditions receive the required
evaluations within the specified timeframes. Nursing staff further indicated every youth with a
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chronic health condition is added to the chronic log and receives a follow-up evaluation every
three months, or more frequently as needed.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
medication management. All five youth were found applicable for receiving medication at the
program. All five youth had a completed Facility Entry Physical Health Screening (FEPHS) form.
The FEPHS form indicated three of the five youth were admitted with medication. In addition,
prescription verification was included in each of the three youth’s progress notes and the
prescription medication verification checklist. The designated health authority (DHA) and
psychiatrist were contacted to resume the specified medications prescribed prior to admission.
All prescribed medications for each of the five youth had a current valid order and were
administered according to valid prescriptions. All medications prescribed had a practitioner order
form completed by the DHA. The program does not have restricted housing. Two of the five
youth were applicable for being prescribed over-the-counter (OTC) medication not listed on
Authority for Evaluation and Treatment (AET) form and were administered according to
approved protocols or the Practitioner’s Order unless the parent/guardian prohibited the
administration of OTC medications. The Department Medication Administration Record (MAR)
was used to document all medications and treatments for all reviewed IHCRs, which included all
information required by Florida Administrative Code. None of the five youth were applicable to
receive medication from non-healthcare staff. The program adheres to a policy requiring both
healthcare and non-healthcare staff to initial each medication administration entry, alongside the
youth’s initials. A review of all MARs confirmed all entries were appropriately initialed. There
were no instances of undocumented explanations for lapses or errors in medication
administration. Each youth had documented weekly side-effect monitoring, as required, on their
MAR. Each of the five youth was applicable for one refusal of medication, with none of the
refusals occurring on the same day. In each case, the refusal treatment form was signed and
properly filed in the youth’s IHCR, as required. Each refusal was clearly documented on the
MAR. All five youth had multiple MARs completed during the annual compliance review period
and a review revealed each had all required elements. None of the reviewed youth required
parenteral medication. Three of the five youth reviewed were applicable for having prescribed
psychotropic medication upon admission to the program. Although only three youth were
admitted with psychotropic medications, all youth will undergo an initial diagnostic psychiatric
interview. Documentation in the IHCR confirms the psychiatrist was notified of the admission of
all five youth. Each of the five youth received an initial diagnostic psychiatric interview within
fourteen days of admission. Three youth were initially prescribed psychotropic medications,
while two were prescribed these medications after admission. All five youth receiving
psychotropic medications underwent medication monitoring every thirty days, as required. There
were no standing orders for psychotropic medications observed. There was no indication of any
emergency treatment orders for psychotropic medications observed. There was no indication of
any pro re nata (PRN) orders for psychotropic medications observed. A medication
administration pass was observed during the annual compliance review. The youth was
escorted to the medical clinic by direct care staff. The youth approached the nurse administering
medication individually. The medical staff identified themselves and the purpose for the youth’s
visit. In addition, the medical staff asked for the youth to identify themselves by providing their
name, date of birth, and allergies. The medical staff also prepared the medications and
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reviewed any allergies and alerts with the youth. The Six Rights of Medication Administration
were observed to have been conducted by the medical staff administering the medication. The
prescription medication was never pre-poured from its original packaging and placed in another
container for subsequent administration. The medical staff provided the youth water and
medication. The youth took the medication along with the water and swallowed the pill. The
medical staff had the youth open their mouth and performed a visual check. The medication
pass was documented on the youth’s MAR. An interview was conducted with five youth
regarding medication administration. One youth reported receiving medication from the nurse,
while the remaining four indicated they do not take medication. A separate interview with nursing
staff confirmed only the registered nurse (RN) verifies medications. All youth admitted with
medications undergo verification with the pharmacy, and this information is recorded on the
Department form. The standard Department MAR is utilized for this process. All staff members
receive training on medication administration upon hire, with annual updates. Medication
administration occurs three times daily. Routine gynecological exams are not performed for
female youth at the program. The program holds a modified Class II permit. Written
prescriptions are provided by the DHA or psychiatrist, then faxed to the pharmacy, from which
medications are mailed by First Pharmacy. Upon admission, all youth receive an initial
psychiatric evaluation. Those on psychotropic medications are reassessed within two weeks of
admission, while others are evaluated within 30 days. Additionally, all youth are scheduled for a
follow-up appointment with the psychiatrist within 30 days of the initial assessment. Youth on
psychotropic medications are seen monthly for medication management. Beyond psychiatric
evaluations, all youth receive individual, group, and family counseling sessions with a mental
health therapist. No separate fee is charged for these services.
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 equipment in the medical clinic classified as sharps was observed to be secured and
inventoried utilizing a routine weekly perpetual inventory. Three sharps were observed and
counted, and the final count listed on the program’s inventory matched the actual count
observed. All observed medications were identified and secured in locked area designated for
storage of medications. The medication cart was observed to be clean and organized. Three
over-the-counter (OTC) medications were observed and counted and the final count listed on
the program’s inventory matched the actual count observed. There were no controlled
medications on site during annual compliance review period; however, an observation verified it
would be stored behind two locks as required. There were no medications which require
refrigeration on site during annual compliance review period; however, an observation of
refrigerator was made which is used for medication only. Supervisory-level, non-healthcare staff
are trained by the director of nursing (DON) in the delivery and oversight of medication
administration. A review of the sign-in sheet confirmed training was conducted on December 9,
2024, for nine supervisors and team leads. The program’s process for the destruction and
disposal or return of expired or discontinued medications is go to the pharmacist if it came from
the pharmacy. The pharmacist visits the program monthly. If the medication did not come from
the pharmacy, then nurse and pharmacist will destroy medication and document it. If there is a
discrepancy with inventory, then the nurse will try to reconcile count. If there is still a
discrepancy, the program director will be notified, and a call to the Department’s Central
Communications Center (CCC) will be completed. An interview with nursing staff confirmed all
routine prescription medications which are discontinued are returned to the pharmacy.
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Controlled medications are disposed of in a destroyer drug bottle in the presence of the
pharmacist and nurse. These controlled medications are securely stored in a locked, two-tiered
cabinet on the medication cart. The program maintains an active agreement with a consulting
pharmacist, who conducts monthly visits and performs quarterly and annual inspections. The
pharmacist also provides assistance with updates and addresses any concerns. Additionally, the
program keeps a current copy of the pharmacy consultant’s license 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 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’s infection control procedures include prevention, containment, treatment, and
reporting requirements related to infectious diseases, according to federal regulations and the
Centers for Disease Control (CDC) and Prevention guidelines. The infection control procedures
and exposure control plan were reviewed last by the designated health authority (DHA) January
31, 2025, by the program director January 1, 2025, by the health service administrator (HSA)
January 28, 2025, and registered nurse (RN) January 28, 2025. The infection control practices
included all required elements. Hepatitis B immunizations and protective equipment is available
to all staff. There were no instances in which the local county health department, Centers for
Disease Control and Prevention (CDC), and/or the Department’s Central Communications
Center (CCC) had to be notified for an infectious disease during the annual compliance review
period. The program has an exposure control plan. The written exposure control plan included
all required elements, in addition addresses a process for post- needle stick exposure. The
exposure control plan is available to all staff and located in the medical clinic and program
director’s office. The program director has an established separate file maintained for any youth
or staff who may have experienced a facility and or occupational exposure. An interview with the
program director confirmed the exposure control plan is available in each office and is reviewed
with staff annually, as well as whenever changes occur. Nursing staff further confirmed the
exposure plan is maintained within the medical office. The director of nursing (DON) is
responsible for providing infection control training to staff, which is completed during intake and
as needed. The RN conducts annual training for new hires on the exposure control plan. The
Madison County Health Department offers immunizations, HIV testing, STD testing and
treatment, as well as prenatal care. Bulk medications are securely stored in a locked cabinet
within the medical office, with a weekly count performed. A small supply is kept on the
medication cart, which is counted daily.
4.19 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for prenatal care
and education. None of the youth were applicable for completion of prenatal care or education.
Three additional youth records were requested, and one was applicable and provided. Upon
confirmation of pregnancy, the applicable youth immediately began prenatal care, which
continued until discharge from the program. The designated health authority (DHA) provided
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routine care, including medical evaluations every thirty days or sooner if necessary. The youth
was placed on the internal alert system to ensure staff were informed of her nutritional and
health needs. Additionally, an alert was entered regarding the youth’s sleeping arrangements.
The youth was offered human immunodeficiency virus (HIV) testing but declined, as
documented by the signed HIV consent form. The youth did not report any pregnancy-related
issues; however, the DHA would have been notified immediately if any arose. A plan for post-
birth psychological and physical care was documented in the youth’s IHCR. Prenatal care was
provided at the recommended intervals, and the youth received nutritious food in quantities
suitable for a pregnant individual, as ordered by the practitioner. Licensed healthcare
professional staff conducted daily monitoring of the youth’s nutritional and weight status
throughout the pregnancy. The youth’s education included all necessary topics, and both the
youth and healthcare staff signed to acknowledge the completion of prenatal care education. All
educational content was recorded in the youth’s IHCR as required. Non-healthcare staff
involved in the supervision or treatment of pregnant youth participated in annual in-service
training on healthcare for girls. A licensed nurse provided this in-service education, which
included observation and monitoring for emergency care needs or symptoms of potential
miscarriage. The program maintains nursing protocols and treatment plans specific to pregnant
youth. An interview with nursing staff revealed prenatal education is provided through various
services. Additionally, education is provided by a nurse at the program. Female youth are
routinely tested for pregnancy upon admission. All pregnant youth are referred to the Madison
County Health Department for prenatal care. The program also conducts daily and weekly
monitoring of pregnant youth. These youth are provided with a special diet, and the director of
nursing offers educational programs for non-licensed healthcare staff on topics related to girls’
health. This includes pre- and postnatal care, alcohol and drug use, smoking, sexually
transmitted infections (STIs), birth control, the birthing process, baby and child/infant care, as
well as parenting skills.
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Standard 5: Safety and Security
Satisfactory
5.01 Youth Supervision (CRITICAL) Compliance
<---Update--->
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures which addresses youth supervision, movement, and
checks. The program’s policy indicates program staff shall maintain active supervision of youth,
including interacting positively with youth, engaging in a full schedule of activities, closely
observing behavior of youth, and changes in behavior, while consistently applying the behavior
management system. The program’s ratio requirement of staff to youth is one to eight for
daytime activities, and one to twelve during sleeping times. Observations were made each day
of the annual compliance review which found youth and staff adhering to the posted daily
activity schedule. Youth were observed in classes, at mealtimes, in line movements, recreation,
and during searches. Observation also confirmed staffs supervision of youth in their sleeping
areas. Youth room windows were not covered and staffs line of sight was not affected. Positive
interactions were observed between youth and staff. Random informal interviews with three
separate staff were done and found each staff was able to give an accurate count of youth
under their direct supervision at the time. Video observation of youth supervision indicated the
youth were being watched while inside their dorm rooms during sleeping hours.
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’s behavior management system (BMS) was observed to be documented within the
program’s policy and procedures, youth handbook, and seen posted on walls in living areas.
The BMS was reviewed within the provider’s contractual agreement and revealed all appropriate
parties were involved in the development, implementation, and on-going maintenance of the
BMS. The program’s policies include a protocol where staff are provided feedback regarding the
implementation of the BMS. There is an agreement between the program and the school related
to the BMS. The program’s training coordinator is responsible for training all program and
education staff on the BMS. Five applicable pre-service records were reviewed and found the
staff received BMS training as part of their pre-service training requirement. Each of the five
reviewed youth case management records included evidence each youth was orientated on the
program’s BMS after admission. Samples of five position descriptions were reviewed, each of
these position descriptions detailed job functions which included implementation of the
program’s BMS. The program’s BMS was posted in areas accessible to youth which included
rules governing conduct and positive and negative consequences. The program’s BMS has not
changed from the previous year. The BMS includes all required information such as promoting
safety, respect, and fairness. The BMS also includes recognition of accomplishments and
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positive behaviors at a five to one ratio, a process for youth to explain behaviors, and
opportunities for staff to discuss with youth the impact their actions have on others as well as
alternate acceptable behaviors. The BMS does not include promotion of group discipline,
increased length of stay, denial of a youth’s basic rights, punishment by other youth, or
disciplinary confinement. The program provides a variety of rewards such as Purple Room,
snack times, outings, and education incentives. The program director was interviewed and
stated the BMS used is the Measurable Achievement Plan (MAP) system. It is an incentive-
based system which allows youth to know their status in the program daily along with being
provided incentives for all achievements made daily. The system consists of five levels in which
the youth have to petition their peers and the treatment team for advancement from level to
level. Rewards are monitored by the director of student services. The program ensures the
practice takes place daily in the daily meeting with the youth at which time the youth have the
opportunity to discuss with all staff and issues or concerns they may have. The program director
reported consequences are tracked daily to ensure consistency. The program uses an internal
fidelity check tool to monitor the process. It is also monitored by the program director and
treatment team. Each of the five interviewed staff reported they received BMS training. All five
were able to summarize the BMS process. All five staff gave examples of rewards a youth may
receive such as extra telephone time, Fun-Friday, movie nights, Purple Room, outings, and
school incentives. None of the interviewed staff reported anything can be taken away from a
youth as a result of a consequence. All five interviewed staff reported supervisors provide them
feedback on their implementation of the BMS through face-to-face meetings, counseling, and
evaluations. Five interviewed youth were able to summarize the program’s BMS and provide
examples of rewards and consequences they may receive. All five youth stated the system
consists of obtaining points and rising through levels by completing a checklist for each level.
None of the five-youth stated youth were allowed to punish other youth. All five youth reported
staff are consistent with rewards and consequences
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a total of forty-three cameras, all of which were operating as required
according to the program administration. Video recordings are stored for up to thirty days. The
program operates on a night and day shift. A sample of security tapes were reviewed for each
shift. A total of eight time period increments, covering both night shift rotations were reviewed
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and found each check was conducted by staff at or within ten-minute increments. Staff were
observed documenting on logs and using flashlights when walking down youth living area
wings. The program has a total of two separate wings which youth are assigned. No
discrepancies were observed. A sample of logs were reviewed for the annual compliance review
period for both living areas. The sample included a review of these logs for each month of the
scope of the review. Twenty-four total logs were reviewed with thirty-minute timeframes each.
All were documented at or within ten-minute increments as required. Staff initialed by each
entry. Documentation was completed in real-time as required. There were no discrepancies
identified. Each of the five interviewed staff all reported checks for youth during sleep times are
done so at or within ten-minute increments. The program director was interviewed and reported
there are forty-three operational video cameras at the facility.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program has a policy and procedures outlining the requirements for youth census, counts,
and tracking of youth. Formal and informal youth counts are done throughout each day. Formal
headcounts are conducted every hour and informal head counts are conducted every half hour
or upon each youth movement. Observations of formal headcounts were made during the
annual compliance review week. One day for each month of the annual compliance review
period was reviewed within the master logbook. The logbooks reviewed found counts were all
completed each shift daily and at multiple times throughout the workday. Formal counts are
done at the beginning of the shifts, after youth movement from classes, outdoor activities, during
emergency situations, and when youth were temporarily away from the program. Five staff were
interviewed. All five stated headcounts are done at every youth movement. Emergency counts
may be done at times such as fire, natural disasters, or when a youth is missing and not
accounted for. All five interviewed staff were able to give the program’s current youth census
count.
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 one master logbook, which is maintained by the shift supervisor or direct
care staff. The logbooks used were observed bound with numbered pages. Entries were made
in ink with no white-out or erasure signs. No pages were observed to be destroyed or removed.
Logbooks were provided for the scope of the annual compliance review. Errors observed were
marked through with a single line as required. One full twenty-four-hour day for each month of
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the annual compliance review was reviewed and found no discrepancies. Logbook
documentation reflected youth counts, youth arrivals, adherence to the daily schedule for
recreation, mealtimes, and education activities. All entries included the dates and times of
events, with the names of the staff and youth involved, brief description of events, and the
names of staff making the entries. Incidents requiring a report to the Florida Abuse Hotline or
the Department’s Central Communications Center (CCC) was accurately documented. Logbook
reviews were also documented in a different ink color by the staff or supervisor reviewing the
logbook. Significant events were highlighted for easier identification. Logbook information
included all required events such as emergency situations, special instructions, population
counts, security checks, transports, admissions and releases, and perimeter and security
checks. In addition to the logbook, the program completes a Shift Report for each shift which
documents the total population count, youth alert information, and significant events. Staff
oncoming to the shift sign a review of the shift report. Shift reports were maintained in the two
separate wings of the youth assigned areas for at least forty-eight hours. Completed shift
reports were maintained in the director of student services’ office. A review of completed shift
reports was done for the annual compliance review period, which confirmed the program’s
practice of completing these reports as required.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures for key control which includes key assignment and
usage, including restrictions on usage. The policy also notates inventory and tracking of keys,
secure storage, procedures for missing, or lost keys, and reporting and replacement of
damaged keys. Personal keys and visitor keys were observed taken up by supervisors and
stored in a secure storage box located in the lobby of the program. The personal keys were
replaced with a numbered chit. Upon arrival to the program, direct care staff are required to turn
in their personal keys and replace them with their assigned facility keys. This assignment is
notated on the daily tracking Key Inventory log which is signed by the staff and supervisor and
indicates the date and time in and out of the keys, as well as the key ring issued. According to
an informal interview with the director of student services and human resources staff,
permanent keys are assigned in writing by the program director. Permanent keys, which are
also called Twenty-Four Hour keys, are assigned to designated staff and monthly checks are
done for these keys. Documentation of these monthly checks were done for the annual
compliance review period, which confirmed the program’s practice. Restricted keys, such as
case management, medical, mental health, and administrative keys are documented in the key
log and permanently assigned to those staff authorized by the program director to maintains
those keys. Direct care does not have access to those keys. A review of the Department’s
Central Communications Center (CCC) reports for the annual compliance review period found
no incidents of lost or missing keys. A sampling of key rings was observed and compared with
the inventory and key log, which confirmed all keys were in their required location and matched
the key number and total number of keys listed. Three random staff were questioned regarding
their work issued keys. Each staff had the correct keys as notated on their signed key log and
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stated they knew the function of each key on the ring assigned. All five interviewed staff were
able to summarize the program’s key control process.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures which outlines contraband, defines items considered
contraband, and lists consequences and search procedures within the program. The program
provides a list of items considered contraband to each youth. Youth are given this in the student
handbook upon admission to the program. The policy also outlines searches of the facility
grounds, searches of youth, staff and visitors, and incoming, and outgoing mail. The program’s
policy addresses any staff who is found in possession of contraband in the program will be
subject to disciplinary action up to and including dismissal. Law enforcement is contacted in the
event any item found would be considered illegal as defined in Florida Statutes. The program
documents the confiscation of contraband and maintains the documentation on search forms
and within the youth management records in the event contraband is found. Random searches
are done daily and documented in the logbook and on program area search forms. The forms
were observed for the annual compliance review period which confirmed the program’s practice.
An interview with the program administration and a review of the Department’s Central
Communications Center (CCC) reports for the annual compliance review period was done and
found no report of illegal or non-illegal contraband. The program director was interviewed and
stated contraband items will be confiscated and delivered to the shift supervisor for proper
locking and storage and/or elimination. Visitors in possession of contraband will be asked to
lock the items in their vehicle and leave the facility. Illegal contraband will be quarantined until
law enforcement is called and arrives on-site to investigate. A review of all seven newly hired
staff was conducted. All seven new staff had signed attestation forms in their record. The
program maintains a visitor logbook containing a contraband attestation statement. Five
interviewed staff summarized the search process for youth rooms and reported searches are
done daily.
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5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a policy and procedures outlining searches of the youth, staff, and
facility grounds for contraband items. Youth searches were observed during the annual
compliance review week, when youth were seen moving from one location to another. Staff of
the same gender were observed performing the searches. Youth were treated with dignity and
respect. The program performs searches prior to youth being moved from one place to another,
and for youth transports, and after visitation. Youth searches were observed in compliance with
the program’s policy requirements. Five interviewed youth all confirmed staff perform searches
at every youth movement. Five interviewed staff also confirmed searches are done at every
movement. Visitor searches were observed each day of the annual compliance review. Staff of
the same gender performed the searches. Visitors were asked to remove items from pockets,
remove shoes and jackets. A hand-held metal detecting wand was used in this process. In
addition, visitor bags and cases were also checked by staff prior to entering the program areas.
Video observations indicated all youth, staff, and visitors were searched upon entering into the
facility. Each person was pat searched by a staff of the same gender, a wand device was
utilized to assist with detecting metal objects, and all bags were searched before entry into the
secured area was allowed.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a policy and procedures regarding transportation of youth and the
maintenance of vehicles used in these transports. Five random vehicles were inspected which
ensured they were secured in the program’s parking lot as required. The program has two vans
used to transport vehicles; these two vehicles were also found secured when not in use. Each
vehicle door could not be accessed by the youth inside being transported. Each vehicle had an
updated annual safety inspection which documented items checked as well as correction of any
deficiencies identified during the inspection. Maintenance records are maintained by the
program’s maintenance staff. Both vehicles have an approved first aid kit, approved by the
designated health authority (DHA). These kits are maintained in the program when not being
used during transports. In addition, both vehicles had an approved fire extinguisher, seatbelt
cutter, window punch, appropriate number of seat belts, flashlight, and roadside emergency
equipment. Weekly safety inspections are done by the maintenance staff. Van keys are kept in
a secure locked box.
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5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a policy and procedures regarding the transportation of youth and
vehicle maintenance requirements. The program issues a cellular telephone on transports of
youth. The cellular telephone is in the human resources office at the front of the main building. A
driver’s license check is conducted by human resources upon initial hire and once a month
thereafter to ensure all staff operating a program vehicle have a current driver’s license. The
ratio for transportation is one staff to five youth (driver not included). A transportation was
unable to be observed during the annual compliance review week due to no transports being
completed. Five youth interviews confirmed seatbelts are used when transporting. All five
interviewed youth reported they feel safe when being transported by staff. None of the five
interviewed youth expressed they have witnessed someone place contraband in a transport
vehicle. Five interviewed staff all confirmed they are provided a cellular telephone on transports.
All five gave examples of safety equipment provided as well, which included items such as first
aid kits, road flares, snacks, and club bar lock. All five staff denied they are allowed to use
personal vehicles to transport youth. All five confirmed vehicles are searched prior to and after
each use. All five were able to explain the emergency response process during vehicle
transports.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a policy and procedures outlining the Weekly Safety and Security Audit
inspection process. The program’s maintenance staff maintains the facility weekly inspection
forms which detail inspections of all program areas for proper functioning. The director of
student services and maintenance staff person are primarily responsible for completing the
weekly security audits and safety inspections. The documentation is captured using the
Department’s Facility Security Audit and Safety Inspection form. The forms are done weekly,
every Tuesday. A review of this documentation was done for the annual compliance review
period which confirmed the program’s practice. The development and implementation of any
corrective actions warranted for areas of concern were observed documented on the
corresponding forms. The program had no outstanding deficiencies at the time of the annual
compliance review week. The program director was interviewed and stated the process for
identifying and tracking safety and security deficiencies are done through weekly safety and
security audits and perimeter checks.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures addressing tool inventory and management of
tools. Class B tools such as brooms and mops are maintained in two secured closets clearly
marked outside each door prohibiting youth form entering. The class B tool inventory was
maintained in both these locations daily by direct care staff. All class A and remaining class B
maintenance tools are maintained secured in an outside storage building, which also serves as
the maintenance staff person’s office. The tools are inventoried daily for class A and weekly for
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class B tools. In addition, when tools leave the building, the maintenance staff signs them in and
out on a perpetual inventory form. All inventory forms were reviewed which confirmed the
program’s practice. Ten percent of tools in the storage area were observed to compare with the
inventory log. A total of thirteen tools were completed for review. Each was found secured and
on the inventory form. All tools had an identifying marking on them which matched the inventory
form. In addition to the maintenance tools, kitchen knives were also observed to be secured in
the kitchen area. The dietary staff provided documentation showing these items are inventoried
daily. All knives were accounted for. Each had a corresponding identifying number as well for
easy identification. The program’s policy and procedures prohibit machetes, bowie knives, or
other long bladed knives. In the event a tool goes missing it is reported to shift supervisor,
master control, and administration, the program goes on lock down until the tool is found in
area, and if not found, a report to the Department’s Central Communication Center (CCC) is
made, and a full program search is conducted.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures regarding the handling, inventory, and storage
of tools. Vocational tools are used by youth are done so at a one staff to five youth supervision
ratios. The policy outlines all requirements to include ratio, tool distribution, and supervision of
youth when using tools. Observations of youth tool usage were unable to be made during the
annual compliance review period. Youth who have been given permission to utilize tools have
successfully passed a training for the tool usage and have an approved risk assessment
completed by the treatment team. A sample of five youth were reviewed and found each had a
verified tool usage form for class B tools and an updated risk assessment. Five interviewed
youth all reported they only have utilized brooms and mops in the program. Five interviewed
staff all reported youth use only class B tools such as brooms, mops, and scrub brushes.
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’s policy and procedures for outside contractors includes requirements for outside
contractors to receive written instruction detailing tool management and contraband, as well as
confining work to authorized areas only. Guidelines include tool check-in and out, tool
restrictions, missing tool follow-up, and restricting youth from work areas. The program’s
maintenance staff person is responsible for escorting all outside vendors within the program
areas. A review of outside contractor sign-in forms found evidence tools were signed in and out
and checked by program staff as required. A review of three invoices for projects completed
was done which matched dates for outside contract sign-in forms reviewed and included all
required elements.
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.
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The program practices emergency drills such as fire drills and Continuity of Operations Plan
(COOP) drills once a month on each shift. Reviewed drill documentation included all
requirements including a list of participants, brief scenario, and recommendations, or corrective
actions needed. All drills were maintained in a marked drill binder. A review of this
documentation for the annual compliance review period was done and found fire drills and
COOP drills were done monthly for all shifts with no exceptions noted. Fire evacuation and
egress routes were clearly posted within all program areas of the facility. The program has a
total of twenty fire extinguishers, provided documentation showed all twenty extinguishers had
their annual inspection completed on November 22nd, 2024, by Fire Protection Systems. Each of
the five interviewed staff confirmed they have participated in various drills over the past year.
Five interviewed youth all reported they have participated in drills and been instructed by the
program as to what to do in the event of a fire. The program director was interviewed and
reported monthly medical, fire, mental health, and COOP drills are completed at the program.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program has a Continuity of Operations Plan (COOP) available in all offices at the program.
The COOP was last approved by the Department’s Office of Residential Services April 9th,
2024, and approved by the Department on May 2nd, 2024. The program’s COOP addresses
alternative relocation sites approved by the Department. The program administration reported
they have utilized COOP procedures during the scope of the annual compliance review, as they
underwent two evacuations earlier in the annual compliance review period due to inclement
weather conditions in the area. There were no issues reported for the evacuation process.
Emergency supplies and equipment are in the director of student services’ office closet area
and in the attic space above the gym. The program maintains a hard copy binder which includes
all required demographic, legal, and medical information for each youth. The program
administration reported, this binder is used, along with all youth medical, mental health, and
case management records in the event an evacuation occurs. The program director was
interviewed and reported the COOP is provided in all offices, and it is available for all staff.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains a policy and procedures for the storage, inventory, and disposal of
flammable, poisonous, and toxic items and materials. According to the maintenance staff, no
gasoline is maintained at the program. All toxic chemicals and cleaning agents are maintained
in secure locations which are inaccessible to youth. Areas used to store these items are as
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follows: the kitchen, storage closets on youth living area halls, and outside maintenance shed.
Each area was observed secured. An inventory of ten percent of items in each area was done
and found each contained a daily perpetual inventory which matched the corresponding item, as
well as a Safety Data Sheet (SDS). There were no discrepancies observed. An SDS binder was
located with each area used to maintain these toxic items. Within the binder, there was a list of
position titles who were authorized to handle or dispose of any chemicals. These positions
included the maintenance staff, floor manager, program director, and director of student
services. According to the maintenance staff, disposal procedures are done so through policy
and procedures as well as the SDS. All dirty mop water is poured down standard plumbing
drains. Kitchen grease is disposed of in a grease vat located outside the program building.
The medical staff maintains a contract with Brooks Environmental Bio-Medical Waste, who
comes monthly to the program to collect all bi-hazardous waste, which was observed clearly
marked and secured within the medical office. The medical department maintains these records
within a disposal log binder. The maintenance staff stated there had been no disposals during
the annual compliance review period, but if the facility were to be in need of a disposal, they
contract with Waste Management.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedures for the storage, inventory, and disposal of
flammable, poisonous, and toxic items and materials. According to the program’s policy, youth
shall not be permitted to use, handle, or clean with dangerous, or hazardous chemicals,
respond to chemical spills or clean, handle or dispose of any person’s biohazardous material,
bodily fluids or human waste. The program maintains strict control of all hazardous chemicals.
All areas observed to store these items were secured and inaccessible to youth. Each of the five
interviewed youth reported they do not handle any chemicals or cleaning agents. No youth were
observed using any cleaning agents during the annual compliance review week.
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
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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 has a visitation schedule posted within youth handbooks and in the lobby area of
the facility. Visitation is scheduled for Sunday from 2:00 p.m. until 5:00 p.m.. The visitation log
was reviewed which confirmed visitation is held as scheduled. Case managers maintain each
youths’ telephone, mail, and visitation approved contact list. According to the case manager,
youth are given up to three stamps weekly, and mail is sent out twice a week. The program
director may approve alternate visitation for a youth and family in the event the need arises.
Each of the five interviewed youth all confirmed they can call and send their parent/guardian a
letter. According to an interview with the case manager and program director, the program uses
Language Line Solutions for their third-party language service. For youth who have a history of
Human Trafficking, the case manager stated each youth’s juvenile probation officer (JPO) is
contacted and is sent a Juvenile Probation Officer Comments for Needs Assessment form. This
form is used to verify the youth’s parent/guardian and family members to confirm whether on
current or past investigation for Human Trafficking related issues. According to the case
manager, no current youth have had any alerts for Human Trafficking.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has an activity schedule visibly posted in all program areas. The program provides
outdoor and indoor activities for youth, which was confirmed in a review of the daily activity
schedule and logbook documentation. Activities provided and observed promote social and
cognitive skill development, creativity, teamwork, healthy competition, mental stimulation, and
physical fitness. The program takes precautionary measures to prevent overexertion, heat,
stress, dehydration, and frostbit. The program has an indoor climate-controlled gymnasium
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which youth may utilize in the event of inclement weather conditions. The provider’s contractual
agreement requires employment of a recreational therapist. The recreational therapist holds all
required credentials for the position. Each of the five reviewed youth case management records
found evidence each youth’s performance plan contained goals for recreation and leisure
activities. Each of the five youth all confirmed the program allows them at least one hour daily
for physical activities, the opportunity to exercise, play outside, or down time to read books, or
play board games. Each of the five interviewed staff all confirmed youth are given at least one
hour of recreational activity time. These activities may include things such as volleyball,
basketball, football, and yoga classes.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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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.
Documentation review confirmed the program has provided career and technical education
services required by contract such as ServSafe and Safe Food Handler Certifications, training in
cardiopulmonary resuscitation (CPR), first aid, and automated external defibrillator (AED),
Occupational Safety Hazard Administration (OSHA)-10 certifications, Florida Ready to Work,
hair braiding, and Certified Nursing Assistant certification (CNA). Career and technical
education services are provided in conjunction with the program’s activity schedule. Services
are rendered by qualified staff with necessary certifications to train youth at the program. The
following are identified industry certifications and provided by the program on an on-going basis;
ServSafe, OSHA, and CNA. A total of five of the ten enrolled youth received certification in
ServSafe during the annual compliance review period. One youth was enrolled in and received
certification in OSHA-10 during the annual compliance review period. There were no youth
enrolled in the CNA program during the annual compliance review period. Three youth
completed certifications in hair braiding. All twenty-eight youth were enrolled in Florida Ready to
Work, but none of the youth had achieved certification at the time of the annual compliance
review. Five youth were interviewed and eachreported they are receiving educational services.
The program director was interviewed and indicatededucation services are available, and the
program is providing vocational services: ServSafe, OSHA, CPR/First Aid, and CNA.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program shall integrate educational instruction (career and technical education, as well as
academic instruction) into their daily schedule in such a way ensuring the integrity of required
instructional time. The program has a policy and procedures to provide for educational access.
The center provides education services through Florida Virtual School (FLVS) and the 250-day
calendar, which is distributed over twelve months, including twenty days used for teacher
training and planning was reviewed. A review of five random dates in the logbook showed the
daily class schedule was being followed. Further review of logbook entries and video footage for
three days verified the youth were attending school as scheduled.
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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.
The educational provider shall integrate educational instruction (career and technical education,
as well as academic instruction) into their daily schedule in such a way ensuring the integrity of
required instructional time. Education services are provided through a contract with Florida
Virtual School (FLVS) and the 250-day calendar, distributed over twelve months, including
twenty days used for teacher training and planning. A review of the daily school schedule
revealed the center provides six fifty-minute class periods daily, fulfilling the weekly requirement
of twenty-five hours of instructional time. Five youth were interviewed, and all five reported they
attend school Monday through Friday. All five felt the school was preparing them either well or
very well regarding preparation towards General Education Development platform (GED), high
school, vocational, employment, and/or college. The five youth also reported there is minimal
interference with instruction. The interview with the instructional leader reported there is minimal
interference with educational services.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The career education program is to be appropriate for the educational abilities and goals of
each youth at the program. The career education program is appropriate for length of stay and
classification of each youth at the program. The program’s career educational programming is a
Type 2. The career education programming includes communication, interpersonal, and
decision-making skills. An interview with the lead educator was conducted and it was reported
youth are provided with career and technical education (CTE) courses such as digital
Information technology, personal finances, and other CTE courses.
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.
Upon admission, staff and youth develop an Education Transition Plan which includes
provisions for the continuation of education and/or employment. The educational provider’s
contract requires the educational provider to develop an Education Transition Plan for each
youth. The program’s education services are provided by Florida Virtual School (FLVS), which
began their contract on July 1, 2024. None of the closed youth records were applicable for the
current provider as they entered the program prior to July 1, 2024. None of the current program
youth had an Education Transition Plan initiated, as required, by the FLVS staff. It was reported
FLVS has recently created an Education Plan Template and trained their staff to implement the
development of a plan for each youth moving forward.
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
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teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The superintendent is responsible for ensuring qualified instructional personnel are provided to
teach and provide exceptional education and related services to students in the program.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience. The contracted educational provider has procedures in place to
provide qualified instructional personnel. Two educational instructional personnel were
reviewed, and both had a valid Florida educator’s certificate with appropriate coverage as
provided for in the Course Code Directory. A review of the Florida Department of Education’s
website confirmed both staff had active credentials. Both teachers were teaching courses out-
of-field, and notification letters were sent out to the parent/guardian by email. The letters
addressed the teachers were out-of-field; however, it did not state which out-of-field subjects
were being taught.
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.
A review of three closed youth case management records indicated the Florida Youth College
(FYC) referral process for each youth who has earned a high school diploma or general
education degree (GED). Documentation review and an informal interview with the FYC
director, lead instructor, and program director confirmed the program does not have any youth
from the program who were eligible or referred for participation in services. Five youth were
interviewed. Each of the five youth indicated they are not participating in any post-secondary
education services. The lead educator was interviewed and reported all youth who complete
their diploma or GED complete a survey with Florida Youth College and career exploration
survey. Then, youth are allowed to start working on the site and has supplies needed.
6.08 Florida Youth College (Post-Secondary Contract Provider) Non-Applicable
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.
Three closed youth records were reviewed to determine if the post-secondary provider, upon
receiving the referral for services, has assigned a Florida Youth College Career Navigator to
each youth. Documentation review and informal interview with FYC director confirmed the
program does not have any youth from the program participating in services.
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report_type: QI Residential